Bilateral Bases Research Articles

The role of computed tomography in severe sepsis

Introduction: Sepsis is a common presentation in the emergency department (ED ). Early recognition and management is crucial for patients' prognosis, as 30-50% of patients presenting with sepsis have treatment initiated in the ED. Aims / objectives Highlight the importance of utilizing CT imaging particularly CT hypoperfusion complex in obtaining a complete and rapid diagnosis of clinically suspected septic shock, etiologies and complications. Case summary: A 66-year-old male patient brought to the ED with worsening generalized swelling mainly over the lower extremities, abdomen, and an \"abdominal infection\". He was hospitilized at another facility where he was treated for an unknown intra-abdominal infection. During hospitalization found to have liver problem, and valvular heart problem. ED vitals: blood pressure 97/83, pulse 91, respiratory rate 26, oxygen saturation 93% on room air. Review of systems was significant for: fatigue, chills, myalgia, shortness of breath, leg swelling, abdominal distention, abdominal pain, constipation, easy bruising, and confusion. On exam patient was severely jaundiced, confused , GCS 14/15, decreased breath sounds at the bilateral bases, and rales noted in the right middle field. His abdomen was soft, very mildly distended, without tenderness or guarding. Pitting edema was noted in his lower extremities. The remainder of the exam was unremarkable. Management and results: A full septic work up was sent. Piperacillin-tazobactam was given empirically in addition to an initial dose of IV furosemide. Labs results were remarkable for Leukocytosis with WBC count of 17.1, and Low platelet of 63. Hyponatremia with a sodium of 129, hyperkalemia with a potassium of 5.7, significantly elevated urea of 24.9. Elevated bilirubin of 289, with direct bilirubin predominance of 233, and indirect of 56. And significantly elevated pro-BNP of 16,400. The CT abdomen and pelvis was concerning for incidental findings of bilateral pulmonary emboli, thrombi in the right atrium and left ventricle with right heart strain, Marked right-sided pleural effusion and extensive pulmonary infiltrates, patchy nodular infiltrates in the left lower lobe , ‘Nutmeg' liver, ascites and anasarca. Additionally, there was cholelithiasis and severe contrast enhancement in both adrenal glands concerning for septic shock. The patient was dispositioned to the ICU for septic shock. Discussion: This was a case of septic shock evident on the CT scan, associated with pulmonary embolism in a patient with possible underlying right heart failure causing nutmeg liver and liver derangements. Conclusion and educational outcome: Even with the lack of clear history or localizing symptoms, high clinical suspicion, and utilization of assessment tools such as qSOFA and CT imaging alongside laboratory testing can help with prompt diagnosis and management . In this case, the presence of severe adrenal contrast enhancement is what alerted us to the severity of the patient's clinical picture. This sign highlights the central role played by the adrenal glands in mediating the sympathetic response to hypotensive shock and is associated with poor prognosis.

ACUTE RESPIRATORY FAILURE WITH FATAL OUTCOME DUE TO PENICILLIUM CHRYSOGENUM IN A MAN FROM GUATEMALA WITH A SEMINOMA (GERM CELL TUMOR )

TOPIC: Chest Infections TYPE: Global Case Reports INTRODUCTION: This type of mycosis has a rare presentation and even as an oportunistig pathogen is not common. The diagnosis is difficult because there is not a specific clinical finding, and carries a high-mortality risk despite an aggressive therapy. We presented a case of a patient with acute hypoxic respiratory failure with lung involvement, and pericardial tamponade in a patient without past medical history. This was a challenging diagnosis and required a multidisciplinary approach CASE PRESENTATION: 29-year-old man farmer, without past medical history presents with dyspnea on exertion associated with non-specific symptoms for the last two-months. The dyspnea on exertion has progressed to the extent to be present at rest. On the physical exam there are distant heart sounds, and diffuse lung crackles. CT-non contrast of chest showed disseminated miliary nodes with ground glass opacities at the bilateral bases and a large pericardial effusion. There was presence of a large pericardial effusion with right ventricular and atrial collapse in the trans-thoracic echocardiogram. Conidia in chains were found with KOH in the pericardial drainage. A bronchoscopy with bronchoalveolar lavage, brushing and transbronchial biopsy was performed and fungal structures were observed. Later, a lung biopsy was performed and Penicillium chrysogenum grew and was observed with lactophenol blue and confirmed by mass spectrometry (MALDI-TOF). Aggressive treatment with liposomal amphotericin-B plus voriconazol was started. Despite treatment the patient expired and seminomatous germ cell tumor was given, which supported the immunosuppression state of the patient DISCUSSION: The infections caused by the Penicillium species are rare, and can presented as cutaneous, pulmonary or disseminated infections due to the fact that it is a ubiquitous fungus and the spores are easily disseminated. The diagnosis of P.chrysogenum was challenging due low suspicious, lack of knowledge of the immunosuppressive state of the patient, and low prevalence in an immunocompetent patient. The microbiological growth was achieved in lung tissue with the addition of the finding of the seminomatous germ cell neoplasia. We did not consider P.chrysogenum as a contaminating due to the presence of conidia and hyphae in the pericardial fluid and bronchial tissue. Treatment usually includes liposomal Amphotherecin-b, Itraconazole, Voriconazole, and the addition to removal of the source of infection. However, despite prompt interventions the prognosis is poor. CONCLUSIONS: P.chrysogenum is a rare, ubiquitous, oportunistic fungus that was unsuspected due to the lack of knowledge of the immunosuppression status of the patient and despite of the aggressive treatment, the outcome was fatal REFERENCE #1: Barcus AL, Burdette SD, Herchline TE. Intestinal invasion and disseminated disease associated with Penicillium chrysogenum. Ann Clin Microbiol Antimicrob [Internet]. 2005 Dec 21 [cited 2021 Apr 22];4:21. Available from: /pmc/articles/PMC1343575/ REFERENCE #2: Avilés-Robles M, Gómez-Ponce C, Reséndiz-Sánchez J, Rodríguez-Tovar AV, Ceballos-Bocanegra A, Martínez-Rivera Á. Disseminated penicilliosis due to Penicillium chrysogenum in a pediatric patient with Henoch–Schönlein syndrome. Int J Infect Dis. 2016 Oct 1;51:78–80. REFERENCE #3: Ramírez I, Hidrón A, Cardona R. Successful treatment of pulmonary invasive fungal infection by Penicillium non-marneffei in lymphoblastic lymphoma: case report and literature review. Clin Case Reports [Internet]. 2018 Jun 1 [cited 2021 Apr 22];6(6):1153–7. Available from: /pmc/articles/PMC5986030/ DISCLOSURES: No relevant relationships by Jose Aguilar, source=Web Response No relevant relationships by Jorge Luis Aguilar Castellanos, source=Web Response No relevant relationships by SARA BARILLAS, source=Web Response no disclosure on file for jose castillo; No relevant relationships by MARIA EUGENIA CHOC DE AJANEL, source=Web Response No relevant relationships by Jose Cifuentes, source=Web Response No relevant relationships by Cesar Conde-Pereira, source=Web Response No relevant relationships by Gabriel Rios, source=Web Response no disclosure on file for angel soto

Computed Tomography-Assisted Auricular Cartilage Graft for Depression of the Alar Base in Secondary Unilateral Cleft Lip Repair: A Preliminary Report.

To evaluate the feasibility, effectiveness, and safety of computed tomography-assisted auricular cartilage grafting for treating alar base depression secondary to unilateral cleft lip. For patients with obvious depression of the alar base, the difference in heights of the alar base and the piriform margin between the cleft side and the noncleft side were measured with computed tomography. If both were >3.0 mm, the cartilage was harvested postauricularly and subdivided into 2 to 4 pieces. A multiple layer graft was inserted under the depressed alar base. The procedure was performed from 2006 to 2013, and the follow-up period was 3 to 15 months. Chinese patients with alar base depression secondary to unilateral cleft lip were selected. Suture and cartilage graft techniques. Differences in bilateral alar base heights and piriform apertures. There was no wound dehiscence, exposure of bone, or donor site morbidity. The difference in heights in the bilateral alar bases and piriform apertures decreased. There were no obvious scars in any of the cases. This technique has several advantages including ease of operation, minimal trauma, satisfactory outcomes, and useful references for operation provided by computed tomography. It is a superior alternative for reconstruction of secondary alar depression.

Case 3: Respiratory Distress in a 3-Month-Old Boy

1. Nancy Tran, BA* 2. Harold S. Bernstein, MD, PhD† 3. Michael D. Cabana, MD, MPH‡ 1. *University of Vermont College of Medicine, Burlington, VT. 2. †Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY. 3. ‡Departments of Pediatrics, University of California San Francisco, San Francisco, CA. A 3-month-old boy whose parents say that he has been “breathing hard” for 1 day presents to the urgent care clinic. According to his parents, there is no history of fever, cough, or symptoms with feeding. Medical history includes a normal spontaneous vaginal delivery at 39 weeks. Immunizations are up to date. There are no sick contacts. His vital signs are as follows: temperature, 98.2°F (36.8°C); pulse, 168 beats per minute; respiratory rate, 70 breaths per minute; oxygen saturation in the right upper extremity is 100% in room air; and blood pressure was not obtained. Head circumference and length are in the 50th percentile, and weight is at the 25th percentile. On examination, he is well-appearing with adequate perfusion. Lungs are clear to auscultation. Pulses are good in all extremities. Abdomen is soft with a normal liver span. Cardiac examination reveals a hyperdynamic precordium with a rapid heart rate; normal S2 and splitting of S2 could not be heard because of the rapid heart rate. No murmurs or extra sounds are heard. Chest radiography reveals normal cardiothymic silhouette with an ill-defined, hazy opacification within the bilateral bases with obscuration of the right heart border and another opacification of the retrocardiac …

Pleural Effusion, Ascites, and Periportal Edema in the Absence of Fulminant Hepatic Failure Secondary to Nimesulide

Introduction: Nimesulide is a non-steroidal antinflammatory drug that has been associated with hepatoxicity leading to acute hepatitis, as well as fulminant hepatic failure. The mechanisms have been studied, but are still poorly understood. We hereby report the first case of nimesulide leading to ascites in the presence of bilateral pleural effusions in the absence of fulminate hepatic failure. Case Report: A 44-year-old Brazilian woman with no remarkable past medical history presented with sharp right upper quadrant epigastric pain following a recent 2-week trip to Brazil. She was visiting her family, who lived in a mountainous region and owned a farm that housed cows and pigs, but she did not have any direct contact with animals during her visit. However, she did drink local, unfiltered tap water. Prior to travel, she had sustained an ankle sprain and in Brazil; she was prescribed nimesulide 200 mg 3 tablets a day for 5 days. On presentation, she reported nausea with episodes of non-bloody emesis with body aches, chills, and weakness. On exam, she was afebrile with no scleral icterus. Abdomen was tender to palpation in the right upper quadrant, with positive Murphy’s sign. Her lungs exhibited absent to decreased breath sounds in the bilateral bases. Her white blood cell count was 7,600 per μL. Liver tests showed an AST 327 U/L and ALT 518 U/L. CT abdomen revealed large-volume ascites, periportal edema, and bilateral pleural effusions. Hepatitis A IgM antibody, hepatitis B core IgM antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis C, and hepatitis E antibodies were all negative. Anti-smooth muscle antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, and antimitochondrial antibodies were also negative. She subsequently underwent a transjugular liver biopsy, which was noted for acute lobular hepatitis with prominent zone 3 necrosis and a trans-sinusoidal gradient of 5 mm Hg. Additionally, a simultaneous diagnostic paracentesis was also obtained, which was significant for a SAAG gradient of 1.1. Further infectious work-up revealed a negative HIV, HSV, EBV, and CMV. Yellow fever, Strongyloides, Dengue fever, Leptospira, Schistosoma, and Brucella antibodies were also negative. Conclusion: There have been reports associating nimuselide with fulminant hepatic failure, but none involving nimuselide with pleural effusions and ascites without frank hepatic failure. Although the exact mechanism remains unclear, a clinician still needs to be aware of nimesulide as a possible cause of ascites and pleural effusion in spite of the absence of fulminant liver failure, as documented in our patient, and a thorough drug history is very pivotal.

Clinical management of acute interstitial pneumonia: a case report.

We describe a 51-year-old woman who was admitted to hospital because of cough and expectoration accompanied with general fatigue and progressive dyspnea. Chest HRCT scan showed areas of ground glass attenuation, consolidation, and traction bronchiectasis in bilateral bases of lungs. BAL fluid test and transbronchial lung biopsy failed to offer insightful evidence for diagnosis. She was clinically diagnosed with acute interstitial pneumonia (AIP). Treatment with mechanical ventilation and intravenous application of methylprednisolone (80 mg/day) showed poor clinical response and thus was followed by steroid pulse therapy (500 mg/day, 3 days). However, she died of respiratory dysfunction eventually. Autopsy showed diffuse alveolar damage associated with hyaline membrane formation, pulmonary interstitial, immature collagen edema, and focal type II pneumocyte hyperplasia.

Ultrasound in austere settings: a case report from a field hospital in Haiti

Abstract This case report from a field hospital in post-earthquake Haiti underscores the utility of portable ultrasound in austere environments. An 8-year-old boy was evaluated for several weeks of fevers and chills, general malaise, and increasing abdominal girth. He appeared ill with mild tachypnea, decreased breath sounds at bilateral lung bases, a distended abdomen with a palpable fluid wave, and bilateral pitting edema. This clinical picture was concerning for advanced schistosomiasis and ultrasound findings supported this presumptive diagnosis and helped direct treatment. Images from this case demonstrated several classic ultrasound findings described by the WHO including hepatosplenomegaly and diffuse fibrotic changes in the hepatobiliary and urogenital tracts. This case report demonstrates the effective use of portable ultrasound in making an accurate diagnosis and forming a definitive treatment plan for a patient in a resource-limited environment.

Fetal head anomaly restricted to the eye, the mandible, and the pterygoid process of the sphenoid: A histological study

A report on an unusual combination of anomalies in the head of a female fetus. The authors examined whole body semiserial paraffin sections of a female fetus (155 mm CRL; ∼18 weeks of gestation), with a particular focus on the head region. Cranial autonomic ganglia, nasal olfactory cells, and the orbital muscle were investigated using immunohistochemistry for tyrosine hydroxylase, vasoactive intestinal peptide, calretinin, and smooth muscle actin expression. The surface gross anatomy of the fetus appeared normal. The left eyeball lacked a lens (the eyeballs were otherwise normal). The orbital muscle was very thick and located in the anterolateral side of the extraocular muscles. Conversely, the extraocular muscles made a cluster in the superoposterior side of the orbit. The infratemporal fossa was small due to the bulky, transversely extended lateral pterygoid process in contrast to the small coronoid process of the mandible. The bilateral mandibular bases overlapped at the midline symphysis. The thin orbitosphenoid and thick alisphenoid provided an almost flat, anterior cranial base. Nasal olfactory cells and cranial autonomic ganglia appeared to be normal. No major anomaly was observed in the brain. Because of the changes in topographical anatomy, the orbital muscle probably lost its normal bony attachment and appeared to push the extraocular muscles superoposteriorly. A gene function redundancy rather than mutation may explain the present restricted anomalies in the mandible and pterygoid process.

Multifocal enhancing cortical lesions in a patient with Churg-Strauss syndrome

CNS involvement is rare in Churg-Strauss syndrome (CSS); only approximately 6 to 8% of patients with CSS have CNS complications.1,2 To date, only a few cases of CNS vasculitis in CSS have been described in detail. They usually consist of reports about cerebral infarctions, intracerebral hemorrhages, and subarachnoid hemorrhages.1–6 Herein, we describe a patient with CSS presenting as multifocal enhancing cortical lesions on MRI. ### Case report. A 62-year-old woman with a history of bronchial asthma for approximately 10 years was admitted to our hospital due to left-sided weakness and visual disturbance. The symptoms developed over 1 week, and were accompanied by multiple skin rashes, occasional fresh hematochezia, and worsening shortness of breath due to frequent attacks of asthma. Her examination was remarkable for erythematous maculopapules distributed over her abdomen and extensor surface of the lower extremities (figure, A), slight tachypnea with a room air saturation of 93%, and expiratory wheezing with inspiratory crackles at bilateral lung bases. Neurologic examination disclosed mild left hemiparesis and binocular blurred vision, especially in the central visual field. Figure Cutaneous lesions and brain MRI findings Multiple erythematous maculopapules are evident on the extensor surface of the lower extremities (A). Biopsy specimens obtained from the skin lesions demonstrated multiple foci of granulomatous angiitis (B) and dense perivascular eosinophilic infiltrates (C) in …

Competing Images and American Official Reconsiderations of China Policy, 1961&–1968

AbstractIn February 1972, President Richard Nixon made a historic visit to the People”s Republic of China (PRC), marking a Sino-American rapprochement and the beginning of the route to normalization of relations. This came more than twenty years after mainland China turned Communist and fought American-led United Nations forces in Korea. Thereafter, the United States had sought to ”contain“. Communist China by means of bilateral alliances and military bases in East Asia, and to isolate it by refusing to recognize the Communist regime. The next twenty years were marked by American opposition to UN membership for the PRC, three crises in the Taiwan Strait, much offensive rhetoric, and a proxy war in Vietnam. Thus it appeared in 1972 that Nixon had executed a dramatic reversal of U.S. China policy in ending this hostile estrangement.