Fam Physician Research Articles

Nephrotic syndrome: delays in diagnosis and a cause of pulmonary embolism not to miss

British Journal of Hospital MedicineEarly view Case ReportNephrotic syndrome: delays in diagnosis and a cause of pulmonary embolism not to missFrancesca Wright, Mark GilchristFrancesca WrightCorrespondence to: Francesca Wright; E-mail Address: [email protected]Department of Nephrology, Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, UKSearch for more papers by this author, Mark GilchristDepartment of Respiratory Medicine, Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, UKUniversity of Exeter Medical School, Exeter, UKSearch for more papers by this authorFrancesca Wright; Mark GilchristPublished Online:22 May 2023https://doi.org/10.12968/hmed.2023.0011AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article References Hull RP, Goldsmith DJA. Nephrotic syndrome in adults. BMJ. 2008;336(7654):1185–1189. https://doi.org/10.1136/bmj.39576.709711.80 Crossref, Medline, Google ScholarKerlin BA, Ayoob R, Smoyer WE. Epidemiology and pathophysiology of nephrotic syndrome-associated thromboembolic disease. Clin J Am Soc Nephrol. 2012;7(3):513–520. https://doi.org/10.2215/CJN.10131011 Crossref, Medline, Google ScholarKidney Disease Improving Global Outcomes Guidelines. Clinical practice guideline for the management of glomerular diseases. Kidney Int. 2021;100(4S):S1–S276. https://doi.org/10.1016/j.kint.2021.05.021 Medline, Google ScholarKodner C. Diagnosis and management of nephrotic syndrome in adults. Am Fam Physician. 2016;93(6):479–485 Medline, Google ScholarLeeaphorn N, Kue-A-Pai P, Thamcharoen N et al.. Prevalence of cancer in membranous nephropathy: a systematic review and meta-analysis of observational studies. Am J Nephrol. 2014;40(1):29–35. https://doi.org/10.1159/000364782 Crossref, Medline, Google ScholarMahmoodi BK, ten Kate MK, Waanders F et al.. High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome. Circulation. 2008;117(2):224–230. https://doi.org/10.1161/CIRCULATIONAHA.107.716951 Crossref, Medline, Google ScholarNational Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. 2020. https://www.nice.org.uk/guidance/ng158 (accessed 24 April 2023) Google Scholar FiguresReferencesRelatedDetails Ahead of PrintISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 22 May 2023 Information© MA Healthcare LimitedPDF download

Elderly Woman With Fever and Hypotension.

An 83-year-old woman with hypertension and dementia presented from an assisted living facility with confusion and diarrhea. She had recently been treated for a small bowel obstruction. On examination, her blood pressure was 75/57 mmHg and her temperature was 38.9 °C (102 °F). She was confused, clinically dehydrated, and had diffuse abdominal tenderness. She had a serum creatinine of 1.6 mg/dL, and her urinalysis demonstrated extensive WBCs with clumps and bacteria. The emergency physician obtained a point-of-care ultrasound to examine the bladder (Figure 1) and then placed an indwelling catheter (Figure 2).Figure 2Catheter bag with purulent material.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pyelonephritis with purulent obstruction. Infection can cause retention due to urethral edema.1Selius B.A. Subedi R. Urinary retention in adults: diagnosis and initial management.Am Fam Physician. 2008; 77: 643-650PubMed Google Scholar Furthermore, the patient accumulated significant purulent material, which caused obstruction and hydronephrosis. Ultrasonography is highly accurate in determining bladder volumes and potential obstruction.1Selius B.A. Subedi R. Urinary retention in adults: diagnosis and initial management.Am Fam Physician. 2008; 77: 643-650PubMed Google Scholar,2D'Silva K.A. Dahm P. Wong C.L. Does this man with lower urinary tract symptoms have bladder outlet obstruction?: the rational clinical examination: a systematic review.JAMA. 2014; 312: 535-542Crossref PubMed Scopus (38) Google Scholar The patient was administered fluids and broad-spectrum antibiotics and was admitted to the hospital. Her culture grew Escherichia coli. At follow-up a few weeks later, her daughter endorsed that she had returned to her baseline function.

Pregnant Woman With Abdominal Pain and Vaginal Bleeding

Pregnant Woman With Abdominal Pain and Vaginal Bleeding

Bilateral, tender axillary nodules

Bilateral, tender axillary nodules

Predictors of confidence and trust in government and institutions during the COVID-19 response in Australia

Predictors of confidence and trust in government and institutions during the COVID-19 response in Australia

Web-based exercise therapy for the treatment of depression

Web-based exercise therapy for the treatment of depression

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

BACTERIAL MENINGITIS: A SERIOUS COMPLICATION OF ACUTE OTITIS MEDIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Otitis media can be complicated by bacterial meningitis that can have high mortality and morbidity. With the advent of antibiotics this complication is significantly rare but delay in getting treatment for Otitis media increases the risk of meningitis exceptionally. (1) We present a case of otitis media complicated by bacterial meningitis in a young adult patient. CASE PRESENTATION: A 36 years old male presented with complaints of right ear pain and discharge. On presentation he was febrile to 102 F. On examination he was sick in appearance with a tender right ear and purulent discharge. He was intubated for airway protection and altered mental status. Initial lab investigations showed a WBC count of 24.3 k/ul. Lactic acid and Procalcitonin were raised. CT Scan of head showed right mastoid effusion. Blood cultures were sent and a Lumbar puncture with an opening pressure of 55 cmH2O was done. Patient was started on vancomycin and ceftriaxone along with intravenous steroids. CSF analysis showed a WBC count of 11400 k/ul, predominantly neutrophils. CSF protein content was >750 mg/dl with no glucose in it. A tympanostomy tube was placed in the right middle ear for drainage and purulent discharge was sent for culture and sensitivity. MRI Scan of head showed restricted diffusion in subarachnoid spaces consistent with pus and ventriculitis in the setting of meningitis without any evidence of abscess. Right sided mastoid effusion was also present. Magnetic resonance venography was negative for venous thrombosis. Blood, middle ear fluid and CSF cultures grew streptococcus pneumoniae and staphylococcus epidermidis. Patient improved clinically after 72 hours on antibiotics and was extubated after that with normalization of inflammatory markers. Antibiotics were tailored as per sensitivity data and will require mastoidectomy as outpatient after completion of intravenous antibiotics. DISCUSSION: Most common organisms causing otitis media and its complications include streptococcus pneumoniae, group A streptococci, staphylococcus aureus, H. Influenzae and pseudomonas aeruginosa. (2) In some cases no bacterial organism is isolated. Due to the development of antibiotic therapies the complications of otitis media can be controlled. Delay in receiving antibiotic therapy can complicate the middle ear infection. If otitis media is complicated by middle ear effusion then tympanostomy tube can help in drainage of the purulent material preventing the seeding of other surrounding structures. It can extend to mastoid and further to brain tissue if not treated in a timely fashion resulting in meningitis and abscess formation as happened in our patient it resulted in meningitis. Appropriate antibiotics with surgical intervention for drainage if needed is the course of treatment. CONCLUSIONS: Acute otitis media should be treated in a timely fashion to avoid the complication of bacterial meningitis. REFERENCE #1: 1. Harmes KM, Blackwood RA, Burrows HL, Cooke JM, Harrison RV, Passamani PP. Otitis media: diagnosis and treatment. Am Fam Physician. 2013 Oct 1;88(7):435-40. Erratum in: Am Fam Physician. 2014 Mar 1;89(5):318. Dosage error in article text. PMID: 24134083. REFERENCE #2: 2. Leichtle A, Hoffmann TK, Wigand MC. Otitis media – Definition, Pathogenese, Klinik, Diagnose und Therapie [Otitis media: definition, pathogenesis, clinical presentation, diagnosis and therapy]. Laryngorhinootologie. 2018 Jul;97(7):497-508. German. doi: 10.1055/s-0044-101327. Epub 2018 Jul 9. Erratum in: Laryngorhinootologie. 2018 Jul;97(7):E2. PMID: 29986368 DISCLOSURES: No relevant relationships by Muhammad Ibrar Islam, source=Web Response No relevant relationships by Namra Mahmood, source=Web Response No relevant relationships by Junaid mir, source=Web Response

NECROTIZING PNEUMONIA AND MASSIVE AIR LEAK IN A PATIENT WITH COVID-19

TOPIC: Cardiothoracic Surgery TYPE: Global Case Reports INTRODUCTION: To observe the pathological characteristics and the clinical significance of COVID 19 infected pneumonia causing degeneration and necrosis of parenchymal cells, thrombus in small and medium vessels. Pulmonary pathological changes of fatal COVID-19 are diffuse alveolar damage that is presents in the acute exudative stage and the organic proliferative stage. There is alveolar cavity formation, fibrinous exudate, fibroblastic proliferation in alveolar septum, and alveolar epithelial cell injuries. A large number of neutrophils and monocytes infiltration is present in most cases and bacteria and fungi are detected in some cases, suggesting a serious combination to generate lung necrosis and huge air leak. CASE PRESENTATION: The case of a 50 years old female with severe COVID 19 pneumonia, requiring admission to the ICU during her hospitalization present bilateral pneumothorax that was solved with bilateral chest tube, one week later present persistent right pneumothorax and a continuous air leak that prevented ventilation, surgical intervention was decided as a result of the ventilatory, hemodynamic deterioration and state of sepsis finding in the right lower lung focal hemorrhage, organization of exudates in various cavities in the lung, and pulmonary fibrosis generating degeneration and necrosis of parenchymal cells, formation of thrombus in small vessels, and pathological changes of chronic diseases were observed with fibrous tissue, firm adhesions DISCUSSION: Infectious disease by COVID 19 pneumonia can generate cavitary lung process, necrotizing pneumonia, lung abscess and septic pulmonary embolism. Being able to aggregate infections that include cavitating fungal and superinfection of preexisting spaces. Accompanied by infarction from thromboembolic disease. In these cases, we found an extensive lung necrosis with a grade 4 air leak, accompanied by intraparenchymal purulent fibrin, infected cavities with fluid and bronchial necrosis as well as blood vessel thrombosis CONCLUSIONS: The management of this pathology include treatment as any lung necrosis with major resection and reinforcement of the bronchial stump with the considerations of the aerosol that are generated by bronchial necrosis and parenchyma, the initial approach includes immediate obturation of the bronchus and subsequently continue with vascular dissection. Which indicates that COVID pneumonia can present in a short time all the changes of acute and chronic disease. Generally, an acute or subacute process suggests bacterial and fungal causes of pulmonary abscesses, necrotizing pneumonias, and septic emboli. And a chronic process suggests mycobacterial, fungal, viral, or parasitic infections;malignancy or autoimmune disorders REFERENCE #1: Anaesthesia. 2020 Nov;75(11):1509-1516. doi: 10.1111/anae.15112. Epub 2020 Jun 2. Management of the airway and lung isolation for thoracic surgery during the COVID-19 pandemic: Recommendations for clinical practice endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and IrelandM Thornton 1, D Reid 1, B Shelley 2 3, M Steven 1 REFERENCE #2: Anaesthesia. 2020 Nov;75(11):1509-1516. doi: 10.1111/anae.15112. Epub 2020 Jun 2.Management of the airway and lung isolation for thoracic surgery during the COVID-19 pandemic: Recommendations for clinical practice endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and IrelandM Thornton 1, D Reid 1, B Shelley 2 3, M Steven 1 REFERENCE #3: Am Fam Physician. 1991 Nov;44(5):1719-21.Necrotizing aspiration pneumoniaD Disler 1, S A Deluca DISCLOSURES: No relevant relationships by Gabriela Alejandra Buerba Romero Valdes, source=Web Response No relevant relationships by Gabriela Del Angel Millan, source=Web Response No relevant relationships by EMMANUEL PENA GOMEZ PORTUGAL, source=Web Response No relevant relationships by ALMA SOLANO NIETO, source= eb Response

COVID-19 vaccination intention in the Western Pacific Region - insights from Japan.

COVID-19 vaccination intention in the Western Pacific Region - insights from Japan.

The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19.

The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19.

A Man Named Peter: Living in Long-Term Care as a Younger Adult

A Man Named Peter: Living in Long-Term Care as a Younger Adult

Infant malignant ectomesenchymoma masquerading as inguinal hernia in two patients

Infant malignant ectomesenchymoma masquerading as inguinal hernia in two patients

Scoping the Problem

Scoping the Problem

New Classification and Management of Abetalipoproteinemia and Related Disorders

New Classification and Management of Abetalipoproteinemia and Related Disorders

Necrotizing fasciitis caused by diabetic foot

Necrotizing fasciitis caused by diabetic foot

HYPOTHERMIC EMERGENCY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hypothermia is defined as a core temperature below 95℉. The causes for hypothermia can be divided into two categories, impaired thermoregulation and increased heat loss. Increased heat loss can result from disorders that impair the skin barrier, heat stroke, cold exposure, and shock. Central failure, peripheral failure, hypothyroidism, hypoglycemia, and neuromuscular compromise are examples of causes secondary to impaired thermoregulation. In a severe state of hypothyroidism, known as myxedema coma, low thyroid hormone levels lead to a decrease in basal metabolic rate impairing thermogenesis. CASE PRESENTATION: A 65 year old male was brought to the hospital after being found unresponsive, lying outdoors for an unknown amount of time while temperatures were below freezing. Upon presentation to the ED, the patient was found to be obtunded, hypothermic to 80.6 F, bradycardic, and hypotensive. The patient's presentation was assumed to be from extended cold exposure and rewarming was initiated. He was intubated for airway protection, started on vasopressors, and admitted to the medical intensive care unit.Further work up showed an acute kidney injury, hyperkalemia, lactic acidosis, and rhabdomyolysis. His endocrine studies showed an elevated thyroid stimulating hormone (TSH) of 28.14, an undetectable triiodothyronine (T3) and thyroxine (T4), and abnormally normal cortisol. The patient was diagnosed with myxedema coma (MC) and started on an IV of liothyronine and levothyroxine as well as stress dose steroids for presumed adrenal insufficiency. Eight days after this presentation and after the initiation of thyroid hormone therapy, his mental status improved and he was successfully extubated. He was ultimately discharged to a skilled nursing facility 5 weeks later. DISCUSSION: Given several mechanisms contributing to the development of hypothermia, it is imperative to be conscious of endocrine disorders which can impair thermoregulation. MC is a medical emergency with a reported incidence of 0.22 per million per year in the Western world and a mortality rate as high as 60%. Mortality decreases to 20%–40% in treated individuals mainly as a result of clinician awareness, improvements in diagnostic testing, and advances in intensive care. If diagnostic criteria for MC is met, initiation of appropriate therapy should not be delayed as results of endocrine testing may not be readily available. CONCLUSIONS: Despite the high mortality rate associated with MC, due to prompt management in the intensive care unit with appropriate therapy of glucocorticoids and thyroxine, this patient's condition improved. We wish to emphasize the need for early detection and treatment of endocrine emergencies. In patients with severe hypothermia, initial steps for resuscitation efforts should also include early treatment of MC due to the associated mortality benefit. Reference #1: Zafren, Ken. "Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia.” Emergency Medicine Clinics of North America, vol. 35, no. 2, 2017, pp. 261–279., https://doi.org/10.1016/j.emc.2017.01.003. Reference #2: Brown, Douglas J.a. "Accidental Hypothermia.” New England Journal of Medicine, vol. 367, no. 20, 2012, pp. 1930–1938., https://doi.org/10.1056/nejmra1114208. Reference #3: Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000;62(11):2485-2490. DISCLOSURES: No relevant relationships by Michael Blaj, source=Web Response No relevant relationships by Priyanka Durai, source=Web Response No relevant relationships by Jennifer Lindsey, source=Web Response No relevant relationships by Daisy Ngwainmbi, source=Web Response No relevant relationships by Luis Rauseo Lopez, source=Web Response

Association between halo nevi and melanoma in adults: A multicenter retrospective case series

To the Editor: The halo nevus is thought to be of little concern in children. In adults, however, a new-onset halo nevus has been suggested to be a harbinger of melanoma either within the halo nevus or at distant cutaneous or noncutaneous sites, according to case reports and small case series.1Epstein W.L. Sagebeil R. Spitler L. Wybran J. Reed W.B. Blois M.S. Halo nevi and melanoma.JAMA. 1973; 225: 373-377Crossref PubMed Scopus (62) Google Scholar,2Pellegrini J.R. Wagner Jr., R.F. Nathanson L. Halo nevi and melanoma.Am Fam Physician. 1984; 30: 157-159PubMed Google Scholar Multiple widely used dermatologic reference texts3Bolognia J. Schaffer J.V. Cerroni L. Dermatology: 2-Volume Set. Elsevier, Philadelphia, PA2017Google Scholar,4James W.D. Berger T.G. Elston D.M. Andrews' Diseases of the Skin. Saunders/Elsevier, London, England2011Google Scholar and online references (eg, UpToDate.com, DermNetNZ.org) advocate extensive melanoma screening in adults with new-onset halo nevus, including full cutaneous, oral, ophthalmic, and vaginal examinations, despite limited evidence supporting an association between halo nevus and melanoma. We aimed to further investigate the association between new-onset halo nevus and melanoma in adults by evaluating the incidence of melanoma in the year after a new halo nevus diagnosis. A multicenter retrospective chart review of clinical and histopathologic records at 8 university hospitals identified 879 patients in whom 888 halo nevi were diagnosed at aged 18 years or older (Brigham and Women's Hospital [n = 80], Massachusetts General Hospital [n = 166], New York University [n = 7], Northwestern University [n = 36], Oregon Health & Science University [n = 103], University of Pennsylvania [n = 27], Huntsman Cancer Institute and the University of Utah [n = 364], and Yale University [n = 96]). Ethical approval was obtained from each university's institutional review board. Patients being treated with immunotherapy for melanoma were excluded. Mean age at halo nevus diagnosis was 36.3 years (standard deviation 13.2 years) (Table I). Clinical records review identified 95 occurrences of melanoma in these 879 patients. Only 9 halo nevi were diagnosed within 1 year before melanoma diagnosis, representing a melanoma incidence rate of 0.01 (95% confidence interval 0.004-0.017) per person per year. All 9 of these melanomas represented primary cutaneous melanoma; there were no occurrences of primary noncutaneous melanoma, metastatic melanoma, or melanoma within the incident halo nevus. None of these 9 patients presented with multiple halo nevi. The remaining 86 melanoma diagnoses occurred either before the halo nevus diagnosis (n = 78) or greater than 1 year after (n = 8) (mean 5.75 years [standard deviation 4.30 years]). Personal history of vitiligo was not significantly associated with odds of melanoma development within the year after an incident halo nevus (odds ratio 3.97; 95% confidence interval 0.65-24.2; P = .13).Table IPatient demographicsCharacteristicAll patients with HN, n = 879Patients with melanoma diagnosed in the year after a new HN, n = 9Patients without melanoma diagnoses, n = 784Mean age at HN diagnosis ± SD, y36.3 ± 13.239.1 ± 11.935.3 ± 12.7 18–39580 (66)5 (55.6)540 (68.9) 40–59212 (24.1)4 (44.4)174 (22.2) 60–7968 (7.7)051 (6.5) ≥801 (0.1)01 (0.1) Unknown18 (2.0)018 (2.3)Mean age at melanoma diagnosis ± SD, y39.4 ± 14.740.4 ± 11.8NASex Men348 (39.6)5 (55.6)307 (39.3) Women529 (60.2)4 (44.4)475 (60.6) Unknown2 (0.2)02 (0.3)Race White799 (90.9)9 (100)711 (90.7) Nonwhite18 (2.0)017 (2.2) Unknown62 (7.1)056 (7.2)Halo nevus biopsied Yes396 (45.1)6 (66.7)345 (44.0) No474 (53.9)3 (33.3)431 (55.0) Unknown9 (1.0)08 (1.0)Vitiligo Yes78 (8.9)2 (22.2)70 (8.9) No450 (51.2)3 (33.3)391 (49.9) Unknown351 (39.9)4 (44.4)323 (41.2)Values are provided as No. (%) unless otherwise indicated.HN, Halo nevus; NA, not applicable; SD, standard deviation. Open table in a new tab Values are provided as No. (%) unless otherwise indicated. HN, Halo nevus; NA, not applicable; SD, standard deviation. Limitations of the study include the retrospective design and heterogeneity by which each site identified halo nevus cases. Halo nevus and melanoma were identified by documentation and coding that may not accurately reflect the true date of onset or incidence. In conclusion, this study found that adult-onset halo nevi were associated with a 1% risk of primary cutaneous melanoma development in the year after halo nevus diagnosis, with no cases of primary noncutaneous or metastatic melanoma. This melanoma risk is comparable to that of individuals with a history of atypical nevi or personal or family history of melanoma.5Varedi A. Bishop M.D. Boucher K.M. Kim C.C. Grossman D. Powering a prospective melanoma chemoprevention trial in high-risk cohorts.Int J Dermatol. 2019; 58: e232-e234Crossref PubMed Scopus (3) Google Scholar Given these findings, we recommend annual total body skin examinations in adults with a new diagnosis of halo nevus and without additional risk factors, and we do not advocate reflexive screening for primary noncutaneous or metastatic melanoma.

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

The Minimal Effect of Zinc on the Survival of Hospitalized Patients With COVID-19: An Observational Study

The Minimal Effect of Zinc on the Survival of Hospitalized Patients With COVID-19: An Observational Study