Absence Of Classical Symptoms Research Articles

AN UNDIAGNOSED FOURNIER’S GANGRENE IN ADVANCED UROGENITAL CANCER WITH INCARCERATED INGUINAL HERNIA

Objective: This study aims to report an undiagnosed Fournier’s gangrene. Case(s) Presentation: A 62-year-old male with advanced urogenital cancer and an incarcerated inguinal hernia. Sudden-onset scrotal pain was initially diagnosed as hydrocele with an incarcerated hernia. Radiological examinations not revealing typical Fournier's gangrene features. Despite the absence of classical symptoms, further investigation uncovered a complex medical history involving urogenital issues, failed catheterization, and urethrotomy. The patient presented with malnutrition, weight loss, and signs of systemic distress. Discussion: Pus and necrotic tissue were debrided, with cultures indicating E. Coli growth. Biopsies suggested carcinoma, requiring further evaluation at a tertiary facility. Despite complications, the patient showed an excellent prognosis after a 14-day hospital stay. Conclusion: This case underscores the atypical presentation of Fournier's gangrene, emphasizing the need for comprehensive assessment in patients with scrotal pain. The association with advanced urogenital cancer adds complexity to diagnosis and management, highlighting the importance of a multidisciplinary approach.
 Keywords: Fournier’s gangrene, urogenital cancer, incarcerated inguinal hernia.

313 BRUGADA SYNDROME MIMICRY: THE IMPORTANCE OF AN EXTENDED FOLLOW-UP

Abstract Introduction Brugada Syndrome (BrS) is a genetically inherited condition associated with the risk of fatal arrhythmias and sudden cardiac death (SCD) occurring in a structurally normal heart. This disorder was historically related to mutations in the SCN5A gene, but recent observations suggest a more complex genetic inter-play, highlighting the possible overlap with structural cardiomyopathies, including hypertrophic cardiomyopathy (HCM). Case Presentation In May 2005, an asymptomatic 56-year-old man with a family history of unexplained SCD was referred to our outpatient clinic. A 12-lead ECG showed a type 2 Brugada pattern whilst transthoracic echocardiogram (TTE) was normal. Ventricular fibrillation (VF) was induced during an elective electrophysiological study and a transvenous implantable cardioverter-defibrillator (ICD) was implanted for primary prevention. More than 10 years later, in March 2022, our patient was admitted to the hospital because of palpitations. The ECG revealed a typical atrial flutter with a high ventricular rate, successfully treated with catheter ablation. Post-procedural ECG showed the persistence of type 2 Brugada pattern in association with new-onset T wave inversion in inferolateral leads and signs of ventricular hypertrophy. TTE revealed asymmetric left ventricular hypertrophy, with left ventricular outflow tract (LVOT) obstruction determined by mitral systolic anterior motion and preserved LV systolic function. The patient was treated with optimal medical therapy with symptom improvement and reduction of LVOT obstruction at a 3-month follow-up TTE. Discussion The distinction between Brugada phenocopy and BrS electrocardiogram patterns is not obvious, and according to our experience a Brugada type 2 pattern could be an early ECG marker of a concealed HCM which became manifest over an extended follow-up. Brugada ECG phenocopies are clinical entities characterized by type 1 or type 2 Brugada patterns elicited by an underlying condition, the disappearance of the pattern with the resolution of the condition and the absence of classical symptoms. Several pathogenic variants involving other and different genes have been recently reported suggesting a possible overlap with structural cardiomyopathies. Recently, two other cases of incidental findings of a Brugada ECG pattern in the context of HCM were described. Both patients had a common pathogenetic splicing mutation in the MYBPC3 sarcomeric gene (encoding for the cardiac myosin-binding protein C) responsible for HCM with no genetic mutations associated with Brugada syndrome. This fact suggests that patients are not simultaneously affected by BrS and HCM but a clinically manifest HCM with a specific genetic background can lead to an early BrS electrical manifestation. Conclusion Our experience confirms that a Brugada type 2 ECG pattern could be a very early sign of a concealed HCM manifested over 10 years later. The importance of proper risk stratification and regular follow-up has thus crucial implications in patient clinical management. However, whether Brugada pattern associated with structural heart disease is linked to an increased risk of sudden cardiac death is still unknown and needs further investigations.

Meckel's Diverticulum Mimicking Inflammatory Bowel Disease

AbstractIntermittent abdominal pain is the most common gastrointestinal (GI) complaint in the pediatric age group. When basic investigations and sonograms do not give etiological basis, functional GI disorders are diagnosed. Meckel's diverticulum (MD), being the common GI surgical condition, can be missed in absence of classical symptoms. Clinical presentation varies based on the size, location, and presence of ectopic gastric mucosa. We report a case of an adolescent female with MD presenting as chronic abdominal pain. Abdominal ultrasonogram was normal. Abnormal fecal calprotectin level and colonoscopy directed for a suspicion of inflammatory bowel disease. Persistence of symptoms with increasing severity prompted a relook into the diagnosis. The presence of intussusception on abdominal scan during one of the painful episodes warranted emergency exploratory laparotomy. Intraoperatively, the lead point for intussusception was identified as MD, which was resected. Postoperative period was uneventful. There are no abdominal symptoms since a year during the follow-up period.

Non-Hodgkin’s lymphoma: unexpected cause of shoulder pain. A systematic review of the literature

The non-Hodgkin lymphoma (NHL) is one of the most common shoulder neoplasms, especially the diffuse large B cell lymphoma (DLBCL). We report a rare case of shoulder pain in a 80-year-old man presenting with a six-month history of continuous severe pain to the right shoulder. Routine laboratory studies were normal. Shoulder MRI showed an in-growing inhomogeneous lesion in the anteromedial aspect of the right humeral head extended within the cortical bone of the humerus (osteolitic lesion), next to the surrounding soft tissues. He also underwent shoulder arthroscopy: the intra-articular involvement of the shoulder was therefore excluded. A percutaneous bone biopsy performed on the same day was diagnostic for lymphoma. Three days later, the patient underwent surgical excision of the mass; a reverse shoulder prosthesis was then implanted (Aequalis reversed prosthesis). The patient started chemiotherapy according with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen, but did not tolerate it because of the sudden onset of herpes zoster. At 9-month follow-up, the patient is doing well, with fair range of motion, due to the delay of rehabilitation, but no shoulder pain and no evidence of local or systemic recurrence. A painful shoulder may be due to lymphoma even in the absence of classical symptoms. In suspected patients, plain radiographs should be followed by magnetic resonance imaging and bone biopsy. Tumor removal and shoulder arthroplasty can be an effective therapy. Given the devastating side effects of adjuvant chemotherapy, we do not recommend it in elderly patients.

Age-related differences in symptoms, diagnosis and prognosis of bacteremia

BackgroundElderly patients are at particular risk for bacteremia and sepsis. Atypical presentation may complicate the diagnosis. We studied patients with bacteremia, in order to assess possible age-related effects on the clinical presentation and course of severe infections.MethodsWe reviewed the records of 680 patients hospitalized between 1994 and 2004. All patients were diagnosed with bacteremia, 450 caused by Escherichia coli and 230 by Streptococcus pneumoniae. Descriptive analyses were performed for three age groups (< 65 years, 65–84 years, ≥ 85 years). In multivariate analyses age was dichotomized (< 65, ≥ 65 years). Symptoms were categorized into atypical or typical. Prognostic sensitivity of CRP and SIRS in identifying early organ failure was studied at different cut-off values. Outcome variables were organ failure within one day after admission and in-hospital mortality.ResultsThe higher age-groups more often presented atypical symptoms (p <0.001), decline in general health (p=0.029), and higher in-hospital mortality (p<0.001). The prognostic sensitivity of CRP did not differ between age groups, but in those ≥ 85 years the prognostic sensitivity of two SIRS criteria was lower than that of three criteria. Classical symptoms were protective for early organ failure (OR 0.67, 95% CI 0.45-0.99), and risk factors included; age ≥ 65 years (OR 1.65, 95% CI 1.09-2.49), comorbid illnesses (OR 1.19, 95% CI 1.02-1.40 per diagnosis), decline in general health (OR 2.28, 95% CI 1.58-3.27), tachycardia (OR 1.50, 95% CI 1.02-2.20), tachypnea (OR 3.86, 95% CI 2.64-5.66), and leukopenia (OR 4.16, 95% CI 1.59-10.91). Fever was protective for in-hospital mortality (OR 0.46, 95% CI 0.24-0.89), and risk factors included; age ≥ 65 years (OR 15.02, 95% CI 3.68-61.29), ≥ 1 comorbid illness (OR 2.61, 95% CI 1.11-6.14), bacteremia caused by S. pneumoniae (OR 2.79, 95% CI 1.43-5.46), leukopenia (OR 4.62, 95% CI 1.88-11.37), and number of early failing organs (OR 3.06, 95% CI 2.20-4.27 per failing organ).ConclusionsElderly patients with bacteremia more often present with atypical symptoms and reduced general health. The SIRS-criteria have poorer sensitivity for identifying organ failure in these patients. Advanced age, comorbidity, decline in general health, pneumococcal infection, and absence of classical symptoms are markers of a poor prognosis.

Atypical Presentation of Cytomegalovirus Infection in a Liver Transplant Patient

Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. Symptomatic infection usually presents with fever, pneumonia, colitis, or cytopenia. We describe a case of symptomatic CMV infection in a liver transplant recipient presenting with atypical symptoms of only persistent nausea and vomiting, in the absence of classical symptoms and signs; thus, highlighting the importance of high index of suspicion of CMV in immunocompromised patients, keeping in mind the high morbidity and mortality associated with this disease.

Recurrent Urosepsis and Cardiogenic Shock in an Elderly Patient with Pheochromocytoma

Pheochromocytomas are thought to be uncommon in the elderly. However, the prevalence is likely to be higher than reported, as older patients are less likely to be diagnosed due to absence of classical symptoms of sympathetic overactivity and confounding effects of aging, comorbidities, and medications. We describe a hypertensive elderly patient with incidentally diagnosed pheochromocytoma complicated by recurrent urosepsis, cardiomyopathy, and fatal myocardial infarction. Our case demonstrates that, in older hypertensive patients without classical symptoms, orthostatic hypotension and urinary retention, which are common in the elderly, may indicate catecholamine excess and that the deleterious cardiovascular consequences of catecholamine excess in the elderly are not prevented by pharmacological α- and β-blockade.

A 75‐YEAR‐OLD CAUCASIAN MAN WITH UNUSUAL PRESENTATION OF MYASTHENIA GRAVIS

A 75‐YEAR‐OLD CAUCASIAN MAN WITH UNUSUAL PRESENTATION OF MYASTHENIA GRAVIS

Older Subjects with Hyperthyroidism Present with a Paucity of Symptoms and Signs: A Large Cross-Sectional Study

The absence of classical symptoms and signs of hyperthyroidism often results in delayed diagnosis and treatment. The objective of the study was to determine the prevalence of symptoms and signs of hyperthyroidism according to patients' age and gender as well as severity and type of hyperthyroidism. This was a cross-sectional study of 3049 consecutive patients with hyperthyroidism presenting to a single secondary/tertiary care clinic. Calculation of adjusted odds ratios for presence/absence of symptoms/signs of hyperthyroidism simultaneously analyzing the influence of patients' age/gender, disease etiology/severity, symptom duration, and smoking. The majority of patients older than 61 yr had two or more symptoms. The lowest proportion of subjects reporting five or more symptoms was found in those older than 61 yr. Increasing age was associated with reduced adjusted odds ratio for the presence of most classical symptoms except for weight loss and shortness of breath, independent of disease severity. Those with more severe hyperthyroidism and smokers had increased odds ratios for most symptoms. Older age, higher serum free T(4) concentrations at diagnosis, male gender, and toxic nodular hyperthyroidism were independently associated with risk of atrial fibrillation. Signs of ophthalmopathy were associated with increasing age, smoking, longer symptom duration, and female gender. Classical symptoms and signs of hyperthyroidism are significantly less prevalent in older patients and more prevalent in smokers and subjects with higher free T(4) concentrations. We propose a lower threshold for performing thyroid function tests in patients older than 60 yr, especially in those presenting with atrial fibrillation, weight loss, or shortness of breath.

Effects on goat milk quality of the presence of Mycoplasma spp. in herds without symptoms of contagious agalactia

This study was designed to assess the possible effects of mycoplasmas on the quality of milk produced by goat herds in a contagious agalactia (CA) endemic area with absence of classical symptoms. Several factors related to milk quality (percentages of fat, total protein, lactose and total solids, standard plate counts (SPC) and presence of Staphylococcus aureus) were compared in mycoplasma-infected and non-infected herds. To define the CA status of 26 herds on the island of Lanzarote (Spain), where CA is endemic, 570 individual milk samples and 266 bulk tank milk (BTM) samples were microbiologically analysed for the presence of Mycoplasma spp. A herd was considered infected by mycoplasmas when at least a sample (individual or BTM) was positive. BTM samples were also used to determine milk quality parameters. Mycoplasma infection was confirmed in 13 herds. A total of 31, 10 and 11 strains of Mycoplasma mycoides subsp. mycoides LC (MmmLC), Mp. agalactiae and Mp. capricolum subsp. capricolum were isolated. No significant differences were observed between the least square means of the variables fat, total protein, lactose and total solids or SPC recorded for the infected v. non-infected herds. The Staph. aureus status of a herd was also found to be independent of the presence of Mycoplasma spp. Our findings indicate that neither the presence of mycoplasmas in a goat herd with absence of classical symptoms seem to compromise the quality of the BTM.

Prevalence of autoimmune diseases in islet transplant candidates with severe hypoglycaemia and glycaemic lability: previously undiagnosed coeliac and autoimmune thyroid disease is identified by screening

Autoimmune diseases such as Addison's or coeliac disease can contribute to hypoglycaemia or malabsorption and are more common in Type 1 diabetes (T1DM). This brief report describes the prevalence of known and newly detected autoimmune disease in clinical islet transplant candidates with longstanding T1DM and severe hypoglycaemia and/or glycaemic lability who are routinely screened for coexisting autoimmune disease. One hundred and twenty-four C-peptide negative T1DM subjects [77 (62%) female, mean age 44 +/- 9 years, diabetes duration 28 +/- 11 years, body mass index 24.9 +/- 3.5 kg/m(2)] with indications for clinical islet transplantation at the University of Alberta were screened for autoimmune disease by history and measurement of anti-transglutaminase antibodies (positive > 10 U/ml), 09.00 h cortisol (followed by adrenocorticotrophic hormone-stimulation if < 495 nmol/l) and thyroid-stimulating hormone to determine the prevalence of coeliac disease, Addison's disease and autoimmune thyroid disease, respectively. Forty per cent of subjects had one or more coexisting autoimmune disease. The prevalence of autoimmune disease was 35%, coeliac disease 8% and Addison's disease 1.6%. In 11 individuals (9%), one or more autoimmune disease were newly detected (seven coeliac disease and five thyroid disease). Seven of 10 cases of coeliac disease were newly detected. A gluten-free diet in individuals with newly diagnosed coeliac disease reduced gastrointestinal symptoms, but indications for clinical islet cell transplantation persisted. Coexisting autoimmune disease is common in candidates for clinical islet cell transplantation. Screening in this group identified a substantial number of previously unrecognized cases. Clinicians should consider the presence of autoimmune disease even in the absence of classical symptoms.

A Case of Difficult Diagnosis of Rabies in the Absence of a Dog Bite in a Patient With Depression

A Case of Difficult Diagnosis of Rabies in the Absence of a Dog Bite in a Patient With Depression

A Case of Difficult Diagnosis of Rabies in the Absence of a Dog Bite in a Patient With Depression

A Case of Difficult Diagnosis of Rabies in the Absence of a Dog Bite in a Patient With Depression

Chronic inspiratory stridor secondary to a retained penetrating radiolucent esophageal foreign body

Although foreign body ingestions are common in infants and young children, penetration of the esophagus is a relatively rare event. Timely diagnosis is impeded by the absence of classical symptoms and by the ingestion of radiolucent foreign bodies. The authors present a 17-month-old girl with a 6-month history of inspiratory stridor. An extensive workup found a penetrating radiolucent foreign body at the thoracic inlet. J Pediatr Surg 38:E6. Copyright 2003, Elsevier Science (USA). All rights reserved.

Therapeutic controversies in primary hyperparathyroidism.

There is little debate about the primacy of surgery in the management of classical PHPT. Rather, the question has been what to do about the many patients with nonclassical disease. A 1990 NIH consensus conference (55) clearly recommended surgery for patients with significant adverse effects of PHPT, for patients with complicating coexistent illnesses, for younger patients, and for those in whom consistent long-term follow-up could not be assured. It allowed that conscientious surveillance may be justified in patients with minimal hypercalcemia and no adverse effects, but it recognized that for many patients, the time and expense involved in rigorous follow-up would outweigh the burden of surgery. Nine years later, the demonstrated prevalence of nonclassical symptoms and their reversibility, the evidence of "asymptomatic" but harmful effects reversible by surgery, and the accumulating evidence for surgical reduction of increased long-term mortality risk substantially strengthen the argument for surgery in such patients. For these reasons, parathyroidectomy should generally be recommended for patients with a secure diagnosis of PHPT, even in the absence of classical symptoms.

Diagnosis of postinfarction heart aneurysms

The results of clinical and instrumental examination of 300 patients with myocardial infarction are presented. The leading role of complexes of diagnostic signs in the recognition of postinfarction heart aneurysms in the absence of classical symptoms is shown.

A Case of Frontal Lobe Tumour

1. A case of left-sided frontal lobe tumour is described, and the recent literature of these tumours is reviewed. 2. The differential diagnosis in such a case is discussed. 3. The prominence of mental symptoms in the left-sided tumour is stressed. 4. The absence of classical symptoms and the presence of aphasic symptoms in a case of tumour deep in the frontal lobe are raised as diagnostic and localizing points.

Report of an unusual case of leiomyosarcoma occurring in the urinary bladder

1.1. Leiomyosarcoma is one of the rarest types of tumor. The case here presented makes the nineteenth on record in English literature. It is notable for its great size, its rapid growth, its perfect encapsulation, and the absence of classical symptoms.2.2. A review of the reported cases of leiomyosarcoma discloses the finding that the great majority of these tumors are of uterine origin.3.3. The histologic criteria for this type of malignancy are indefinite. It is hoped that an effort may be made to standardize the classification of nonepithelial tumors.4.4. As with carcinoma, metastases are a late symptom; when this stage is reached, the case has usually become hopeless. The only safeguard lies in periodical examinations and the early recognition of malignancy or potential malignancy.