Distal Extremity Involvement Research Articles

Role of Skeletal Scintigraphy in Evaluation of Low Backache in Treated Cases of Carcinoma Cervix

The presence of bone metastases indicates advanced disease in cervical cancer. Lumbar spine is the most common site affected followed by pelvis with rare involvement of distal extremities. Low back ache in these patients has wide spectrum of etiologies including benign conditions like musculoskeletal causes, inflammatory, Infectious and metastatic spread of disease. In this study, we evaluated the causes of low back ache in treated cases of carcinoma cervix based on different patterns of radio tracer uptake on 99m Tc Methylene diphosphonate (99m Tc MDP) bone scan.To evaluate the role of 99m Tc MDP bone scan in differential diagnosis of low back ache in treated cases of carcinoma cervix. 99m Tc MDP bone scans of treated carcinoma cervix patients presenting with low back ache were reviewed retrospectively from May 2012 to May 2016. A total of 120 patients were reviewed, 99m Tc MDP bone scan detected metastases in 69 (57.5%) patients, degenerative changes in 26 (21.6%) patients, insufficiency fractures in 13 (10.8%) patients, erosion from adjacent nodal mass in 4 (3.3%) patients. No abnormality was detected on bone scan in 8 patients (6.6%). Skeletal scintigraphy plays a vital role in the evaluation of low back ache in carcinoma cervix and changes management in significant proportion of patients. Pattern recognition especially in identifying insufficiency fractures and erosion of bone from adjacent nodal mass is an important aspect in the interpretation of skeletal scintigraphy.

Adult-onset Idiopathic Focal Lower Extremity Dystonia: A Rare Task-Specific Dystonia

<strong>Background:</strong> Adult-onset focal lower extremity (LE) dystonia is rare, but there have recently been a number of case series that have reported an idiopathic variant triggered during ambulation. <strong>Methods:</strong> We describe nine patients with idiopathic, focal task-specific LE dystonia. We conducted a comparative analysis that included our cohort and several recently published case series to further characterize the disorder. <strong>Results:</strong> A total of 48 patients (37 female, 11 male) were compared. The average age of onset was 48 years; 36 patients had distal extremity involvement (75%), 5 proximal (10%), and 7 both proximal and distal (15%). Among 33 patients in which the dystonic side was known, 20 were affected on the left (61%). Inversion of the foot with flexion of one or more toes was the most prevalent pattern in those with distal extremity involvement. <strong>Discussion:</strong> This is a novel task-specific dystonia triggered during ambulation that is often misdiagnosed as an orthopedic or psychogenic issue.

Adult-onset Idiopathic Focal Lower Extremity Dystonia: A Rare Task-Specific Dystonia.

Adult-onset focal lower extremity (LE) dystonia is rare, but there have recently been a number of case series that have reported an idiopathic variant triggered during ambulation. We describe nine patients with idiopathic, focal task-specific LE dystonia. We conducted a comparative analysis that included our cohort and several recently published case series to further characterize the disorder. A total of 48 patients (37 female, 11 male) were compared. The average age of onset was 48 years; 36 patients had distal extremity involvement (75%), 5 proximal (10%), and 7 both proximal and distal (15%). Among 33 patients in which the dystonic side was known, 20 were affected on the left (61%). Inversion of the foot with flexion of one or more toes was the most prevalent pattern in those with distal extremity involvement. This is a novel task-specific dystonia triggered during ambulation that is often misdiagnosed as an orthopedic or psychogenic issue.

Rhabdomyosarcoma with Bone Marrow Infiltration: A Diagnostic Dilemma

Rhabdomyosarcoma is the most common soft tissue sarcoma in children and adolescents. In adults, the prevalence is much lower. Most patients present with a mass in the head and neck region, urogenital region or even with distal extremity involvement. A bone marrow infiltration at the time of clinical presentation has also been documented in literature. But a simultaneous marrow infiltration can simulate a hematopoietic neoplasm, leading to diagnostic errors. We document one such challenging case of a 47 year old male patient presenting with bicytopenia. Patient was hospitalized following a referral due to a mass in the left cheek, diagnosed earlier as clear cell sarcoma. Bone marrow aspirates yielded a dry tap, with sinusoidal blood and both the aspirate as well as the imprint smear showed pleomorphic cells with vacuolated cytoplasm. The corresponding trephine biopsy showed diffuse and interstitial infiltrates of rhabdoid cells with focal areas of infarct. Considering the morphological details, a diagnosis of rhabdomyosarcoma was rendered after ruling out other possibilities. A review of the lesional biopsy with ancillary techniques eventually corroborated the bone marrow diagnosis.

Acute lower limb ischemia is a frequent complication of severe diabetic hyperosmolarity

Aim To describe the outcome of intensive care unit (ICU) patients admitted with a hyperglycaemic hyperosmolar non-ketotic syndrome (HHNS), with a specific analysis of precipitating conditions and complications including lower limb ischemia. Methods Retrospective review of patients admitted in a university-hospital ICU for HHNS. Results Seventeen consecutive patients (9F/8M, age: 75 years [57–81] (median [25–75% percentiles], Glasgow Coma score: 13 [12–14]) were admitted for HHNS over an 8-year period (1998–2005). On admission, the blood glucose level was 40.0 mmol/l [26.3–60.8], the corrected serum sodium concentration 167 mmol/l [158–174], and the calculated plasma osmolarity 384 mosmol/l [365–405]. All the patients presented with renal failure due to severe dehydration. An infection was identified as the precipitating factor in 8/17 cases. Three (18%) patients died in the ICU. Non-survivors were significantly older than survivors ( P = 0.02). Using univariate analysis, no other parameter measured on admission was related to mortality. Four patients (24%) presented with lower limb ischemia. They had a significantly more elevated blood urea nitrogen ( P = 0.03), creatinine phosphokinase level ( P = 0.04), and leukocyte count ( P = 0.02). The bilateral, symmetrical, and distal extremity involvement suggested diminished blood flow due to hyperviscosity, hypotension, vasoconstrictors, or cholesterol emboli rather than a proximal arterial obstruction as causative mechanisms. No patient was treated surgically. Ischemia reversed with fluid loading and resulted in toe dry digital necrosis. Conclusion HHNS is a rare but life-threatening cause of ICU admission. There is a high incidence of lower limb ischemia in HHNS patients, which may be related to dehydration and blood hyperviscosity.

Clinical presentations of chlamydial and non-chlamydial reactive arthritis

The aim of this study was to investigate the triggering micro-organisms and the clinical as well as laboratory differences between Chlamydial and non-chlamydial reactive arthritis (ReA) in a prospective study on 98 patients with acute/subacute arthritis. An inciting organism was found in 42 patients. Eighteen of these were chlamydial. Fifty-seven percent of all ReA patients were carriers for HLA-B27, which increased to 67% in the chlamydial group. Chlamydial ReA patients had more urethritis (P<0.05) with a longer period between arthritis and inciting infection, significantly lower CRP levels, and involved joint counts (P<0.05). Additionally, sacroiliitis was more frequent besides extra-articular manifestations in chlamydial ReA group. This study shows that chlamydial ReA differs in some points from non-chlamydial ReA, which in turn may affect the evaluation of an arthritic patient. ReA due to chlamydia more frequently encompasses a monoarticular or oligoarticular clinical picture with predominant distal extremity involvement. Non-chlamydial ReA presents higher joint counts and may involve upper extremity joints.

Complex regional pain syndrome-like symptoms during herpes zoster

Complex Regional Pain Syndrome (CRPS) associated with herpes zoster (HZ) was first reported by Sudeck in 1901 (Sudeck, 1901) and is recognized clinically. However, only 13 cases have been published in the literature, and nothing is known about the incidence, prevalence, or natural history (Chester, 1992; Foster et al., 1989; Grosslight et al., 1986; Ketz and Schliack,1968; Kishimoto et al., 1995; Querol and Cisneros, 2001; Sudeck, 1901; Visitsunthorn and Prete, 1981). The aim of the present study was to determine the prevalence of CRPS-like symptoms in a prospectively gathered cohort of subjects with HZ and to follow the natural history of their pain and sensory disturbance during the first 6 months after onset of HZ. Subjects were evaluated at four time points after HZ: 2–6 weeks, 6–8 weeks, 3 months, and 6 months. Only subjects aged 50 or older with pain VAS ratings of ≥20/100 at 2–6 weeks were eligible. The first (screening) visit included a neurological and physical examination that was updated at each subsequent visit. Assessments included ratings of pain intensity, allodynia severity, and rash severity. The neurological exam included determination of presence or absence of the following CRPS-like symptoms: (1) increased sweating, (2) color changes, (3) skin temperature changes, (4) weakness of the affected area based on physical exam, (5) edema, and (6) extension of CRPS-like symptoms outside the affected dermatome. For subjects with HZ in dermatomes that can include the limbs (C4–T2 and L1–S2), extremity involvement was considered present if allodynia or rash extended beyond the neck of the humerus (upper extremity), the inguinal ligament (anterior lower extremity), or gluteal sulcus (posterior lower extremity). Involvement of the extremity was considered proximal if neither HZ rash nor allodynia extended past the elbow (upper extremity) or knee (lower extremity). Of the first 75 subjects recruited, 25 had HZ outbreaks in dermatomes that extended into the extremities (C4–T2 and L1–S2). In this group, 8 subjects had no extremity involvement, 8 had proximal extremity involvement, and 9 had distal extremity involvement. Subjects with distal extremity HZ reported more pain across the four visits ( p<0.05). At 3 months, more subjects with distal extremity involvement met criteria for PHN (8 out of 9, 89%), while only 4 out of 8 (50%) with proximal involvement and 2 out of 8 (25%) of subjects without extremity involvement met criteria for PHN (Chi-square test: p<0.05). Only 25 out of the remaining 50 (50%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN at 3 months (Chi-square test: p<0.05). Six months after onset of HZ, 6 out of 9 subjects with distal extremity involvement met PHN criteria compared with 2 out of 8 (25%) with proximal involvement and 2 out of 8 (25%) without extremity involvement (Chi-square test: p=0.12). Fifteen out of 50 (30%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN (Chi-square test: p<0.05). No subject had all six CRPS-like symptoms. Of the 17 subjects with extremity involvement, 9 subjects had ‘0–2 CRPS-like symptoms’ and 8 had ’3–5 CRPS-like symptoms’. None of the eight subjects without extremity involvement had any CRPS-like symptoms. Of the 50 subjects with HZ outside the extremity, only one had abdominal weakness. Pain ratings were higher in subjects with ‘3–5 CRPS-like symptoms’. More subjects with ‘3–5 CRPS-like symptoms’ met criteria for PHN at 3 months (7 out of 8, 88%), compared to 5 out of 9 (55%) of subjects with ‘0–2 CRPS-like symptoms’ ( p=0.07). At 6 months, 2 out of 9 (22%) of subjects with ‘0–2 CRPS-like symptoms’ met criteria for PHN, compared with 6 out of 8 (75%) of subjects with ‘3–5 CRPS-like symptoms’ (Chi-square test: p<0.03). Two case-reports are presented. In summary, the occurrence of CRPS-like symptoms is common in subjects with HZ outbreaks affecting the extremity, particularly if the distal extremity is involved. It is uncertain if the pathophysiology underlying the CRPS-like symptoms observed in this study is similar to that of CRPS from other causes, or if it is relatively specific to HZ. Development of PHN is common in subjects who have experienced CRPS-like symptoms. More aggressive preventive treatments may be justified in this high-risk subset of HZ subjects to prevent development of PHN. Prospective randomized controlled studies are needed to determine which subjects are most likely to benefit and when treatment should begin.

Juvenile hyaline fibromatosis of the hand in an adult

the literature since his original description. 1-s In the case presented here, a non-Hodgkin’s IU1 T-cell lymphoma is documented. This case has several unique aspects: (1) The tumor growth was aggressive. (2) Distal extremity involvement is rare. In fact, no prior forearm presentations could be located in the literature. (3) This is the youngest patient in whom extranodal primary skeletal muscle infiltration has been reported. (4) Despite complex radiographic analysis (magnetic resonance imaging), muscular infiltration is difficult to assess. No discrete mass was identified. Plain x-ray films are frequently nonspecific or normal.‘-5 Cytochemistry and immunohistochemistry studies are essential for the diagnosis of extranodal lymphoma. Differentiation between carcinoma, sarcoma, and lymphoma by light microscopy alone is not reliable. Treatment is still controversial. Type and staging are critical to therapeutic options. Chemotherapy and radiotherapy should be first-line treatment. Decompressive fasciotomies forced operative therapy in the case presented here. Loss of function, nerve exposure, tissue and scar contracture, proximal tumor extension, early need to begin chemotherapy, and the fact that the patient was a poor candidate for reconstruction/rehabilitation prompted selection of above-elbow amputation over attempts at reconstruction. Earlier presentation and identification of the lymphoma by soft tissue biopsy would have allowed management with systemic therapy alone. Oncologic suspicions must be included in the differential diagnosis. Muscle debulking should not be performed routinely. A heightened awareness is necessary when one is dealing with muscular infiltration to the upper extremity.

Three body collisions in an ionized gas

Complex Regional Pain Syndrome (CRPS) associated with herpes zoster (HZ) was first reported by Sudeck in 1901 (Sudeck, 1901) and is recognized clinically. However, only 13 cases have been published in the literature, and nothing is known about the incidence, prevalence, or natural history (Chester, 1992; Foster et al., 1989; Grosslight et al., 1986; Ketz and Schliack,1968; Kishimoto et al., 1995; Querol and Cisneros, 2001; Sudeck, 1901; Visitsunthorn and Prete, 1981). The aim of the present study was to determine the prevalence of CRPS-like symptoms in a prospectively gathered cohort of subjects with HZ and to follow the natural history of their pain and sensory disturbance during the first 6 months after onset of HZ.Subjects were evaluated at four time points after HZ: 2–6 weeks, 6–8 weeks, 3 months, and 6 months. Only subjects aged 50 or older with pain VAS ratings of ≥20/100 at 2–6 weeks were eligible. The first (screening) visit included a neurological and physical examination that was updated at each subsequent visit. Assessments included ratings of pain intensity, allodynia severity, and rash severity. The neurological exam included determination of presence or absence of the following CRPS-like symptoms: (1) increased sweating, (2) color changes, (3) skin temperature changes, (4) weakness of the affected area based on physical exam, (5) edema, and (6) extension of CRPS-like symptoms outside the affected dermatome. For subjects with HZ in dermatomes that can include the limbs (C4–T2 and L1–S2), extremity involvement was considered present if allodynia or rash extended beyond the neck of the humerus (upper extremity), the inguinal ligament (anterior lower extremity), or gluteal sulcus (posterior lower extremity). Involvement of the extremity was considered proximal if neither HZ rash nor allodynia extended past the elbow (upper extremity) or knee (lower extremity). Of the first 75 subjects recruited, 25 had HZ outbreaks in dermatomes that extended into the extremities (C4–T2 and L1–S2). In this group, 8 subjects had no extremity involvement, 8 had proximal extremity involvement, and 9 had distal extremity involvement. Subjects with distal extremity HZ reported more pain across the four visits (p<0.05). At 3 months, more subjects with distal extremity involvement met criteria for PHN (8 out of 9, 89%), while only 4 out of 8 (50%) with proximal involvement and 2 out of 8 (25%) of subjects without extremity involvement met criteria for PHN (Chi-square test: p<0.05). Only 25 out of the remaining 50 (50%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN at 3 months (Chi-square test: p<0.05). Six months after onset of HZ, 6 out of 9 subjects with distal extremity involvement met PHN criteria compared with 2 out of 8 (25%) with proximal involvement and 2 out of 8 (25%) without extremity involvement (Chi-square test: p=0.12). Fifteen out of 50 (30%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN (Chi-square test: p<0.05).No subject had all six CRPS-like symptoms. Of the 17 subjects with extremity involvement, 9 subjects had ‘0–2 CRPS-like symptoms’ and 8 had ’3–5 CRPS-like symptoms’. None of the eight subjects without extremity involvement had any CRPS-like symptoms. Of the 50 subjects with HZ outside the extremity, only one had abdominal weakness. Pain ratings were higher in subjects with ‘3–5 CRPS-like symptoms’. More subjects with ‘3–5 CRPS-like symptoms’ met criteria for PHN at 3 months (7 out of 8, 88%), compared to 5 out of 9 (55%) of subjects with ‘0–2 CRPS-like symptoms’ (p=0.07). At 6 months, 2 out of 9 (22%) of subjects with ‘0–2 CRPS-like symptoms’ met criteria for PHN, compared with 6 out of 8 (75%) of subjects with ‘3–5 CRPS-like symptoms’ (Chi-square test: p<0.03). Two case-reports are presented.In summary, the occurrence of CRPS-like symptoms is common in subjects with HZ outbreaks affecting the extremity, particularly if the distal extremity is involved. It is uncertain if the pathophysiology underlying the CRPS-like symptoms observed in this study is similar to that of CRPS from other causes, or if it is relatively specific to HZ. Development of PHN is common in subjects who have experienced CRPS-like symptoms. More aggressive preventive treatments may be justified in this high-risk subset of HZ subjects to prevent development of PHN. Prospective randomized controlled studies are needed to determine which subjects are most likely to benefit and when treatment should begin.