Level Of Suspicion Research Articles

P4 TRANSTHYRETIN–INDUCED CARDIAC AMYLOIDOSIS: A RARE MUTATION IN AN ITALIAN FAMILIAL CASE

Abstract A 65–year–old man came to our hospital for a subacute stroke of the left parietotemporal area. An aorto–coronary bypass for stable coronary artery disease and aortobisiliac bypass for infrarenal aortic aneurysm (with post–operative courses complicated by multiple atrial fibrillation paroxisms which were pharmacologically cardioverted) was reported. No undergoing anticoagulant therapy for CHADSVASc=1 was reported. Hypothesizing a cardioembolic origin of the stroke, echocardiographic analysis was performed which showed increased ventricular thickness and mass, inhomogeneous texture, reduced systolic function and strain with apical sparing, II degree diastolic dysfunction and severe left atrial dilatation. The strong suspicion of amyloidosis, raised by the echocardiographic findings, was confirmed by bone scintigraphy. The absence of free immunoglobulin chains in blood and urine and a normal protein electrophoretic pattern, would have instead excluded the diagnosis of AL amyloidosis. Thus we performed genetic testing to characterize the type of ATTR (transthyretin). An homozygous Val142Ile mutation in exon 4 of the TTR gene was found. This mutation, typically found in patients of African ancestry, is extremely rare in the Caucasian population. In fact, only 5 cases of patients with this mutation and with phenotypic manifestations very similar to the African ancestral ones have been so far reported, thus indicating that this mutation is not restricted to African ancestry but may be an underestimated Caucasian variant. The large GnomAD database estimates that this homozygous mutation is present in only 0.72% of the general population, while the remaining part of the carriers are heterozygous. Val142Ile leads to increased formation of amyloid fibrils and to the formation of a particularly unstable TTR tetramer. This variant is associated with a worse quality of life, a higher incidence of AF and a lower survival than the wild type TTR. In light of the worse clinical outcomes associated to this variant it is therefore essential to maintain a high level of clinical suspicion in order to perform an early diagnosis from a clinical and molecular point of view in order to be able to direct the patient as soon as possible to the current available therapies that can modify the course of the pathology and avoid premature fatal events.

Three Ds for diagnosing necrotizing fasciitis by front-line clinicians

Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages. To develop a diagnostic algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals. Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm. The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the "3Ds" of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation. The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.

Acute hemorrhagic pancreatitis following influenza infection: a case report

BackgroundAcute hemorrhagic pancreatitis is a life-threatening condition leading to shock and multiorgan failure. Although prevalent in the general population, the incidence during pregnancy is low, with a high maternal and fetal mortality rate. The highest incidence is in the third trimester/early postpartum period. Infectious etiology for acute hemorrhagic pancreatitis is rare with only a handful of cases following influenza infection being documented in the literature.Case presentationA 29-year-old Sinhalese pregnant lady in the third trimester presented with an upper respiratory tract infection and abdominal pain, for which she was managed with oral antibiotics. An elective caesarean section was done at 37 weeks gestation due to a past section. On postoperative day 3 she developed a fever with difficulty in breathing. Despite treatment, she succumbed to death on the sixth postoperative day. The autopsy revealed extensive fat necrosis with saponification. The pancreas was necrosed and hemorrhagic. The lungs showed features of adult respiratory distress syndrome and necrosis was observed in the liver and kidneys. Polymerase chain reaction of lungs detected influenza A virus (subtype H3).ConclusionAlthough rare, acute hemorrhagic pancreatitis from an infectious etiology carries risk of morbidity and mortality. Therefore, a high level of clinical suspicion must be upheld among clinicians to minimize adverse outcomes.

DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) SYNDROME SECONDARY TO PHENYTOIN

This article presents a case report of a 38-year-old man who developed DRESS syndrome 40 days after being prescribed phenytoin prophylactically for seizures following a bike accident. DRESS syndrome is an uncommon yet potentially lethal drug reaction that can manifest within 2-6 weeks following medication exposure. Symptoms include fever, rash, and systemic symptoms such as lymphadenopathy, hepatitis, and interstitial nephritis. The liver is the organ most commonly affected by DRESS syndrome, which can result from over 40 medications, and severe hepatitis leading to liver failure and myocarditis are the leading causes of mortality in DRESS syndrome. There is no specic diagnostic test for DRESS syndrome, and clinicians must have a high level of suspicion and exclude other conditions. Treatment includes stopping the offending drug, supportive care, and early initiation of corticosteroids

Small bowel intussusception in an adult secondary to gastrointestinal stromal tumor: a rare case report.

A 32-year-old male presented with abdominal pain and vomiting for 3 days. Vitals parameters and abdominal examinations were normal. Abdominal ultrasonography revealed target sign suggesting ileoileal intussusception in right lower quadrant. Abdominal contrast-enhanced computed tomography of abdomen showed features suggestive of ileoileal intussusception. Diagnostic laparoscopy was done which was later turned to laparotomy for segmental resection and anastomosis of ileum for ileoileal intussusception. Polypoidal growth noted in the resected section of ileum was found to be GIST (CD117 and DOG-1 positive) which was considered to be the lead point. Patient recovered well during postoperative period and later referred to oncology clinic for chemotherapy. Intussusception and subsequent obstruction are very uncommon presentation in a patient with GIST because of their tendency to grow in an extraluminal fashion. As intussusception is rare in adult, high level of suspicion and proper imaging technique plays important role in diagnosing the condition. Ileoileal intussusceptions due to GIST are a rare clinical entity in adult intussusceptions and generally have a vague variable clinical presentation thus requiring high index of clinical judgement and suspicion with judicious use of imaging.

Skin lesions in a man with end-stage renal disease.

Calciphylaxis is an uncommon condition most often seen in patients with end-stage renal disease. It is easily mistaken for other more common conditions and requires a high level of suspicion to make a timely diagnosis. Although various treatments such as IV sodium thiosulfate and bisphosphonates have been used for management, calciphylaxis remains a condition with a high mortality that requires an interdisciplinary approach for optimal management.

Extensive septic pelvic thrombophlebitis in a puerperal woman: a case report

OBJECTIVE: This article aims to report an extensive case of septic pelvic thrombophlebitis, a rare, severe, and challenging diagnostic condition. The clinical picture may range from mild to severe sepsis. Its diagnosis is of exclusion, but it can be complemented with imaging exams. CASE DESCRIPTION: We report a case of postpartum thrombophlebitis in the infrarenal portion of the inferior vena cava, external and internal common iliac veins, bilateral common femoral veins, as well as in the right ovarian vein, presenting with persistent fever and negative cultures. The patient showed significant clinical improvement after association of anticoagulation and antibiotic therapy. CONCLUSION: Septic pelvic thrombophlebitis is an important differential diagnosis for abdominal pain and fever in the postpartum period, but the absence of specific complementary tests makes its diagnosis challenging, which often leads to misdiagnosis of acute appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, adnexal torsion, or pelvic abscess. The key to correct diagnosis is a high level of clinical suspicion, especially when there is resistance to broad-spectrum antibiotic therapy and remission after systemic anticoagulation. Given the large number of cesarean sections performed today and their correlation with septic pelvic thrombophlebitis, an increase in the number of cases should be accompanied by greater familiarity of health professionals with this complication, in order to avoid inadequate propaedeutics and conducts. In this context, the present case report documents the importance of investigating pelvic septic thrombosis in patients with fever in the puerperium and its differential diagnoses for early initiation of therapy to reduce morbidity and mortality.

Inflammatory biomarkers behavior profile among patients following elective degenerative spine surgery and their differences with those coursing with a postoperative spinal infection: Protocol for a Systematic Review.

The incidence of postoperative spinal infection (PSI) ranges from 0% to 10%, devastatingly affecting the patient prognosis and increasing costs to the healthcare system because of higher morbidity. Postoperative spinal infections require a high level of suspicion as they are difficult to diagnose, especially in the early postoperative state, because of many confounding factors such as clinical symptoms, serum biomarkers rise or confusing imaging studies. Current research has focused on serum biomarkers at the early stages of disease, nevertheless, most rely on retrospective cohorts with serum biomarkers studied individually and at different time points. To determine the Inflammatory biomarkers behavior profile among patients following elective degenerative spine surgery and their differences with those coursing with postoperative spinal infection. The proposed systematic review will follow the PRISMA statement. This protocol was registered at PROSPERO on January 19th, 2022, obtaining the following register CRD42022304645 on February 19th, 2022. We will include studies related to biomarkers in adult patients operated on because of degenerative spinal diseases, and those developing a postoperative spinal infection. The following information will be extracted: (1)study title; (2)Study Author (3)year; (4)evidence-level; (5)Research-type; (6)diagnosis group (elective postoperative degenerative disease / PSI); (7a)region (Cervical, Thoracic, Lumbosacral, Coccigeal); (7b)Type of infection by anatomical or radiological site, (8)Surgery-Type (including instrumentation or not); (9)number of cases; (10)mean age or individual age; and (11) individual serum biomarker values from the preoperative state up to 90 days postop for both groups including: (10a)interleukine-6, (10b)Presepsine, (10c)Erythrocyte Sedimentation Rate, (10d)Leukocyte Count, (10e)Neutrophil Count, (10f)C-Reactive Protein, (10g)Serum Amyloid, (10h)White Cell Count, (10i)Albumin, (10j)Prealbumin, (10k)Procalcitonin, (10L)Retinol associated protein, (10M)Dickopf-1, (11)postoperative days at symptoms or diagnosis, (12)Type of organism, (13)day of starting antibiotics, (14)duration of treatment and (15)any biases (including comorbidities, especially those affecting immunological status). All biomarkers' data will be presented graphically over time. Figure 1 contains the flow diagram of the methodology. No ethical approval will be required, as this review is based on published data and does not involve interaction with human participants. The search for this systematic review commenced in February 2021, and we expect to publish the findings in middle 2023. The present study will provide the biomarkers' behavior profile for PSI and patients following elective surgery for degenerative spinal diseases from the preoperative period up to 90 days postoperative providing cut-off values at the day of diagnosis. It will provide clinicians with a better background to diagnose based on highly trustable information based on cut-off values from this systematic review. Finally we expect this review to provide a basis for future research on biomarkers to establish more accurate and timely diagnosis in the early stages of illness ultimately impacting the patient's physical and mental health, reducing the disease burden. PROSPERO register ID: CRD42022304645.

P025 The knee that gave it away: a case report of melioidosis

Abstract Background/Aims Melioidosis, an infectious disease caused by the Burkholderia pseudomallei is very rare within the UK. This gram-negative bacterium is endemic in Southeast Asia predominately Thailand and Northern Australia which is found within the soil and fresh surface water. We present a challenging case of melioidosis who was diagnosed following a culture of a discharging knee swelling. Methods N/A Results 35-year-old, Caucasian gentleman with no previous past medical history presented with a ten week history of diffuse abdominal pain, weight loss, dry cough, fatigue and night sweats. On examination, he appeared pale and initial bloods showed a CRP of 229 mg/L. His other initial observations and baseline blood tests were normal. Abdominal ultrasound detected free peritoneal fluid and a subsequent CT chest and abdominal showed abnormal thickening of his small bowel, mediastinal and retroperitoneal lymphadenopathy along with bilateral pulmonary nodules. A laparoscopy and laparotomy with peritoneal, intraperitoneal and mesenteric lymph node biopsies were inconclusive. Microscopy and culture (MC&S) as well as acid fast bacilli MC&S were both negative. He continued to have systemic symptoms, as well as elevated inflammatory markers. He underwent a bronchoscopy which showed erythematous and a nodular endobronchial mucosa with white plaques seen within the lower trachea and minor narrowing of the lumen. Endobronchial biopsies showed chronic inflammation with no evidence of any malignant cells. Repeated bloods including retroviral screening, anti-nuclear antibody (ANA) and antinuclear cytoplastic antibodies (ANCA) and serum ACE were normal. At this stage, the clinical picture was suggestive of sarcoidosis, however a subsequent rigid bronchoscopy and biopsy did not evidence of granulomas or vasculitis. The patient started to develop increasing right knee swelling with difficulty in walking. The swelling burst open, and the discharging fluid was sent for MC&S. This was positive for Burkholderia pseudomallei. The gentleman completed a 20-week course of antibiotics with clinical resolution. Conclusion Meliodosis can cause a wide range of clinical manifestations varying from asymptomatic to septicemia, osteomyelitis, abscesses, septic arthritis and encephalomyelitis. Our case had travelled to Thailand around 8 months prior to the onset of symptoms. This highlights the possible long latent period between exposure and clinical presentation. Definite diagnosis is through isolation of Burkholderia pseudomallei in cultures. This proved challenging in our case, as multiple biopsies and cultures from different sites did not grow the bacterium. The diagnosis was confirmed following knee fluid culture. Musculoskeletal involvement of melioidosis is a known presentation and its potential to mimic other conditions, may render a diagnostic challenge especially when it occurs outside an endemic area. The case highlights the need for rheumatologists to have a high level of clinical suspicion for early detection, isolation of the organism and proper disease management. Disclosure A. Maksoud: None. L. Sammut: Other; LS has received funding for educational events and activities - from Lilly, Roche/Chugai.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach.

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Umbilical cord hematoma – a successful case of a non-frequent acute fetal distress etiology

Background: Umbilical cord hematoma is a rare condition, with mortality rates up to 50%. Most of the literature describes cases with poor prognosis. Case description: In this case, a healthy pregnant woman in labor presented some variable decelerations on the fetal heart rate monitoring ending in sustained bradycardia. An emergency C-section was performed, giving birth to a 40-weeks male newborn with an umbilical cord hematoma until placental insertion and, slightly stump bleeding. Newborn got pale and, had respiratory distress in the first hour of life. He presented transient metabolic acidosis with hyperlacticaemia and, anemia. There was a favorable evolution with supportive therapy. No risk factor was identified and, histological examination confirmed the diagnosis. The patient remained asymptomatic and, presented normal neurodevelopment during follow-up. Discussion: This case report aims to demonstrate a good outcome when a high level of suspicion is taken and immediate medical and, surgical interventions are performed

Teaching NeuroImages: Rupture and spontaneous resolution of a P1 perforator pseudoaneurysm

A 47-year-old man with a history of smoking and hypertension had a severe, sudden headache. Head CT showed subarachnoid hemorrhage (SAH) (figure, A). Progressive ophthalmoplegia developed without alteration of consciousness. Catheter angiography was normal (figure, B). Brain MRI documented bilateral thalamic infarcts (figure, C). Repeat catheter angiography after 4 days showed a 2-mm dissecting pseudoaneurysm of a thalamoperforator (figure, D and E). Serial noninvasive vascular studies documented no growth. Six weeks later, a catheter angiogram demonstrated complete resolution of the pseudoaneurysm (figure, F).Bilateral third nerve palsy persisted at 1 year follow-up. Dissecting pseudoaneurysms of perforating posterior circulation vessels can present with a pattern suggestive of perimesencephalic SAH. Presence of associated neurologic deficits should increase the level of suspicion. Spontaneous resolution can occur without invasive treatment.1

Spinal Dural Arterio-Venous Fistula: A Vital Differential Diagnosis to Consider for Myelopathy.

Spinal dural arterio-venous fistula (SDAVF) is a rare and underdiagnosed cause of myelopathy which can result in a devastating neurological outcome if not properly managed. We report a case of SDAVF in a middle-aged man with gradual progressively deteriorating myelopathy and associated symptoms. This was first managed as demyelinating disease but was refractory to steroid therapy. Vigilant review of his spinal magnetic resonance imaging (MRI) scans showed dilated perimedullary veins, suspicious for SDAVF. The diagnosis was confirmed with catheter angiography. Neurological symptoms resolved after surgical treatment. SDAVF can closely mimic demyelinating conditions such as transverse myelitis or multiple sclerosis. MRI finding of dilated perimedullary veins can be subtle and masked in the late stage, posing a diagnostic challenge for physicians. It is potentially curable after timely treatment. Clinicians should maintain a high level of suspicion for SDAVF and actively review all available radiological imaging for clues, particularly when there is a lack of response to treatment for other causes of myelopathy. Spinal dural arterio-venous fistula (SDAVF) can have clinical and radiological features similar to those of demyelinating disease, often causing a diagnostic dilemma for physicians. Neurological sequalae can be devastating if left untreated.Clinicians should be aware of this rare yet important differential diagnosis for myelopathy and its classic MRI findings (spinal cord oedema and dilated perimedullary veins).The gold standard for diagnosis is catheter spinal angiography. Treatment options include endovascular embolization and surgical ligation of the fistula.

Transverse colon volvulus presenting as bowel obstruction, atelectasis, and displacement of the right lobe of the liver into the left upper abdominal quadrant: a case report

BackgroundTransverse colon volvulus is an uncommon cause of intestinal obstruction. It is a surgical emergency that can lead to bowel infarction, peritonitis, and death.Case presentationWe report a case of transverse colon volvulus in a 35-year-old Congolese immigrant man who had a rare presentation with features of intestinal obstruction associated with right lung collapse and left mediastinal shift.ConclusionThis case is unusual because it presented with respiratory features that mimicked a pneumothorax in addition to features of intestinal obstruction. The use of point-of-care lung ultrasound was helpful in ruling out a pneumothorax, and this could help avoid situations such as unintentional chest drain insertions by other professionals who may encounter a similar case. Because transverse colon volvulus is rare, a high level of suspicion and awareness is required to make an accurate diagnosis.

Head and Neck Manifestations of Necrotizing Fasciitis: A Case Series and Meta-Analysis

Introduction: Plastic surgeons frequently take facial trauma calls, and their responsibilities may include infection care. The head and neck is a site of presentation for necrotizing fasciitis which requires a high level of suspicion and prompt acti2on for diagnosis and treatment. We performed a meta-analysis of the literature on necrotizing fasciitis of the head and neck (HNnf) to summarize clinical factors, causative organisms, and treatment, and included 2 cases presenting to our institution. Methods: A meta-analysis of the literature from 1990 to 2021 was completed on HNnf. After institutional review board approval, medical records of 2 patients presenting with a diagnosis of HNnf to an academic plastic surgery center between July and September 2021 were retrospectively reviewed. Systematic reviews and articles without comprehensive individualized patient data were excluded. Results: A systematic review was performed including 2 cases presenting to our institution. A total of 149 individual cases of HNnf spanning a 30-year period were included. The most common associated comorbidity was diabetes mellitus. The most frequent source of infection was odontogenic. Most patients required serial debridements in addition to IV antibiotics. Streptococcus pyogenes was the most frequent pathogen; however, most infections were polymicrobial. Infections in the periorbital region were significantly monomicrobial ( P = .011). Acute reconstructive surgery requirements: 27 patients had skin grafting, 9 had flap reconstruction. Mortality rate was 12.3%. Increasing age was a significant predictor of mortality ( P = .01). Patients with diabetes were significantly more likely to die from HNnf (52.6%, P = .039) and require multiple debridements ( P = .001) for HNnf as compared to patients without diabetes. Infections initially arising from the submandibular region were found to be an independent negative predictor of mortality ( P = .029). Conclusion: Our experience with HNnf along with meta-analysis of the literature revealed trends in demographics, presentation, organisms, and outcomes, increasing the collective knowledge of this rare entity.

PI-RR: The Prostate Imaging for Recurrence Reporting System for MRI Assessment of Local Prostate Cancer Recurrence After Radiation Therapy or Radical Prostatectomy-A Review.

The purpose of this article is to review clinical application of the Prostate Imaging for Recurrence Reporting (PI-RR) system. This system, released in 2021, represents international consensus-based guidelines for the acquisition, interpretation, and reporting of multiparametric MRI performed to detect locally recurrent prostate cancer after radiation therapy or radical prostatectomy. The system reduces variability through use of a standardized and structured reporting approach whereby the overall level of suspicion of recurrence is classified on a 5-point scale. The overall suspicion score is derived from 5-point scales for assessing DWI and dynamic contrast-enhanced (DCE) imaging. Separate scales for both DWI and DCE imaging are provided for evaluation after radiation therapy and after radical prostatectomy. These scales account for the relation between detected abnormalities and the location of the primary tumor on pretreatment imaging. T2-weighted imaging is also assessed on a 5-point scale and is useful for anatomic imaging but does not influence the overall score. Initial retrospective studies have shown promising results with respect to the reproducibility and accuracy of PI-RR in detecting locally recurrent tumor.

Pneumomediastinum in COVID-19 disease: Clinical review with emphasis on emergency management.

Pneumomediastinum can be primary (spontaneous) or secondary to iatrogenic, traumatic, and non-traumatic causes. The incidence of spontaneous and secondary pneumomediastinum is higher in patients with coronavirus disease 2019 (COVID-19) compared to the general population. So, pneumomediastinum should be considered in the differential diagnosis of any patient with COVID-19 presenting with chest pain and breathlessness. A high level of suspicion is required to diagnose this condition promptly. Unlike in other disease conditions, pneumomediastinum in COVID-19 has a complicated course with higher mortality in intubated patients. No guidelines exist for managing pneumomediastinum patients with COVID-19. Therefore, emergency physicians should be aware of the various treatment modalities besides conservative management for pneumomediastinum and life-saving interventions for tension pneumomediastinum.

Multiple Bone Metastases as the Initial Presentation of Occult Breast Carcinoma in a Kidney Transplant Recipient

Introduction: Due to their immunosuppressive medication regimen, solid organ transplant recipients have an increased risk of developing cancer, which might jeopardize their survival. Specifically, cardiovascular disease and malignancy are the two leading causes of death in kidney transplant recipients. In solid organ recipients, cutaneous malignancies, lymphomas, and Kaposi’s sarcomas also appear to be the most prevalent cancer forms. Thus, carcinoma of unknown primary origin is a clinical entity that diagnosing requires a high level of suspicion and thorough reviewing of laboratory, radiological, and clinical findings. Further, susceptible patients, such as immunocompromised ones, should merit a careful analysis of findings and detailed analytic rationale. We, therefore, present the following case report demonstrating the importance of follow-up of specific suspicious serum markers in transplant patients. To our knowledge, this study is the first case to report an occult breast carcinoma as the initial presentation in a patient with a kidney transplant.Case Presentation: In the following case, the primary indication for malignancy was elevated alkaline phosphatase (ALP), a common finding in patients with chronic renal failure. Once noticed in a scheduled post-transplantation follow-up, further diagnostic tests, such as a broader serum panel, sternal puncture, and mammography, were ordered and returned normal. Subsequently, CT was ordered and revealed lytic and sclerotic bone changes. Afterward, serum tumor markers were ordered together with gynecological ultrasound and PET-CT. Finally, an iliac bone marrow biopsy confirmed a breast cancer diagnosis of unknown primary origin, causing the elevated ALP.Conclusions: This case report presents a uniquely difficult diagnostic challenge as an expected elevated value of ALP in a kidney transplant recipient was the only diagnostic clue for occult breast carcinoma. We discuss further the vigilance that physicians must exert when dealing with kidney transplant recipients and the implication of carcinoma of unknown primary in this population.

Inflammatory response in confirmed non-diabetic foot and ankle infections: A case series with normal inflammatory markers.

The distinction between foot and ankle wound healing complications as opposed to infection is crucial for the appropriate and efficacious allocation of antibiotic therapy. Multiple reports have focused on the diagnostic accuracy of different inflammatory markers, however, mainly in the diabetic population. To evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort. Data was reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals-United Kingdom with musculoskeletal infections over the period between July 2014 and February 2020 (68 mo). All patients with confirmed diagnosis of diabetes were excluded while only those with confirmed microbiological or clinical diagnosis of foot or ankle infection were included in our study. For the included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0-10 mg/L and WCC 4.0-11.0 × 109/L were considered normal. After exclusion of patients with confirmed diabetes, 25 patients with confirmed foot or ankle infections were included. All infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with osteomyelitis (OM) of the foot, 11 (44%) with OM of the ankle, 5 (20%) with ankle septic arthritis and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients, either a corrective osteotomy or an open reduction and internal fixation for a foot or ankle fracture with the infection developing on top of the existing metalwork. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metal work. CRP sensitivity was 84%, while WCC sensitivity was only 28%. CRP has a relatively good sensitivity in the diagnosis of foot and ankle infections in non-diabetic patients, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM.

A Young Skier with Leg Pain

BackgroundProximal tibiofibular joint (PTFJ) dislocation is a rare injury that can disrupt the proximal tibia-fibula joint. The abnormalities in knee x-ray imaging can be subtle and difficult to detect, requiring careful assessment. This rare cause of lateral knee pain requires a high level of suspicion for diagnosis. Treatment is closed reduction; unstable PTFJ dislocations often require surgical intervention. Case ReportA 17-year-old young man presented to the emergency department (ED) with right lateral knee pain and difficulty walking after colliding with another skier 2 days prior. The examination showed right lateral ecchymosis and tenderness over the lateral proximal fibula. He remained neurovascularly intact with a full passive and active range of motion. X-ray studies were obtained. The patient was referred by his outpatient orthopedic surgeon after the initial knee x-ray study was concerning for PTFJ dislocation and unsuccessful reduction. In the ED, the patient underwent moderate sedation and successful orthopedic-guided reduction via medial force on the lateral fibular head, while hyper-flexing the knee and holding the foot dorsiflexed and everted. Post-reduction radiographs showed improved proximal tibiofibular alignment without fracture. Why Should an Emergency Physician Be Aware of This?PTFJ dislocation is a rare injury that can be missed easily and requires a high level of suspicion when presented with an acute traumatic knee pain. Closed reduction of PTFJ dislocation can be achieved in the ED and early identification can prevent long-term sequelae.