Extensive Medical Workup Research Articles

Prime-Time Hypoglycemia: Factitious Hypoglycemia During Insulin-Pump Therapy

Unexplained hypoglycemia in a pediatric diabetic patient can perplex even the savviest health care providers and lead to an extensive medical workup. We present here the cases of 2 children with type 1 diabetes mellitus treated with insulin pumps who were hospitalized for episodes of hypoglycemia. Review of their insulin pumps revealed normal basal and bolus insulin delivery. However, subsequent review of the priming history in the pump revealed that both children were receiving additional insulin under the manual-prime function, which is not included in the daily totals and, therefore, was initially unnoticed. Ultimately, both children confessed to surreptitiously using this priming function to self-administer extra insulin. It is important that health care professionals who are caring for diabetic patients be aware of this possibility.

Giving Bad News: A 13-Year Old With Acute Psychotic Symptoms and Catatonia

Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.

Dacryocystitis Provoked by Recurrence of Extramedullary Plasmacytoma of the Orbit: A Case Report

Extramedullary plasmacytoma (EMP) of the orbit is an extremely rare tumor, which frequently manifests with nonspecific symptoms. In the case reported, the symptoms of relapsing dacryocystitis appeared before the diagnosis of orbital EMP in a 60-year-old man. Moreover, EMP of the right submandibular gland that had been excised and treated by radiotherapy preceded the orbital lesion by seven years. The present report emphasizes the importance of an extensive medical workup to rule out multiple myeloma or other malignant lymphoproliferative diseases, because their treatment and prognosis are very different. Additionally, it is necessary to consider all tumors that can provoke relapsing dacryocystits.

A 17 year old adolescent with chronic neutropenia, recurrent infections, severe dysphagia and peroneus palsy

A 17-year-old German adolescent with a four year history of neutropenia and repeated infections presented with severe dysphagia and progressive right-sided peroneus palsy. In the past four years, extensive medical workup had been performed, and despite conspicuous findings, no diagnosis was made. Finally we diagnosed HIV related CMV esophagitis and HIV associated polyneuropathy. The CMV esophagitis was treated antivirally, and highly active antiretroviral HIV therapy was initiated. The mode of HIV transmission remained obscure until further research revealed a probable nosocomial infection during early childhood in Romania.

Plasmacytoma of the orbit involving lacrimal gland with secondary transformation into multiple myeloma: case report

The authors present a rare case of plasmacytoma of the orbit involving lacrimal gland with secondary transformation into multiple myeloma in a 42-year-old woman. The lesion was surgically removed and analyzed. Histopathological examination with immunostaining revealed it to be positive for immunoglobulin G and Kappa chains, demonstrating monoclonality. However, no abnormality was observed on serum electrophoresis, skeletal survey and bone marrow aspiration. Therefore, the tumor was diagnosed solitary plasmacytoma of bone. The patient was treated with external beam radiotherapy and has remained disease free for 5 years and 6 months until 2007, when she presented a pathological fracture due to multiple myeloma. Extensive medical work-up to rule out multiple myeloma or other malignant lymphoproliferative conditions involving orbit or ocular adnexa is needed when the diagnosis of solitary plasmacytoma of bone is suspected because treatment and prognosis are very different.

Exudative retinal detachment in castleman disease.

To describe the course of a case of Castleman disease (CD) that presented with visual symptoms and retinal disease. Clinical examination, fundus photography, and fluorescein and indocyanine green angiography were used to characterize the presence of bilateral exudative retinal detachments in a patient who was subsequently identified as having systemic lymphadenopathy. After an extensive medical workup including CT scans, blood testing, and a lymph node and renal biopsy, the patient was diagnosed with CD. Steroids were administered to treat CD. During the course of treatment, the patient developed renal failure, which was successfully treated with plasmapheresis. Four weeks later, the bilateral retinal detachments had resolved without local treatment. Exudative retinal detachments as manifestations of CD may be observed under systemic treatment for resolution before considering local therapy.

Severe Occlusive Vasculitis as a Complication of Cat Scratch Disease

The purpose of this communication is to report a severe occlusive vasculitis as a complication of cat scratch. A 34-year-old Hispanic woman presented with a sudden visual loss of the right eye associated with shivers, high fever and arthritis which developed 2 months after a cat's bite. Fundus examination showed papillitis and a palor of the paramacular zone of the retina. Fluorescein angiography revealed multiple arterial and venous vasculitic occlusions. Auto-immune disease and endocarditis were ruled out by an extensive medical work-up. The diagnosis of Bartonella henselae was confirmed by a positive serology. A systemic antibiotherapy with azithromycin, doxycyclin, rifampicin and steroid therapy resulted in a good clinical response, including a rapid visual recovery with a visual acuity of 20/20 and no relapse of the disease at 6 months follow-up. Ocular complications associated with cat scratch disease may include vasculitis with both arterial and venous occlusions causing severe visual loss.

Transmission of Metastatic Glioblastoma Multiforme From Donor to Lung Transplant Recipient

This report describes a case in which a lung transplant patient presented with lung masses. After an extensive medical workup and biopsy, the masses were found to be caused by metastatic glioblastoma multiforme, which the patient acquired from the lung donor. This article will also review similar cases in the literature.

Giving Bad News: A 13-Year Old with Acute Psychotic Symptoms and Catatonia

Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.

Psychogenic Cough in an Asthmatic Child: Case Report with Unusual Findings

A 9-year-old girl with known mild intermittent asthma presented with a persistent cough. Her cough exhibited a four-beat staccato rhythm, was nonproductive, and persisted only while awake. On physical examination, she displayed several unique findings not previously described. An extensive yet non-diagnostic medical workup coupled with absence of aggressive medical treatment for the more usual causes of cough lead to psychologic investigation and intervention with subsequent cough resolution. The appropriate use of psychologic consultation, testing, and success with supportive reinforcement therapy confirmed a psychogenic etiology. Extended medical follow-up of the patient concerning cough reoccurrence remains uneventful.

Épithéliopathies en plaques, choroïdites serpigineuses et multifocales : analyse étiologique et prise en charge thérapeutique

To highlight the importance of an extensive medical work-up in serpiginous and multifocal choroiditis, and acute posterior multifocal placoid pigment epitheliopathy before therapeutic management.Records of patients referred to our department, between January 2000 and January 2002, for the diagnostic and therapeutic management of choroiditis or acute posterior multifocal placoid pigment epitheliopathy were retrospectively reviewed. All patients had a complete ophthalmologic examination, fluorescein and infrared angiographies. An extensive work-up was performed in order to exclude an infectious etiology.Fourteen patients were included (six cases of serpiginous choroiditis, four cases of multifocal choroiditis, and four cases of APMPPE). The mean age was 42.1 years and the sex ratio was 9: 5. Six patients presented with a history of tuberculosis in the family or with a tuberculosis primary infection. Toxoplasmic retinochoroiditis was confirmed in one case by a positive PCR applied to the aqueous humor. In the serpiginous choroiditis group, two patients have been treated with antituberculous drugs, one of whom was initially resistant to immunosuppressive regimens. In the acute posterior multifocal placoid pigment epitheliopathy group, one patient was treated with antituberculous drugs and another received antibiotics.An infectious agent may be associated with this group of clinical presentations. All patients presenting with severe forms of ocular inflammation, who resist to corticosteroids or immunosuppressive regimens, must undergo an extensive infectious work-up in order to propose a specific treatment.

An unusual case of 4-aminopyridine toxicity

4-aminopyridine (4-AP) is an orphan drug in the United States. It enhances neuronal conduction at synapses and is indicated in the treatment of selected neuromuscular disorders, including multiple sclerosis and myasthenia gravis, among others. Its documented toxicity generally has been limited to central nervous system (CNS) hyperexcitation and gastrointestinal upset. In this case, a 56-year-old man accidentally overdosed on an unknown amount of generic 4-AP. This history was unknown by his family and unavailable to initial providers. Approximately 1 h after ingestion, his son found him diaphoretic, vomiting, and having unintelligible speech. In the ensuing 2–3 h, the patient became moderately hypothermic (32.8°C; 91°F), developed atrial fibrillation with a rapid ventricular response, and had neurological changes that were confused with an acute cerebrovascular accident. After a 36-h stay in the intensive care unit that included mechanical ventilation, cardioversion, passive rewarming, and an extensive medical workup, the patient recovered without sequelae. After extubation he stated that he thought he may have ingested too much 4-AP after rubbing a large amount of it against a sore tooth to take advantage of its local analgesic properties. This case of 4-AP overdose resulting in atrial fibrillation with rapid ventricular response, hypothermia, and acute neurological changes mistaken for an acute cerebrovascular accident is an unusual one. This case shows that overdose of 4-AP can cause or mimic several serious medical conditions, and that a detailed history and physical examination are essential for uncovering unusual diagnoses.

Neurosarcoidosis: Clinical Experience and Diagnostic Pitfalls

Objective: To describe a group of patients with neurosarcoidosis and to highlight diagnostic difficulties based on current diagnostic criteria. Methods: The patient database of a general neurological department was searched for patients with established or suspected diagnosis of neurosarcoidosis. Twenty-four patients were identified with definite (n = 3), probable (n = 10) and possible neurosarcoidosis (n = 10). History and clinical, laboratory and imaging data of patients with definite and probable neurosarcoidosis were analyzed. Results: Cranial nerve symptoms were a dominant clinical feature, with the optic nerve being affected most frequently. Cerebrospinal fluid pleocytosis was found in more than half of the patients. Intrathecal IgG synthesis and oligoclonal bands were less frequent. There was a wide array of MRI lesions in both groups. Chest X-ray was false negative in 2 of 5 patients who also underwent a thoracic CT. Therapy with prednisolone was initiated in all patients. After a median of 36 months, 6 of 8 patients with follow-up data of >24 months were still in remission. Aggravation of symptoms required therapy escalation in 2 patients. Conclusion: There is a wide range of clinical symptoms and test results in patients with ‘definite’ or ‘probable’ neurosarcoidosis. Because systemic involvement is a crucial diagnostic criterion, extensive medical work-up may be necessary. Prognosis under corticosteroid treatment may be better than previously thought.

Severe Generalized Edema Associated with Phenelzine

Rabkin, et al. describes a 4% incidence of phenelzine-induced edema, which appears to be due to increased capillary permeability (1,2). This adverse effect is not further characterized in the literature and is not readily mentioned as one of the many drug effects that could result in severe physical morbidity. We present the case of a depressed patient who developed a generalized edema severe enough to deserve an extensive medical workup. Once the drug was tapered, the edema and its associated symptoms rapidly resolved.

Factitious triplegia: Case report

A 37-year-old woman was admitted for rehabilitation of triplegia with diagnoses of conversion disorder and possible multiple sclerosis. Attempts to manage the patient with techniques often effective with conversion disorders were unsuccessful, and the patient was discharged to a nursing home. After the development of further symptoms and a second extensive medical work-up, the factitious nature of her symptoms became evident. Awareness of the characteristics of factitious disorders, early background investigation, and psychiatric consultation can facilitate the appropriate management and referral of these patients, and spare rehabilitation providers the frustrations and possible medicolegal complications of patients with this disorder.

Positron emission tomography of [ 18F]-6-F-(E)-β-fluoromethyl-ene-dl-meta-tyrosine (MDL 72394) in rhesus monkeys

Ishaemic stroke (IS) in the paediatric population is extremely rare. In this age group, the occurrence of IS often concurs with underlying congenital heart disease, haematological, metabolic or immunological conditions. In contrast, the association between IS and minor head injury in children has been sparse in current literature. The authors report a case of a healthy 9-month-old male who was found to have a right middle cerebral artery territory infarct after a minor head injury. An extensive medical workup was performed, and it was negative for any previously undiagnosed co-morbidities. Given the paucity of such cases, the condition and its management are discussed in corroboration with current literature.

Factitious renal stone as a sign of internal conflict about sexual intercourse in an adolescent

Conflicts about the onset of sexual intercourse have been reported to cause a variety of symptoms. A 16-year-old black female claimed to have passed a stone in her urine. Investigation of her complaints caused some doubt that an organic cause was involved. Social history showed that she had recently begun to have sexual intercourse despite a religious belief that intercourse before marriage was wrong. After an extensive medical work-up, she was discharged with instructions to bring in another stone if passed. A stone subsequently presented by the patient proved to be a piece of lead shot. Those caring for adolescents need to be aware that conflicts about sexual intercourse may present in a number of ways, including urinary-tract complaints.

Effects of tobacco smoking and age on the keratinization of palatal mucosa: A cytologic study

Cytologic smears of palatal mucosa were evaluated for degree of keratinization in 217 healthy men ranging in age from 30 to 74 years. Two slides were prepared for each participant, and each slide was read by two different pathologists. Three separate high-power fields were examined on each slide, and the percentage of orange-brown cells, either without nuclei or with pyknotic or fragmented nuclei, was recorded. A mean value was obtained for each participant. Each participant had an extensive medical and dental work-up as part of the Veterans Administration Longitudinal Study of Oral Health in Healthy Veterans. Nonsmokers and smokers were divided into five age groups. Smokers at all ages presented a greater degree of palatal keratinization than nonsmokers, but age differences in keratinization were not statistically significant.

Treatment of ruminations with behavioral techniques: A case report

This is the case history of a 5.5-month-old boy who was admitted to the hospital exhibiting ruminating behavior which had resulted in dehydration and malnutrition. After extensive medical workup, psychological consultation was requested and a behavioral treatment program was implemented. The program employed multiple behavioral procedures including stimulus control, punishment, and continuous massive attention. Results show successful treatment in terms of reduced volume of vomit and significant weight gain. A 4-month follow-up evaluation found no further ruminating, continued weight gain, and approximately normal development.