Clinical Clues Research Articles

Scoring Systems to Evaluate the Mortality Risk of Patients with Emphysematous Cystitis: A Retrospective Observational Study

Emphysematous cystitis (EC) is a complicated urinary tract infection (UTI) characterized by gas formation within the bladder wall and lumen. Immunocompetent people are less likely to suffer from complicated UTIs, but EC usually occurs in women with poorly controlled diabetes mellitus (DM). Other risk factors of EC include recurrent UTI, neurogenic bladder disorder, blood supply disorders, and prolonged catheterization, but DM is still the most important of all aspects. Our study investigated clinical scores in predicting clinical outcomes of patients with EC. Our analysis is unique in predicting EC clinical outcomes by using scoring system performance. We retrospectively collected EC patient data from the electronic clinical database of Taichung Veterans General Hospital between January 2007 and December 2020. Urinary cultures and computerized tomography confirmed EC. In addition, we investigated the demographics, clinical characteristics, and laboratory data for analysis. Finally, we used a variety of clinical scoring systems as a predictor of clinical outcomes. A total of 35 patients had confirmed EC, including 11 males (31.4%) and 24 females (68.6%), with a mean age of 69.1 ± 11.4 years. Their hospital stay averaged 19.9 ± 15.5 days. The in-hospital mortality rate was 22.9%. The Mortality in Emergency Department Sepsis (MEDS) score was 5.4 ± 4.7 for survivors and 11.8 ± 5.3 for non-survivors (p = 0.005). For mortality risk prediction, the AUC of ROC was 0.819 for MEDS and 0.685 for Rapid Emergency Medicine Score (REMS). The hazard ratio of univariate and multivariate logistic regression analyses of REMS for EC patients was1.457 (p = 0.011) and 1.374 (p = 0.025), respectively. Physicians must pay attention to high-risk patients according to clinical clues and arrange imaging studies as soon as possible to confirm the diagnosis of EC. MEDS and REMS are helpful for clinical staff in predicting the clinical outcome of EC patients. If EC patients feature higher scores of MEDS (≥12) and REMS (≥10), they will have higher mortality.

Subcutaneous Granuloma Annulare vs. Subcutaneous Vascular Malformations in Children: A Diagnostic Challenge.

There are various subcutaneous lesions in children and often there is difficulty in obtaining an accurate diagnosis by non-invasive diagnostic procedures. Subcutaneous granuloma annulare (SGA) is a rare granulomatous disease that, even after imaging, is often mistaken for a low-flow subcutaneous vascular malformation (SVM). This study aimed to accurately identify clinical and imaging clues to distinguish SGA from low-flow SVM. We retrospectively analyzed complete hospital records of all children with a confirmed diagnosis of SGA and low-flow SVM who underwent MR imaging at our institution from January 2001 to December 2020. Their disease history, clinical and imaging findings, management, and outcome were evaluated. Among 57 patients with granuloma annulare, we identified 12 patients (nine girls) with a confirmed SGA diagnosis who underwent a preoperative MRI. Their median age was 3.25 years (range 2-5 years). Of 455 patients diagnosed with vascular malformations, 90 had malformations limited to the subcutaneous area. Among them only 47 patients with low-flow SVM were included in the study and further analyzed. Our SGA cohort had a female predilection (75%) and a short history of lump appearance of 1.5 months. SGA lesions were immobile and firm. Before MRI, patients underwent initial evaluation by ultrasound (100%) and X-ray (50%). Surgical tissue sampling was performed in all SGA patients to establish a diagnosis. All 47 patients with low-flow SVM were diagnosed correctly by MRI. A total of 45 patients (96%) underwent surgical resection of the SVM. A careful retrospective review of imaging findings of patients with SGA and SVM showed that SGA present as homogenous lesions in the shape of an epifascial cap with a typical broad fascial base extending towards the subdermal tissue in the middle of the lesion. In contrast, SVMs always present with variable-sized multicystic or tubular areas. Our study shows clear clinical and imaging differences between low-flow SVMs and SGA. SGA presents characteristically in the shape of a homogenous "epifascial cap," which distinguishes these lesions from multicystic heterogenous SVMs.

A novel clinical sign to assess the risk of Parkinson's disease in patients with isolated asymmetric arm swing.

An isolated asymmetric arm swing can represent the beginning of Parkinson's disease (PD) but also be related to physiological or non-specific musculoskeletal pathology. In this brief clinical observation including 15 patients with asymmetric arm swing, we provide a new clinical clue to evaluate the risk of subjacent parkinsonism. Among non-parkinsonian subjects, the immobilization of the contralateral arm, by asking the patient to put his hand on the contralateral shoulder, induced a clear increase in the amplitude of the arm swing, whereas in PD patients, the arm swing amplitude did not significantly vary when the contralateral upper limb was immobilized. This novel clinical sign may be helpful when approaching patients with gait abnormalities and specifically reduced arm swing.

Long-term follow-up of changes in ocular biometric parameters in orthokeratology lens wearers with relatively large-scale axial length reduction

BackgroundTo investigate ocular biological characteristics for myopic children with axial length (AL) reduction during orthokeratology (Ortho-K) treatment and provide clinical clues for better myopia control effects.MethodsChanges in ocular parameters and treatment zone (TZ) in 75 subjects who completed one-year Ortho-K treatment were retrospectively reviewed. The subjects were divided into two groups according to one-year AL change: the AL reduction group (n = 37) and the AL elongation group (n = 38). Univariate and multivariate regression analyses were performed to determine the association between TZ, ocular parameters, and AL change.ResultsThere was no significant difference in baseline between the two groups (all P > 0.05). After one year of Ortho-K treatment, compared with those in the AL elongation group, children in the AL reduction group had a decreased anterior chamber depth (ACD) (P < 0.001), thickened crystalline lens thickness (CLT) (P = 0.002), thinned vitreous chamber depth (VCD) (P < 0.001) and smaller TZ (P = 0.03), but no difference in central corneal thickness (CCT) and pupil diameter (PD). In the multivariable analyses, AL reduction was negatively associated with baseline age (beta: − 0.048; 95% CI: − 0.083 to − 0.013; P = 0.009) and positively associated with the TZ (beta: 0.024; 95% CI: 0.009 to 0.040; P = 0.003).ConclusionsIn AL reduction eyes, thickened CLT, decreased ACD and thinned VCD were observed during Ortho-K treatment, which could be suggested as indicators for better myopia control effects in the clinic. Older baseline age and smaller TZ wearing Ortho-K were also associated with AL change. Thickened CLT may be a result of compensation for AL-reduction eyes.

Body Imaging of Bacterial and Parasitic Zoonoses: Keys to Diagnosis.

Zoonotic infections, which are transmitted from animals to humans, have been a substantial source of human disease since antiquity. As the human population continues to grow and human influence on the planet expands, humans frequently encounter both domestic and wild animals. This has only increased as deforestation, urbanization, agriculture, habitat fragmentation, outdoor recreation, and international travel evolve in modern society, all of which have resulted in the emergence and reemergence of zoonotic infections. Zoonotic infections pose a diagnostic challenge because of their nonspecific clinical manifestations and the need for specialized testing procedures to confirm these diagnoses. Affected patients often undergo imaging during their evaluation, and a radiologist familiar with the specific and often subtle imaging patterns of these infections can add important clinical value. The authors review the multimodality thoracic, abdominal, and musculoskeletal imaging findings of zoonotic bacterial (eg, Bartonella henselae, Pasteurella multocida, Francisella tularensis, Coxiella burnetii, and Brucella species), spirochetal (eg, Leptospira species), and parasitic (eg, Echinococcus, Paragonimus, Toxocara, and Dirofilaria species) infections that are among the more commonly encountered zoonoses in the United States. Relevant clinical, epidemiologic, and pathophysiologic clues such as exposure history, occupational risk factors, and organism life cycles are also reviewed. Although many of the imaging findings of zoonotic infections overlap with those of nonzoonotic infections, granulomatous diseases, and malignancies, radiologists' familiarity with the imaging patterns can aid in the differential diagnosis in a patient with a suspected or unsuspected zoonotic infection. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

EYES THAT LOOK DOWN AND OUT A CASE SERIES ON ISOLATED THIRD NERVE PALSY

Introduction:Isolated oculomotor nerve palsy (ONP) is quite common in general practice. Various causes of ONP have been described in several studies, for instance ischemia, compression from aneurysm or tumor, and trauma. Ischemia was the most common etiology with spontaneous recovery, and it was presumed based on some helpful clinical clues before imaging became available. Materials &amp; Methods:This study comprises of 10 patients with oculomotor nerve palsy who attended regional eye hospital, Kurnool, during my study period of 6 months from 01/02/2022 to 31/07/2022. Patients presented to OPD with complaints of diplopia and drooping of upper eyelid. Patients subjected to VA for distant and near vision, slit-lamp examination, pupillary reactions, extraocular motility, fundus examination, diplopia charting for distant and near vision, hess charting, visual field testing and IOP. Blood pressure, blood sugar profile, lipid profiles were monitored and referred to concerned departments. They were advised for CT and MRI scans to know the etiological cause. Results:Out of 10 patients, DM - 3, CVA due to Hypertension - 1, ocular tuberculosis - 1, mucormycosis - 1, pseudotumor - 1, trauma - 1, unknown etiology - 2. Conclusion: Patients with diabetes has a good recovery rate. We recommend that the patients with oculomotor nerve palsy be carefully examined clinically in a multidisciplinary approach for early diagnosis and treatment.

Periictal water drinking revisited: Occurrence and lateralizing value in surgically confirmed patients with focal epilepsy.

Periictal water drinking (PIWD), which is a rare seizure-related autonomic behavior, has been reported in temporal lobe epilepsy (TLE) but only rarely in extra-TLE. Additionally, the lateralizing value of PIWD is controversial. We aimed to clarify the occurrence and lateralizing value of PIWD in patients with focal epilepsy. This retrospective study included 240 focal epilepsy patients aged >10 years with a favorable postoperative seizure outcome (Engel class I). PIWD was defined as water drinking behavior during a seizure or within 2 min in the postictal phase. The occurrence of PIWD documented on video-electroencephalogram monitoring was assessed. The lateralizing value of PIWD was analyzed among patients whose language dominant hemisphere was identified. Twenty-three (9.5%) patients exhibited PIWD. PIWD occurred more frequently in frontal lobe epilepsy (FLE; eight of 41 patients, 19.5%) than in TLE (15 of 188 patients, 8%). The occurrence of PIWD was significantly different between FLE and extra-FLE (P=0.035), with a low positive predictive value (34.8%). In FLE with PIWD, all but one patient underwent resective surgery involving the medial frontal lobe. In 194 patients whose language dominant hemisphere was determined, the lateralizing value of PIWD in FLE and TLE showed no statistical significance (P=0.69 and P=0.27, respectively). Periictal water drinking occurred more often in FLE than TLE. Thus, PIWD might not be a specific periictal symptom in TLE. There was no evidence for the lateralizing value of PIWD in FLE and TLE. These findings can provide useful clinical clues for preoperative evaluations to estimate the epileptogenic zone based on seizure semiology and allow for a better understanding of pathophysiological insights into PIWD.

Small airway disease: A new “phenotype” of obstructive airway disease

Small airways are usually defined as noncartilaginous airways with an internal diameter &lt;2 mm. Robust data are available regarding small airway involvement in various obstructive airway diseases such as bronchial asthma and chronic obstructive pulmonary disease (COPD). Small airway disease (SAD) can present as a starting point of emphysema, and in few cases, SAD can present with emphysema. Thus, SAD in COPD is a different phenotype along with emphysema and chronic bronchitis. Although bronchial asthma is a disease of large and medium size airways, small airway involvement has been documented in asthma in late stage. Involvement of small airways in asthma is a clinical clue toward the role of inhaled antimuscarinic therapy in this phenotype. Spirometry is a simple and cost-effective but less reliable test to diagnose SAD in comparison to impulse oscillometry. Inhalation therapy with small particle size aerosol long-acting beta-agonist plus inhaled corticosteroids is recommended for treatment of SAD. Targeting small airways in asthma and COPD with ultrafine particle-size inhaled medicines with antimuscarinic drugs will have a successful treatment outcome.

Delirium superimposed on dementia. Clinical practice and perspectives

Delirium is a commonly encountered syndrome in clinical practice. Older people with cognitive disorders are most at risk of developing delirium during the hospital stay. However, the risk of underdiagnosis is significant, particularly because of the overlap of behavioral symptoms and cognitive impairment between delirium and dementia. With an aging population and an ever-increasing prevalence of cognitive disorders, this article exposes the bilateral relationship maintained between dementia and delirium and bring certain diagnostic tools and clinical management clues to support the clinician. Finally, the perspectives of ongoing clinical research that could respond to current challenges are discussed.

Clinical and Imaging Clues of Arteriopathy-Related Pediatric Arterial Ischemic Stroke: A Single Center Experience.

Arteriopathy is a common etiology for childhood arterial ischemic stroke (AIS). In this study, we aimed to address clinical, demographic, and neuroimaging characteristics and the reversibility of vasculopathy in patients with childhood stroke due to arteriopathy by classifying them according to Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria. We included 15 patients with AIS due to arteriopathy presented between 2013 and 2018. All patients were diagnosed and followed up using magnetic resonance imaging (MRI) studies. All acute AIS patients were classified by acute CASCADE criteria (1-4). Moreover, each group was categorized according to the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate courses. In the study population, CASCADE 2 patients were the most common group, and basal ganglia involvement was the most common involvement in CASCADE 2 patients. Of CASCADE 2 patients, 71.4% received steroids, which was compatible with a favorable outcome. In the study, trauma was present in 33.3% of patients, 60% of which was related to CASCADE 4. In the control visit on month 24, there were neuromotor sequelae of 60%, including hemiparesis, facial paralysis, and decreased fine motor skills; furthermore, the recurrence rate was 20%. We strongly emphasize that arteriopathy should be kept in mind in school-age children presenting with hemiparesis and headache. Moyamoya disease must be considered in the differential diagnosis with anterior circulation involvement, while focal cerebral arteriopathy (FCA) in patients with basal ganglia involvement was detected on MRI and dissection in the patients with a history of head-neck injury. We think that steroids have positive influences on neurologic prognosis in patients with FCA.

Effect of high volume enema in children with abdominal pain: Pediatric emergency department experience.

Abdominal pain is one of the most common reasons for admission to the pediatric emergency clinic. The appropriate evaluation of clinical and laboratory clues to make the correct diagnosis is of great importance in terms of directing the treatment medically or surgically and preventing unnecessary investigations. The aim of our study was to evaluate the contribution of high-volume enema application among pediatric patients with abdominal pain in terms of clinical and radiological findings. Among the pediatric patients who applied to the pediatric emergency clinic of our hospital between January 2020 and July 2021 with abdominal pain, those who had intense gas stool image on abdominal X-ray and abdominal distension on physical examination and who underwent high-volume enema treatment were included in the study. The physical examination and radiological findings of these patients were evaluated. During the study period, 7819 patients were admitted to the pediatric emergency outpatient clinic with abdominal pain. Classic enema was performed in 3817 of these patients who had a dense gaseous stool image and abdominal distention on abdominal X-ray graphy. Defecation occurred in 3498 (91.6%) of 3817 patients who underwent classical enema, and the complaints regressed after enema. High-volume enema was applied to 319 (8.4%) patients who did not find relief with classical enema. Complaints of 278 (87.1%) patients regressed after the high-volume enema. Control ultrasonography (US) was performed in the remaining 41 (12.9%) patients, 14 (34.1%) patients were diagnosed with appendicitis. US results of 27 (65.9%) patients who had repeated US were evaluated as normal. High volume enema treatment is an effective and safe method in children with abdominal pain who are unresponsive to classical enema application in the pediatric emergency department.

Primary Immunodeficiencies in Children Initially Admitted with Gastrointestinal/Liver Manifestations.

The gastrointestinal system is the most commonly affected organ, followed by the lungs, in patients with primary immunodeficiency disease (PID). Hence, it is common for children with PIDs to present with gastrointestinal symptoms. We aimed to analyze the clinical and histopathological findings of patients who were initially admitted to pediatric gastroenterology/hepatology clinics and subsequently diagnosed with PIDs to identify the clinical clues for PIDs. The demographic, laboratory, and histopathological findings, treatment modality, and outcomes of patients initially admitted to the pediatric gastroenterology/hepatology unit and subsequently diagnosed with PIDs were recorded. The study included 24 patients (58.3% male; median age [range]: 29 [0.5-204] months). Common clinical presentations included chronic diarrhea (n=8), colitis (n=6), acute hepatitis (n=4), and acute liver failure (n=2). The association of autoimmune diseases, development of malignant diseases, and severe progression of viral diseases was observed in 20.8%, 8.3%, and 16.6% of the patients, respectively. Antibody deficiency was predominantly diagnosed in 29.2% of patients, combined immunodeficiency in 20.8%, immune dysregulation in 12.5%, defects in intrinsic and innate immunity in 4.2%, autoinflammatory disorders in 8.3%, and congenital defects of phagocytes in 4.2%. Five patients remained unclassified (20.8%). Patients with PIDs may initially experience gastrointestinal or liver problems. It is recommended that the association of autoimmune or malignant diseases or severe progression of viral diseases provide pediatric gastroenterologists some suspicion of PIDs. After screening using basic laboratory tests, genetic analysis is mandatory for a definitive diagnosis.

P235: Cerebellar ataxia with hypogonadism: Clinical clues to diagnosis adult PMM2-CDG patients

P235: Cerebellar ataxia with hypogonadism: Clinical clues to diagnosis adult PMM2-CDG patients

Novel Treatments for Chronic Ocular Surface Pain.

Several etiologies can contribute to ocular surface pain including nociceptive, peripheral neuropathic, and central neuropathic mechanisms. Clinical clues can help identify contributors to ocular surface pain in a patient. In individuals whose pain persists despite targeting nociceptive contributors, neuropathic mechanisms should be considered and addressed using oral, topical, and/or adjuvant agents.

Central sensitization in osteoarthritic knee pain: A cross-sectional study.

The aim of this study was to investigate central sensitization and associated factors in knee osteoarthritis (OA) patients and compare them with rheumatoid arthritis (RA) patients and healthy controls. This cross-sectional study was conducted with 125 participants (7 males, 118 females; mean age: 57.2±8.2 years; range, 45 to 75 years) between January 2017 and December 2018. Sixty-two patients with symptomatic knee OA, 32 RA patients with knee pain, and 31 healthy controls constituted the participants. Central sensitization was investigated with the Central Sensitization Inventory (CSI) and pressure pain threshold (PPT) measurements. Pain, functional status, and psychosocial features were assessed with self-reported questionnaires. The OA and RA groups had significantly lower PPT values at local, peripheral, and remote regions compared to the healthy controls. Pressure hyperalgesia was shown at the knee with a 43.5% prevalence, 27.4% at the leg, and 8.1% at the forearm of OA patients. Pressure hyperalgesia was present at the knee, leg, and forearm in 37.5%, 25%, and 9.4% of RA patients, respectively. Pressure pain threshold values, CSI scores, frequency of pressure hyperalgesia, and frequency of central sensitization according to the CSI were not statistically different between the OA and RA groups. Psychosocial features and structural damage were not correlated with PPT values in the OA group. The severity of chronic pain and functional status may be the clinical clues to recognizing patients with central sensitization since local joint damage does not play a direct role in the etiopathogenesis of central sensitization in OA patients and severe pain persisting in the chronic process is associated with central sensitization regardless of the pathogenesis.

Dystonia, Chorea, and Ataxia: Three Challenging Cases

Movement disorders comprise a heterogeneous and complex group of neurological disorders that increase (hyperkinetic) or decrease (hypokinetic) the speed or amplitude of movements, or disrupt their coordinated sequencing. In this article, we describe three instructive cases, exemplifying classic movement disorders, namely dystonia, chorea, and ataxia. We highlight the diagnostic approach based on clinical clues, syndromic reasoning, evaluation, and management recommendations. Each case ends with key messages for the clinicians.

3MC syndrome: molecular findings in previously reported and milder patients expand the natural history and phenotypic spectrum.

The 3MC syndromes types 1-3 (MIM#257920, 265050 and 248340, respectively) are rare autosomal recessive genetic disorders caused by pathogenic variants in genes encoding the lectin complement pathway. Patients with 3MC syndrome have a distinctive facial phenotype including hypertelorism, highly arched eyebrows and ptosis. A significant number of patients have bilateral cleft lip and palate and they often exhibit genitourinary and skeletal anomalies. A clinical clue to 3MC syndrome is the presence of a characteristic caudal appendage. Genetic variants in MASP1, COLEC11 and COLEC10 genes have been identified as the causation of this syndrome, yet relatively few patients have been described so far. We consolidate and expand current knowledge of phenotypic features and molecular diagnosis of 3MC syndrome by describing the clinical and molecular findings in five patients. This includes follow-up of two brothers whose clinical phenotypes were first reported by Crisponi et al in 1999. Our study contributes to the evolving clinical and molecular spectrum of 3MC syndrome.

Abstract #1321651: Diagnosing Celiac Disease by Two Distinct Nail Signs in Patients With Hashimoto Thyroiditis: Case Series

Celiac disease is associated with other autoimmune disorders including autoimmune hypothyroidism. Celiac disease should be considered in those with resistant hypothyroidism as it may affect levothyroxine absorption. The author reports 2 cases of resistant hypothyroidism secondary to celiac disease in which clinical clues for the diagnosis were elicited by examination of the hands which showed 2 distinct signs. The first case was a 23-year-old male who presented with resistant hypothyroidism and was found to have finger clubbing that led to the diagnosis of celiac disease.

Quotidian Fever in Secondary Hemophagocytic Lymphohistiocytosis Due to Diffuse Large B-Cell Lymphoma: A Case Report

Hemophagocytic lymphohistiocytosis (HLH) is a highly fatal syndrome characterized by excessive abnormal activation of the immune system. Fever is the most encountered clinical feature and is found in 100% of HLH cases (Al-Samkari & Berliner, 2018) Fever patterns can be an important clinical clue in certain diseases but have not been described in HLH. We report a 74-year-old Caucasian female patient who presented with fever, fatigue, and dyspnea on exertion of 2 months duration. On examination, she was found to be febrile, hypoxic, and disoriented. Initial laboratory workup was significant for normocytic anemia (6.3 g/dl) with severely elevated Ferritin (1501 µg/dL). Infectious and autoimmune workup was negative. Full body CT scan was negative for malignancy or lymphadenopathy but showed mild splenomegaly. The hospital course was complicated by worsening respiratory status despite empiric antibiotic treatment. She was noted to have persistent daily fever spikes in the early hours of the morning. This prompted workup for HLH which revealed rising serum ferritin, hypertriglyceridemia, elevated soluble IL-2 and low NK cell activity receptors, fulfilling the criteria of HLH. Bone marrow aspirate revealed clonal CD20 positive lymphocyte diagnostic of DLBCL as the trigger for HLH. The patient was started on HLH protocol and mini R-CHOP protocol with marked improvement in her symptoms and anemia. Little is known about the patterns of fever in HLH patients. Before this case, two other case reports described quotidian fever in HLH (Kouides et al., 2021; Henter et al., 2007). interestingly both were cases of secondary HLH. This case illustrates the possible association between HLH and quotidian fever and proposes the possibility of quotidian fever being a clinically important clue to secondary causes of HLH. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Teaching NeuroImage: Mobile Hypopyon as a Clinical Clue for the Diagnosis of Behçet Disease.

Teaching NeuroImage: Mobile Hypopyon as a Clinical Clue for the Diagnosis of Behçet Disease.