Initial Complaint Research Articles

Incidental solitary knee mass as the first manifestation of hidden lung cancer

Hypertrophic pulmonary osteoarthropathy (HPOA), also known as secondary hypertrophic osteoarthropathy, is a clinical syndrome characterized by proliferative periostitis of the long bones especially in the distal and periarticular aspects, proliferation of the synovial membranes, causing painful and swollen joints, and often with finger clubbing. It is associated with various underlying causes, including pulmonary, pleural, cardiac, abdominal and miscellaneous conditions. Its pulmonary causes include bronchogenic carcinoma, tuberculosis, pulmonary abscess, bronchiectasis, emphysema, etc. Its radiographic presentation involves periostitis in the lower extremities. We report one case that had an incidental finding of HPOA with initial complaint about an incidental solitary knee mass with painful swelling of right knee, leading to early diagnosis of occult bronchogenic carcinoma. The radiographs and magnetic resonance imaging (MRI) revealed periosteal reactions without definite intraosseous lesion. Chest radiography and CT scan disclosed an infiltrating right upper lobe lesion suspicious malignancy. Patient received right S2 segmentectomy of lung with pathological confirmation of adenocarcinoma of lung cancer. It is important for the clinician to be aware of the radiographic findings of periostitis of HPOA, which may be the clues leading to early detection of lung cancer without significant pulmonary symptoms and to avoid possible tumor progression and distant metastases.

Ankylosing spondylitis in a patient with myelodysplastic syndrome: an association with HLA-B27 or coincidence?

The authors report an unusual case of myelodysplastic syndrome (MDS) associated with ankylosing spondylitis (AS). A 40-year-old-man with MDS presented with chronic low back pain for 6 years. Four years ago, MDS was diagnosed during routine blood analysis for the work-up of his articular complaints. His initial articular complaints were attributed to extramedullary manifestations of MDS. Persistent low back pain with increasing intensity finally led the patient to seek medical attention. Radiograph of the pelvis showed bilateral asymmetric sacroiliitis. A diagnosis of AS was established on the basis of modified New York criteria. Although various autoimmune phenomena associated with MDS have been described, this is the first report of AS in the setting of MDS. Causal relationship between these two disorders is currently unknown. Increased risk of hematological diseases as well as AS in individuals with a positive HLA-B27 provides a feasible explanation for this rare observation.

Catastrophizing and Causal Beliefs in Whiplash

Prospective cohort study. This study investigates the role of pain catastrophizing and causal beliefs with regard to severity and persistence of neck complaints after motor vehicle accidents. SUMMARY OF BACKGROUND DATA.: In previous research on low back pain, somatoform disorders and chronic fatigue syndrome, pain catastrophizing and causal beliefs were found to be related to perceived disability and prognosis. Furthermore, it has been argued with respect to whiplash that culturally dependent symptom expectations are responsible for a chronic course. Individuals involved in traffic accidents who initiated compensation claim procedures with a Dutch insurance company were sent questionnaires (Q1) containing the Neck Disability Index, the Pain Catastrophizing Scale, and the Causal Beliefs Questionnaire-Whiplash. Of 1252 questionnaires dispatched, 747 (59.7%) were returned. Only car occupants with neck complaints were included in this study (n = 140). Complaints were monitored using additional questionnaires administered 6 (Q2) and 12 months (Q3) after the accident. Pain catastrophizing and causal beliefs were related to the severity of concurrent whiplash disability. The severity of initial complaints was related to the severity and persistence of whiplash complaints. Attributing initial neck complaints to whiplash was found to predict the persistence of disability at 6 and 12 months follow-up, over and above the severity of the initial complaints. The results suggest that causal beliefs may play a major role in the perceived disability and course of neck complaints after motor vehicle accidents, whereas pain catastrophizing is predominantly related to concurrent disability.The current findings are consistent with the view that an early conviction that neck complaints are caused by the medico-cultural entity whiplash has a detrimental effect on the course of symptoms.

Robotic intercostal nerve graft for reversal of thoracic sympathectomy: a large animal feasibility model

A subset of patients who undergo video-assisted thoracoscopic sympathectomy for hyperhydrosis develop post-procedure compensatory sweating that is perceived as more debilitating than their initial complaints. We propose a novel treatment to reverse sympathectomy by implantation of an intercostal nerve graft using the da Vinci robot. A robotic swine model was established using single-lung ventilation and four ports. The pleura was incised and a representative segment of sympathetic chain was transected. A nearby intercostal nerve was harvested and sutured to the sympathetic chain using four interrupted 10-0 nylon sutures on the epineurium. The intercostal nerve was an excellent size match and post-procedure necropsy yielded successful anastomoses without apparent complications. Robotic intercostal nerve grafting for reversal of thoracic sympathectomy is technically feasible. The robotic device allows the principles of neural microsurgery to be maintained and provides a minimally invasive option for reconstruction of the sympathetic chain.

Common Presenting Patterns in Patients with Upper Gastroinestinal Crohnʼs Disease

Purpose: Crohn's disease (CD) is a debilitating disease that can affect the entire gastrointestinal tract. While most patients with CD present with symptoms involving the small bowel (particularly, distal ileum), colon, and perianal area, symptomatic upper gastrointestinal (UGI) involvement is uncommon and is currently estimated at 4% of Crohn's cases. In patients with active CD, new UGI symptoms are sometimes misdiagnosed as GERD or ulcer disease until the patient is observed to be refractory to common treatment, thus leading to delayed recognition and possibly increased morbidity. Specific diagnostic guidelines for UGI CD have not been established. A retrospective chart review was conducted to identify presenting characteristics of patients who were eventually found to have UGI CD. Awareness of common presentations of patients with UGI CD may lead to earlier diagnosis and treatment, thus improving patient outcome and avoiding complications. Methods: 33 patients with evidence of CD involving the UGI tract (mouth, esophagus, stomach, duodenum) were identified from University of Pittsburgh Medical Center records during a review period from October 1992 until August 2007. For each patient, usual demographics and initial presenting symptoms of CD, and the areas of Crohn's involvement were assessed. IRB approval was obtained. Results: The average chart review period was 66.0 ± 42.7 months. All patients were Caucasian and 15 (45.5%) were male. Evidence of UGI involvement of CD was confirmed by traditional methods of capsule endoscopy, upper endoscopy with biopsy, or imaging studies. Mean age of initial presentation with CD was 22.5 ± 11.3 years, and 20 patients (60.6%) had upper GI manifestations of Crohn's disease at initial presentation. 10 (30.3%) patients had a positive family history for IBD. The most common initial complaint was abdominal cramping (25 patients, 75.8%) followed by increased frequency of bowel movements (18 patients, 54.5%) and nausea/vomiting (13 patients, 39.4%). Weight loss was reported in 10 (30.3%) patients. Most patients with esophageal involvement reported reflux or odynophagia. The most common areas of UGI involvement in these patients were the duodenum (24 patients, 72.7%) and the stomach (20 patients, 60.6%). Conclusion: Symptoms of abdominal cramping, nausea, heartburn, or odynophagia in patients with known or suspected CD should trigger workup to evaluate UGI CD. Patients with persistent epigastric pain or heartburn despite treatment with proton pump inhibitors should also be evaluated for CD. Early recognition and proper treatment of UGI CD can ensure adequate surveillance and potentially reduce the morbidity of the disease.Table: Common symptoms and areas of involvement in patients diagnosed with upper gastrointestinal CD.

Spontaneous Pneumomediastinum: A Comparative Study and Review of the Literature

Spontaneous pneumomediastinum (SPM) is an unusual occurrence with few cases reported. It is seen after intrathoracic pressure changes leading to alveolar rupture and dissection of air along the tracheobronchial tree. This study was undertaken to provide a thorough clinical and radiologic analysis of this patient population. A retrospective comparative analysis was performed on patients with SPM over 12 years. Patient demographics, clinical presentation, and radiographic and diagnostic studies were recorded. A clinical and radiologic comparison was performed with secondary pneumomediastinum. Seventy-four patients were identified with a diagnosis of pneumomediastinum. A total of 28 patients with SPM were identified. The major initial complaints were chest pain (54%), shortness of breath (39%), and subcutaneous emphysema (32%). The main triggering events were emesis (36%) and asthma flare-ups (21%). No apparent triggering event was noted in 21% of patients. Chest radiograph was diagnostic in 69%; computed tomography was required in 31%. Esophagram, esophagoscopy, and bronchoscopy were performed on an individual basis and were invariably negative. When compared with secondary pneumomediastinum, SPM is more likely to be discovered by chest radiography, has a lower incidence of pneumothorax and pleural effusion, requires a shorter hospital stay, and has no associated mortality. Spontaneous pneumomediastinum is a benign condition that often presents with chest pain or dyspnea. It can develop without a triggering event and with no findings on chest radiography. Treatment is expectant and recurrence is low. Secondary causes must be ruled out to avoid an unfavorable outcome.

Between the Person and the Culture: Israeli Arab Couple's Perceptions of Police Intervention in Intimate Partner Violence

ABSTRACT The purpose of this article to present an in-depth analysis of the initial complaint to police as perceived by abused Israeli Arab women and their perpetrators. The research used in-depth, semi-structured interviews with a purposive sample of 20 Israeli Arab men and women. Findings indicated that women and men in Arab society in Israel are both caught in a struggle between two opposing forces: One is directed towards preserving traditional cultural codes and values concerning asymmetric gender relationships, emphasis on family values, honor, and the powerful delegation of conflict resolution to the extended family; the other expresses increasing awareness of women's right to oppose their own victimization by men and to make their own decisions. Implications for practice in the domain of social control and intervention with cultural minority groups are suggested.

Diagnostic and Therapeutic Challenges of Childhood Brucellosis in a Nonendemic Country

We sought [corrected] to define the current epidemiology, clinical manifestations, and course of childhood brucellosis in the United States. A retrospective chart review was performed of 20 patients who received a diagnosis of brucellosis over a period of 13 years at a large, tertiary care children's hospital in Dallas, Texas. Diagnostic criteria, epidemiology, clinical presentations, and outcomes were recorded. Ninety-five percent of the patients had a recent history of either travel to Mexico or ingestion of unpasteurized milk products from Mexico. Fever was an initial complaint in 80% of the patients, and 50% of the patients presented with arthritis. Diagnosis was made via the identification of Brucella melitensis in the blood cultures of 18 patients. Five patients experienced relapse, and 3 experienced treatment failure. Childhood brucellosis in the United States is now an imported disease, primarily from Mexico. In the context of this epidemiologic link, the diagnosis should be entertained for a patient who presents with signs of systemic inflammation and arthritis. Therapeutic challenges remain.

Periparturient hemorrhage in mares: 73 cases (1998–2005)

To determine signalment, physical examination and clinicopathologic abnormalities, outcome, and subsequent fertility of mares with periparturient hemorrhage (PPH) and identify factors associated with outcome (ie, survival vs death). Retrospective case series. 73 mares. Medical records were reviewed for information on age, breed, initial complaint, physical examination and clinicopathologic abnormalities, treatment, outcome, and subsequent fertility. Median age was 14.0 years (range, 5 to 24 years), and median number of foals produced prior to the diagnosis of PPH was 8 (range, 1 to 16). Ten (14%) mares had prepartum hemorrhage and 63 (86%) had postpartum hemorrhage. Treatment was aimed at restoring cardiovascular volume, enhancing coagulation, controlling pain, and reducing the effects of endotoxemia. Sixty-one (84%) mares survived and 12 (16%) died or were euthanized. Common complications included fever, leukopenia, retained fetal membranes, increased digital pulses, thrombophlebitis, and cardiac arrhythmias. Of the 53 surviving mares for which subsequent breeding information was available, 26 (49%) produced 1 or more foals after recovering from PPH. Results suggested that PPH can develop in mares of any age and parity. Treatment was associated with a good prognosis for survival and a reasonable prognosis for future fertility.

Late Diagnosis of Early Disseminated Lyme Disease: Perplexing Symptoms in a Gardener

The timely diagnosis of early disseminated Lyme disease presenting as multiple secondary erythema migrans lesions is sometimes delayed because this stage is infrequently encountered in a general practice. We report a case of a 60-year-old woman whose initial complaints of an erythematous, "burning" rash and flu-like symptoms led to several laboratory tests with no specific diagnosis. The correct diagnosis was only made after sorting through other possibilities in the differential diagnosis. By reproducing the medical images and reviewing the medical literature, we underscore the importance of including Lyme disease in the list of diagnoses pertaining to diffuse skin rashes in the febrile patient.

A single-case study on the process and outcome of psychoanalysis

This study aimed to explore the specificity of psychoanalytic treatment by investigating one psychoanalysis over a period of its five years as well as two and five years after its termination. The patient and analyst were interviewed and the analyzand filled out questionnaires and self-rating scales every year during the treatment as well as at the follow-ups. The analyzand reported that he found “a space for himself in himself” in which he could contain a range of strong affects. The psychoanalytic relationship was stable and consistent, and the patient's initial complaints decreased significantly over time. “Reflective functioning scores” increased during the treatment; the self-ratings already showed positive changes in the first year of treatment, which were maintained throughout treatment as well as at the two- and five -year follow-ups.

Transendoscopic, laser-assisted ventriculocordectomy for treatment of left laryngeal hemiplegia in horses: 22 cases (1999–2005)

To determine long-term effects of transendoscopic, laser-assisted ventriculocordectomy (LAVC) on airway noise and performance in horses with naturally occurring left laryngeal hemiplegia. Retrospective case series. 22 horses with left laryngeal hemiplegia treated by means of LAVC. Medical records were reviewed and initial complaint, intended use of the horse, duration of abnormal airway noise, preoperative performance level, endoscopic findings, surgical procedure, postoperative treatment, and complications were recorded. Follow-up telephone interviews with owners and trainers were conducted to determine time for return to intended use, level of postoperative performance, and percentage reduction in airway noise. All horses were examined because of excessive airway noise; 10 (45%) had concurrent exercise intolerance. Left ventriculocordectomy was performed in all 22 horses; bilateral ventriculocordectomy (right ventriculocordectomy was done 1 year later) was performed in 1 horse (5%). Complications occurred in 3 (14%) horses. Twenty (91%) horses returned to their intended use. Excessive airway noise was eliminated after surgery in 18 (82%) horses; exercise intolerance improved postoperatively in 8 of 10 horses. Three racing Thoroughbreds returned to racing; 1 additional racehorse returned to racing but required a laryngoplasty 1 year later to continue racing. Results suggested that LAVC was an effective procedure for elimination of excessive airway noise and improvement of performance in horses with left laryngeal hemiplegia.

Clinical and laboratory features of Crimean-Congo hemorrhagic fever: predictors of fatality

To determine the predictors of fatality among patients with Crimean-Congo hemorrhagic fever (CCHF) based on epidemiological, clinical, and laboratory findings. Among the patients with possible CCHF who were referred to Ankara Numune Education and Research Hospital (ANERH) from the surrounding hospitals between 2003 and 2006, those with IgM antibodies and/or reverse transcriptase-polymerase chain reaction (RT-PCR) results positive for CCHF virus in their blood, and who had received only supportive treatment, were included in the study. Sixty-nine patients with CCHF were admitted to ANERH from various cities of the northeastern part of the central region and southern parts of the Black Sea region of Turkey. Eleven (15.9%) patients died. Age, gender, days from the appearance of symptoms to admission, and initial complaints except bleeding were similar between fatal and non-fatal cases (p>0.05). Among the clinical findings, ecchymosis (p=0.007), hematemesis (p=0.030), melena (p<0.001), somnolence (p<0.001), and gingival bleeding (p=0.044) were more common among fatal cases. The mean platelet count was 47.569 x 10(9)/l in non-fatal cases and 12.636 x 10(9)/l in fatal cases (p=0.003). Among the fatal cases, the mean prothrombin time (PT; 18.4s vs. 13.4s; p<0.001) and the mean activated partial thromboplastin time (aPTT; 69.4s vs. 42.7s; p=0.001) were longer, and the mean alanine aminotransferase (ALT; 1688 vs. 293; p<0.001), mean aspartate aminotransferase (AST; 3028 vs. 634; p<0.001), mean lactate dehydrogenase (LDH; 4245 vs. 1141; p<0.001), mean creatine phosphokinase (CPK; 3016 vs. 851; p=0.004) levels and the mean international normalized ratio (INR; 1.38 vs. 1.1; p<0.001) were higher. In a Cox proportional hazards model, thrombocytopenia of < or = 20 x 10(9)/l (hazard rate (HR) 9.67; 95% confidence interval (CI) 1.16-80.68; p=0.036), a prolonged aPTT > or = 60s (HR 11.62; 95% CI 2.40-56.27; p=0.002), existence of melena (HR 6.39; 95% CI 1.64-24.93; p=0.008), and somnolence (HR 6.30; 95% CI 1.80-22.09; p=0.004) were independently associated with mortality. Thrombocytopenia of < or = 20 x 10(9)/l, a prolonged aPTT > or = 60s, the existence of melena, and somnolence were independent predictors of fatality.

Pituitary adenoma and concomitant Rathke’s cleft cyst

Although pituitary adenomas and Rathke's cleft cysts have a shared ancestry, they rarely occur simultaneously. Only 32 reports involving a pituitary adenoma and a concomitant Rathke's cleft cyst were identified upon review of the literature. Most initial presenting complaints include hormonal symptoms, visual disturbances, and headache. Next to growth hormone, Prolactin was the most commonly hypersecreted pituitary hormone. Rathke's cleft cysts show variable position, size, and signal intensity on magnetic resonance imaging (MRI). Here, we report a patient with a growth hormone- secreting pituitary adenoma associated with a Rathke's cleft cyst. The mass contained two different signal intensities on MRI. The lesion was successfully removed assisted by intraoperative MRI, when the presence of both lesions was confirmed. When a non-enhancing cyst-like structure is demonstrated on imaging in a patient with a pituitary adenoma, the possibility of a coexisting Rathke's cleft cyst should be considered.

The reproductive phenotype in polycystic ovary syndrome

The symptoms of women with polycystic ovary syndrome (PCOS) include hirsutism and irregular menstrual bleeding due to ovarian androgen excess and chronic anovulation. Typically, these features emerge late in puberty or shortly thereafter. The proposed mechanism(s) responsible for increased ovarian androgen production include heightened theca cell responsiveness to gonadotropin stimulation, increased pituitary secretion of luteinizing hormone, and hyperinsulinemia. The cause of ovulatory dysfunction is not well understood, but is linked to abnormal follicle growth and development within the ovary. As a result, infertility is common among women with PCOS and, in many instances, is the initial presenting complaint. Insulin resistance and obesity are frequently associated with PCOS and probably contribute to the severity of symptoms. The polycystic ovary that accompanies the syndrome has recently been defined as having 12 or more follicles per ovary or an ovarian volume greater than 10 ml as determined by ultrasonography. In addition, there is an increased number of growing follicles in the polycystic ovary. Despite this distinctive appearance, the cause and development of the polycystic ovary are completely unknown.

Delay in diagnosis of Duchenne muscular dystrophy may reduce benefit from new corticosteroid protocol

About one-third of boys with Duchenne muscular dystrophy (DMD) have associated learning difficulties, particularly speech and language delay, and this may be the initial presenting complaint. Attention is often focused on behaviour and learning difficulties, and the progressive muscle weakness may not be noticed until the condition is advanced. Now that corticosteroids have been established as the gold standard of care, delay in the diagnosis of DMD has become far more relevant because any delay may limit the benefit that can be gained from steroid therapy, since muscle strength that has been lost cannot be regained. We present 3 cases of boys with unexplained learning difficulty in whom the diagnosis could have been made far earlier if a creatine kinase test had been done at presentation.

Oral Burkitt's lymphoma in children: the Moroccan experience

Thirty-seven children with Burkitt's lymphoma of the oral region diagnosed between 1998 and 2005 were reviewed. There were 31 boys and 6 girls. The mean age at diagnosis was 6.64 years (range 2–15 years) with a mean delay to diagnosis of 41 days (range 10 days–2 months). There was a predominance of maxillary over mandibular involvement: 1.44:1. Complaints included exophytic mass with dental displacement (100%), abdominal pain (68%), nerve palsy (28%) and orbital swelling (21%). Toothache as initial complaint led to dental extraction in 12 cases. According to the Murphy classification, there were 4 stage II, 11 stage III and 22 stage IV tumours; 43% and 41% had bone marrow and central nervous system involvement, respectively. After chemotherapy, complete remission was seen in 59% of cases. Remission in two children was relatively brief, lasting no more than 3 months. After a median follow-up of 45 months (range 9–99 months), the disease-free survival rate was 54%. In conclusion, in this series, oral presentation of Burkitt's lymphoma was a component of more widely disseminated disease. The pattern seemed to fall between that of the endemic and the sporadic types. Even with intensive chemotherapy, patients with advanced disease maintained a poor prognosis.

Primary lateral sclerosis mimicking atypical parkinsonism

Primary lateral sclerosis (PLS), the upper motor neurone variant of motor neurone disease, is characterized by progressive spinal or bulbar spasticity with minimal motor weakness. Rarely, PLS may present with clinical features resembling parkinsonism resulting in occasional misdiagnosis as one of the atypical parkinsonian syndromes. Here we describe five patients initially referred with a diagnosis of levodopa-unresponsive atypical parkinsonism (n = 4) or primary progressive multiple sclerosis (n = 1), but subsequently found to have features consistent with PLS instead. Onset age varied from 49 to 67 years. Unilateral limb slowness or clumsiness was the initial complaint in four, and bulbar symptoms in one. Repeated finger/foot tapping was slow in all five, but without fatiguing or decrement. Spasticity with hyperreflexia, exaggerated jaw jerk and extensor plantar responses were eventually seen in all patients. Anterior horn cell involvement developed in three cases. Early gait disturbances resulting in falls were seen in all patients and none of them responded to dopaminergic medications. Two patients underwent dopamine transporter (DaT) SPECT scanning with normal results. Other features included emotional lability (n = 5) and cognitive impairment involving frontal subcortical systems (n = 1). In conclusion, these cases represent a subgroup of PLS patients in whom pyramidal slowness may be mistaken for akinesia, and spasticity misconstrued as rigidity, leading to an erroneous diagnosis of atypical parkinsonism. However, the absence of fatiguing and decrement on repeated finger/foot tapping should help to distinguish these patients from the true atypical parkinsonian syndromes.

Xp11.2 Translocation Renal Cell Carcinoma With Very Aggressive Course in Five Adults

Renal cell carcinomas associated with Xp11.2 translocations ( TFE3 gene fusions) are rare tumors predominantly reported in children. We studied 5 cases of translocation carcinoma in adult patients, 18 years or older (mean age, 32.6 years). Tumors were examined histologically, immunohistochemically, and electron microscopically and correlated with the clinical picture. Most tumors showed solid sheets of clear to eosinophilic cells with rich vasculature and foci of papillary or pseudopapillary architecture. All cases showed strong nuclear positivity for TFE3. Vimentin and CD10 were positive in the cytoplasm. A panel of cytokeratin antibodies, smooth muscle actin, CD45, HMB45, and calretinin were negative. Patients had nonspecific initial complaints and were diagnosed with advanced disease, most with distant metastases. Various treatments met with minimal success. Unlike pediatric patients, the adult patients followed a rapidly terminal course, with a mean survival of 18 months after diagnosis (range, 10-24 months).

Outcome of surgical management of concealed penis

Objective To review the etiological factors, clinical presentations and outcome of our surgical technique to correct the anomaly of concealed penis. Patients and methods Thirty consecutive patients were treated in 2000–2004. Mean age at operation was 6.7 years (range 13 months–15.4 years). They underwent penoplasty alone (22 patients) or penoplasty with liposuction of prominent prepubic fat pad (eight patients). The medical records of all the patients were retrospectively reviewed, and 23 patients were interviewed, examined clinically and questioned about their initial complaint and the results of our technique. Mean follow up was 28 months (range 6 months–5 years). Results The patients most commonly presented with cosmetic (60.0%), voiding (56.6%) and psychosocial (50.5%) concerns. Three underlying anatomic defects contributing to concealment were observed: fibrotic dartos fascia with poor skin attachment at the base of the penis (93%), prominent prepubic fat pad (40%) and postoperative phimosis leading to trapped penis (26%). Early postoperative complications occurred in 4 patients (13.3%) and all were treated conservatively and successfully. Fourteen patients (46.6%) underwent secondary minor day-case operations, the majority for excision of redundant subcoronal preputial collar. Clinical examination of 23 patients showed very good results in terms of general appearance and accessibility. The older boys were generally more satisfied with the results of surgery than the parents of younger children, whose main source of dissatisfaction was the final circumcised appearance of the penis. Conclusion The surgical approach used to correct concealed penis alleviates the initial complaint and provides good cosmetic and functional results with greater satisfaction in older patients. Our technique had a low early complication rate but a significant number of patients needed a secondary procedure to improve the final cosmetic results.