Anterior Chest Area Research Articles

A Prospective Study of Patients Presenting With Pre-sternal Keloids.

Keloid represents a pathological form of scarring. They are very common in the anterior chest area; nearly 50% of all keloids occur in this location. One of the reasons for this is that folliculitis and acne, known for triggering the development of keloids, are common on the anterior chest. The other reason is the tension load in this area due to the frequent movements of the upper limbs and the respiratory movements. These movements stretch the skin of the anterior chest horizontally. When this cyclical tension is imposed on the anterior chest wounds, there is an exacerbation and prolongation of the inflammation in the reticular dermis of the wound. These stresses induce the growth of keloids along the prevailing lines of skin tension. We performed a prospective study in which patients were recruited over a period of one year. Patients presenting with symptomatic pre-sternal keloids and requesting treatment but were unwilling to undergo surgical intervention were included in this study. Patients with a history of previous thoracic surgery were excluded. Baseline assessment and documentation of the lesion were performed. The study patients received three sessions of intralesional injections of a combination of triamcinolone acetonide and hyaluronidase at four weekly intervals. The final assessment was performed four weeks after the third session. The study included 47 lesions in 47 patients with ages of the patients ranging from 16 to 70 years. Pre-sternal keloids were found to be more common among males than females, with a male-to-female ratio of 2.35:1. Patients presented with pre-sternal keloids that had been present for varying periods ranging from three to 81 months. All of our 47 patients completed the three sessions of the treatment. Following the treatment, there was an improvement in the patient's symptoms, as evidenced by the reduction in the mean pruritis scores and pain scores. There was an overall reduction in the size of the lesion. The decrease in the height of the lesions was more evident than the reduction in the craniocaudal or transverse dimensions of the lesions. There were improvements in Vancouver Scar Scale(VSS) vascularity scores and pliability scores following the treatment. We conclude that pre-sternal keloids should be considered as a distinct clinico-pathological entity. There are differences with regard to pathogenesis, clinical presentation, and management when compared to keloids elsewhere. Treatment with intralesional injections of a combination of triamcinolone acetonide and hyaluronidase effectively relieves the symptoms and may be considered in patients not willing to undergo surgical intervention. Recurrences can occur and need further treatments.

A patient with acute myocardial infarction with acute lower extremity arterial embolization underwent amputation under general anesthesia.

Acute peripheral and coronary artery embolism are common complications of diabetes mellitus and greatly affect the clinical outcome of patients with diabetes; however, there are few reports about the symptoms and prognosis of patients with acute myocardial infarction (AMI) and concurrent acute lower extremity arterial embolism (ALEAE). A 44-year-old man with a history of 4 years of type 1 diabetes was admitted to hospital after suddenly experiencing severe pain in his right lower limb and feeling tightness in the left anterior chest area. Ultrasonography revealed distal occlusion of the right superficial femoral artery, and an electrocardiogram showed acute anterior interstitial myocardial infarction. After conservative treatment for 2 days, the patient had severe necrosis of the lower limbs and secondary injury of multiple organs. Haemodialysis and heparin anticoagulant therapy were performed before amputation. Twelve days after the operation, the patient's condition was stable, and he was transferred out of the intensive care unit. If patients with ALEAE miss the opportunity for early treatment, even with AMI, emergency amputation under general anaesthesia is the right strategy to save lives.

Total Face Reconstruction with Flap Prefabrication and Soft-Tissue Expansion Techniques.

Total facial deformities always lead to psychological and functional consequences, making plastic and reconstructive surgery a great challenge. The skin of the anterior chest area is matched in thickness, texture, and color to the head and face. The purpose of this article was to discuss and evaluate reconstructive surgeons' experiences with obtaining a monoblock flap from the anterior thoracic area for entire face reconstruction using flap prefabrication, soft-tissue expansion, and facial plastic surgery following skin flap transplantation. Two patients underwent prefabricated expanded anterior thoracic flap reconstructions for total facial deformities; data collection included face defect size, flap type, the shape of the expander, expansion time, and complications. All the face flaps that were transplanted survived without major complications. It is concluded that using a prefabricated expanded flap to reconstruct an entire facial soft-tissue defect can provide a high degree of matching, a wide enough covering area, and a thin enough skin thickness to cover the face. Autologous flap grafting is easy to implement and has a high application value.

Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar

Objective: To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods: The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results: Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions: The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar.

Contamination of Healthcare Worker Personal Protective Equipment with MRSA Outside the Intensive Care Unit Setting

Background: Estimates of contamination of healthcare personnel (HCP) gloves and gowns with methicillin-resistant Staphylococcus aureus (MRSA) following interactions with colonized or infected patients range from 17% to 20%. Most studies were conducted in the intensive care unit (ICU) setting where patients had a recent positive clinical culture. The aim of this study was to determine the rate of MRSA transmission to HCP gloves and gown in non-ICU acute-care hospital units and to identify associated risk factors. Methods: Patients on contact precautions with history of MRSA colonization or infection admitted to non-ICU settings were randomly selected from electronic health records. We observed patient care activities and cultured the gloves and gowns of 10 HCP interactions per patient prior to doffing. Cultures from patients’ anterior nares, chest, antecubital fossa and perianal area were collected to quantify bacterial bioburden. Bacterial counts were log transformed. Results: We observed 55 patients (Fig. 1), and 517 HCP–patient interactions. Of the HCP–patient interactions, 16 (3.1%) led to MRSA contamination of HCP gloves, 18 (3.5%) led to contamination of HCP gown, and 28 (5.4%) led to contamination of either gloves or gown. In addition, 5 (12.8%) patients had a positive clinical or surveillance culture for MRSA in the prior 7 days. Nurses, physicians and technicians were grouped in “direct patient care”, and rest of the HCPs were included in “no direct care group.” Of 404 interactions, 26 (6.4%) of providers in the “direct patient care” group showed transmission of MRSA to gloves or gown in comparison to 2 of 113 (1.8%) interactions involving providers in the “no direct patient care” group (P = .05) (Fig. 2). The median MRSA bioburden was 0 log 10CFU/mL in the nares (range, 0–3.6), perianal region (range, 0–3.5), the arm skin (range, 0-0.3), and the chest skin (range, 0–6.2). Detectable bioburden on patients was negatively correlated with the time since placed on contact precautions (rs= −0.06; P < .001). Of 97 observations with detectable bacterial bioburden at any site, 9 (9.3%) resulted in transmission of MRSA to HCP in comparison to 11 (3.6%) of 310 observations with no detectable bioburden at all sites (P = .03). Conclusions: Transmission of MRSA to gloves or gowns of HCP caring for patients on contact precautions for MRSA in non-ICU settings was lower than in the ICU setting. More evidence is needed to help guide the optimal use of contact precautions for the right patient, in the right setting, for the right type of encounter.Funding: NoneDisclosures: None

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

The Effect of Intraoperative Nefopam Administration on Acute Postoperative Pain and Chronic Discomfort After Robotic or Endoscopic Assisted Thyroidectomy: A Randomized Clinical Trial.

Acute postoperative pain and chronic discomfort are reported after robotic or endoscopic thyroidectomy. The purpose of this prospective, randomized, and double-blinded clinical trial was to investigate whether intraoperative infusion of nefopam decreases acute postoperative pain and chronic discomfort following either a robotic or endoscopic thyroidectomy via the bilateral axillo-breast approach (BABA). Patients were randomized into two groups: The control group (n=29) or the nefopam group (n=29). Patients in each group were infused with the same volume of saline or nefopam (0.2mg/kg bolus, 120μg/kg/h continuous infusion) during surgery. Acute postoperative pain, the need for rescue analgesics, and other postoperative adverse effects were assessed at 1, 6, 24, and 48h postoperatively. Chronic pain and discomfort was recorded at 3months after surgery. Patients in the nefopam group reported lower pain scores in the neck, as well as the axilla and anterior chest areas at 1, 6, 24, and 48h postoperatively, when compared with the control group (P<0.05 at each time points). Rescue analgesics were required less in the nefopam group than in the control group (1.4 [1] vs. 2.3 [1.5]; P=0.001). The degree of chronic pain and discomfort were relatively lower in the nefopam group (P<0.05). We report that intravenous nefopam infusion during surgery decreased acute postoperative pain and the need for rescue analgesics, as well as chronic discomfort, following BABA robotic or endoscopic thyroidectomy without adverse events.

Investigation of optimal position for implantable loop recorders by potential mapping with Reveal DX

BackgroundElectrode positioning is important for the operation of implantable loop recorders (ILRs). This study aimed to investigate optimal electrode positions for the implantation of ILRs. MethodsFifteen male subjects participated in the study and R wave amplitude data were collected from 15 areas in the left anterior chest area, with 4 variations of electrode angles and body positions. ResultsThe estimated minimum R wave amplitude values were greater than 0.3mV (manufacturer-recommended value) when electrodes were angled vertically and positioned on the midclavicular line of the third and the forth intercostal spaces or on the left sternal border of the fourth and fifth intercostal space and when angled at 45° to the right on the left sternal border of the third and the forth intercostal space. ConclusionsExploring areas around the left sternal border of the fourth intercostal space – where the R wave amplitudes are least affected by body positions – is a reliable method for choosing implantation locations for ILRs.

Low-dose adefovir-induced hypophosphatemic osteomalacia on whole-body bone scintigraphy.

While adefovir dipivoxil (ADV) effectively suppresses the hepatitis B virus, it can cause proximal renal tubular dysfunction leading to phosphate wasting [1, 2]. The safety of low-dose ADV (a dose of 10 mg/day), which does not induce clinically significant nephrotoxicity, is well recognized, but a few cases of hypophosphatemic osteomalacia (HO) caused by low-dose ADV therapy have recently been reported [3–6]. Although HO induced by low-dose ADV therapy is rare, the presence of bone pain in patients treated with ADV should be monitored. Bone scintigraphy can be performed to confirm the occurrence of osteomalacia and to determine the disease extent. Bone scintigraphic and radiological image findings with a brief review of the literature are presented in this article. We report two cases of HO induced by low-dose ADV therapy that showed multifocal increased radiotracer uptakes in the bilateral bony ribs, spines, pelvic bones and lower extremities on whole-body bone scintigraphy (Figs. 1 and ​and2).2). Bone pain gradually improved after phosphate supplementation and by changing the antiviral agent. Fig. 1 A 44-year-old man presented with a 6-month history of diffuse musculoskeletal pain in the chest, back and both knees without antecedent trauma. The patient had a history of chronic hepatitis B infection and had received adefovir dipivoxil (ADV) (10 mg/day) ... Fig. 2 A 42-year-old man who had taken adefovir dipivoxil (ADV) (10 mg/day) for 7 years for treatment of chronic hepatitis B complained of a 2-year history of diffuse musculoskeletal pain in the anterior chest area with absence of antecedent ... Whole-body bone scintigraphy is a highly sensitive imaging tool and can show disease extent at once in the setting of the wide range of the clinical spectrum with nonspecific radiological findings [5]. Furthermore, frequent involvement of the lower extremities, as a result of maximum weight bearing, could be an additional scintigraphic clue for the diagnosis of HO [6, 7]. These cases could be helpful for both clinicians prescribing ADV and nuclear physicians to prevent delayed diagnosis and plan further appropriate treatment.

Reconstruction of the face and neck with different types of pre-expanded anterior chest flaps: A comprehensive strategy for multiple techniques

For large defects or deformities of the face and neck, the anterior chest area appears to be an excellent donor site that provides well-matched skin colour and texture. Many flap techniques based on the anterior chest area have been reported; however, there are few reports that focus on a treatment strategy for these different flap techniques. A retrospective study was performed to propose a treatment algorithm. A total of 69 cases were reviewed from May 2005 to July 2011, in which different types of anterior chest flaps were performed for face and neck reconstruction. The reconstructive procedures, the defect characteristics and the complications were collected and analysed. Thirty-three pedicled thoracic branch of the supraclavicular artery flaps (the pedicled TBSA flap), 11 pedicled internal mammary artery perforator flaps (the pedicled IMAP flap), 8 free internal mammary artery perforator flaps (the free IMAP flap), 4 supercharged TBSA flaps, 17 prefabricated flaps and 3 supercharged prefabricated flaps were performed. The applications of six types of pre-expanded anterior chest flaps were described in an algorithmic approach. A treatment strategy for face and neck reconstruction using six anterior chest flap techniques is proposed. It recommended a personalised flap planning according to the characteristics of deformities/defects and the regionally dominant vessels of the anterior chest area.

Prospective Study of Sensation in Anterior Chest Areas Before and After a Bilateral Axillo‐breast Approach for Endoscopic/Robotic Thyroid Surgery

The bilateral axillo-breast approach for endoscopic/robotic thyroid surgery (BABA) shows good oncologic and surgical outcomes and does not result in neck scars. However, there is concern about potential sensory changes of the skin flaps after BABA, especially of the breast areas. This prospective study was undertaken to evaluate sensory changes in the skin flaps after BABA. A total of 19 women (mean age 36.9 ± 8.7; age range 21-51 years) who underwent BABA were enrolled. Skin flap sensory assessments were performed for each patient preoperatively and again at 1 and 3 months postoperatively. The Semmes-Weinstein monofilament test was used to evaluate the cutaneous light-pressure thresholds, a biothesiometer was used to evaluate the vibration thresholds, and an infrared thermometer was used to measure skin temperatures of the skin flaps. There were changes in the sensations of the anterior chest areas over time, as determined by the Semmes-Weinstein monofilament test (1.5 vs 4.3 versus 1.4; P < 0.05) and the biothesiometer (26.8 vs 31.2 vs 22.3; P < 0.05). The sensations in the anterior chest areas normalized to preoperative levels at 3 months postoperatively. No significant differences were seen in the infrared thermometer test at any of the time points (36.2 vs 36.2 vs 36.3 °C; P = 0.9927). While anterior chest area sensations were changed at 1 month postoperatively, the sensations normalized at 3 months after BABA. These results suggest that BABA has minimal adverse effects on anterior chest area sensation.

Cervical angina because of ossification of the posterior longitudinal ligament

An 80-year-old man with increasing anterior chest pain was admitted to the emergency department. Electrocardiograms, laboratory investigations, and other examinations ruled out both angina and acute myocardial infarction. Computed tomography of the chest showed no evidence of aortic dissection. He reported a 4-year history of difficulty in performing fine finger movements. Increased deep tendon reflexes were observed in both upper and lower extremities. Computed tomography of the cervical spine revealed ossification of the posterior longitudinal ligament (Figs. 1 and 2). His symptoms gradually improved with rest and by wearing a neck collar. He refused surgical intervention. Cervicalspinedisordersmayoftenbepresentwithpainin the anterior chest areas, resembling true angina pectoris [1]. Ithasbeensometimesdescribedascervicalangina.Accurate diagnosis requires a strong sense of suspicion in patients with inadequately explained chest pain. The chief complaint is typically intolerable paroxysmal precordialgia induced by neck motion, as with this patient [2].

Recovery of Sensation in the Anterior Chest Area after Bilateral Axillo-breast Approach Endoscopic/Robotic Thyroidectomy

There is concern that endoscopic/robotic thyroidectomy could impair anterior chest skin sensation. Here, this possibility was assessed. Fifty-one patients who underwent bilateral axillo-breast approach endoscopic/robotic thyroidectomy were asked 8 to 115 days (median: 29 d) later to undergo Semmes-Weinstein pressure threshold testing and to complete a questionnaire. Patient clinicopathological details were extracted. Twenty-one patients (41.2%) showed sensory impairment (sum of sensory changes ≥ 1). The average sum of sensory change (scale of 0 to 95) was 1.4 (range, 0 to 8). Impaired patients did not differ from unimpaired patients in any clinicopathological parameter except for time from operation. Compared with 1 month postsurgery, there was significantly less sensory impairment 3 months postsurgery (P=0.0083). The questionnaires yielded similar observations. The temporary and mild nature of the sensory change in the anterior chest area will relieve surgeons and patients from concerns that bilateral axillo-breast approach endoscopic/robotic thyroidectomy could permanently impair chest sensation.

Decreased sensitivity of lung ultrasound limited to the anterior chest in emergency department diagnosis of cardiogenic pulmonary edema: a retrospective analysis

Abstract Purposes B-lines are vertical echogenic artifacts seen on lung ultrasound that allow bedside diagnosis of pulmonary edema. The BLUE protocol, published by Lichtenstein and Mezière, suggests that cardiogenic pulmonary edema is sufficiently ruled out in the ICU setting when B-lines are not predominant in the anterior chest (the B-profile). Our analysis sought to evaluate the sensitivity of the B-profile for ruling out pulmonary edema in the ED patient population. Methods The ultrasound lung scans of patients with confirmed official diagnoses of acute decompensated heart failure (ADHF) from two ED databases were retrospectively analyzed. 170 acutely dyspneic patients had complete studies (130 from one database and 40 from the other). The scans were reviewed using the B-profile definition for ruling out pulmonary edema and comparing that to an alternate scanning protocol that includes ultrasound evaluation of the lateral and anterior chest. Results Of the 170 ED patients with ADHF diagnoses, the B-profile missed 16.5% (n = 28) for a sensitivity of 83.5% (95% CI 77–89%). These 28 patients did not show anterior bilateral B-lines that fit the criteria for positive under the BLUE protocol. Moreover, 25% (7/28) of these missed patients had only lateral B-lines on their lung scans and B-lines would have been detected only by including scans of the lateral zones. Conclusions Limiting the sonographic lung examination to the anterior chest areas only will miss cases of ADHF in the dyspneic ED patients. The BLUE protocol (B-profile) may need to be modified to include examination of the lateral chest as necessary for ED patients with ADHF.

A fatal case of myocardial damage due to misuse of the “designer drug” MDMA

A 39-year-old woman collapsed after oral intake of 3,4-methylenedioxymethyl-amphetamine (MDMA, “ecstasy”). After ingestion of the drug, she had felt persistent discomfort in her anterior chest area, and lost consciousness for a few minutes on the following morning. She was transported to a hospital and died seven days after collapse. A serum sample obtained on admission revealed an MDMA concentration of 1.2 mg/L, but no evidence of any other drug including amphetamine, methamphetamine, or other ring-substituted amphetamines. Microscopic examination at autopsy revealed striking changes in the heart, including small foci of myocyte necrosis with a surrounding macrophage inflammatory response, foci of fibrosis, and calcification accompanied by myocyte necrosis, these changes being predominant in the right ventricle. In the liver, hepatic necrosis was observed with fatty degeneration accompanied by inflammation. Myoglobinuria was demonstrated in the kidney by immunohistochemistry. Degeneration of neurons throughout the whole brain was also evident, in addition to haemorrhagic foci in the pons and medulla. Serious bronchopneumonia was also found in the right lung. These findings provide evidence that oral intake of MDMA can result in cardiotoxicity, inducing cardiac arrhythmia and cardiovascular collapse. As a consequence of the compromised blood supply, brain necrosis may occur, followed by severe bronchopneumonia. Ingestion of MDMA could also lead to liver damage as well as myoglobinuria resulting from rhabdomyolysis. These data suggest that death in this case had been caused largely by MDMA intoxication.

Diagnostic Values of Sonography for Assessment of Sternal Fractures Compared With Conventional Radiography and Bone Scans

This study was prospectively undertaken to evaluate the diagnostic value of sonography for detection of sternal fractures. We compared sonographic, conventional radiographic, and bone scan examinations of sternal fractures. Fifty consecutive patients (26 male and 24 female; mean age, 45.2 years) were evaluated. Conventional radiography and sonography were performed in all patients, and bone scans were performed in 39 patients. All patients had acute pain and tenderness in anterior midline chest areas. Sonography was performed by 2 musculoskeletal radiologists within 1 to 2 days after admission. Patients underwent conventional radiography at admission and bone scans within 4 to 7 days after admission. Two radiologists reviewed all imaging findings by means of consensus. In addition, sonography was performed in 20 asymptomatic patients in a normal control group. Conventional radiography depicted sternal fractures in 12 of 50 patients. Sternal fractures were detected in 31 of 50 patients on sonography. Fractures on sonography were located in the manubrium (8 cases), upper sternal body (11 cases), mid sternal body (5 cases), and lower sternal body (7 cases). Bone scans showed sternal hot uptakes (accumulations of the radionuclide used) in 18 of 39 patients. In the control group, there were no bony defects or abnormal contours. We could detect sternal fractures more effectively with sonography than with conventional radiography and bone scans. In addition, sternal fracture locations showed relatively even distributions, and focal fractures in the manubrium were not easily detected on bone scans.

An Erythematous Plaque Above the Ear

REPORT OF A CASE A previously fit, 54-year-old woman with non—insulindependent diabetes presented with a 3-month history of an asymptomatic follicular rash involving the anterior chest area, breasts, flexures, periauricular areas, and scalp. The rash had persisted despite 2 courses of systemic antibiotics. She also gave a history of recent weight loss and night sweats. Physical examination revealed a violaceous, pinkish, papular eruption on the anterior chest area, flexures, forehead, and scalp, particularly above the left ear (Figure 1). Systemic examination revealed generalized lymphadenopathy and hepatosplenomegaly. An incisional skin biopsy specimen was obtained from above the left ear and submitted for histologic examination (Figure 2andFigure 3). Immunoperoxidase staining with CD20 is shown inFigure 4. What is your diagnosis? DIAGNOSIS: Skin involvement by a B-cell follicular centrocytic/centroblastic lymphoma. HISTOPATHOLOGIC FINDINGS The skin biopsy specimen revealed follicular aggregates of lymphocytes within the dermis with extension into the subcutaneous fat. Morphologically, the predominant cells

64-Year-Old Woman With Chest Pain and Presyncope

64-Year-Old Woman With Chest Pain and Presyncope

Pericarditis associated with scorpionfish ( Scorpaena guttata) sting

A male stung by a scorpionfish immediately developed the classical symptoms of envenomation: severe localized pain, swelling, and redness, followed in 24 hr by pain in the left shoulder, which spread over the left anterior chest and substernal area. Admitting diagnoses considered in addition to envenomation were: pulmonary embolism, myocardial infarction, myocarditis, and viral pericarditis. Following extensive laboratory studies a diagnosis of viral-type pericarditis was established. This study emphasizes the diversity of disease states that can be associated with but unrelated to the sting or bite of a venomous animal, and also stresses the importance of a careful clinical work-up in every case of venom poisoning.

Karate Chops and Liver Lacerations

To the Editor.— Karate is a fast-growing participation sport due partially to the medical emphasis on the benefits of physical fitness and the individual desire for self-protection in the face of high municipal crime rates. To the best of our knowledge, this letter describes probable complications not previously noted. Report of a Case.— A 39-year-old woman was hospitalized with abdominal pain, nausea, vomiting, and syncope. Six weeks earlier, at her second karate lesson, she received a combination of blows to the right subcostal abdominal region. Roentgenograms the following day of the ribs were normal, and she was treated symptomatically with mild analgesics. On the day of admission she vomited coffee-ground material. Her pulse rate on admission was 110, blood pressure was 90/70 mm Hg, and her temperature was 38.8 C. She had tenderness on palpation of the right anterior chest area. The liver edge was palpable 10 cm below the