Low Index Of Clinical Suspicion Research Articles

A Case of Necrotizing Fasciitis of the Breast Following Lumpectomy and Oncoplastic Closure

Background. NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. Case Report. The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. Conclusion. This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.

Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis.

Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.

The promising role of risk scoring system for Cushing syndrome: Time to reconsider current screening recommendations.

Despite the current screening approach for Cushing syndrome (CS), delayed diagnosis is common due to broad spectrum of presentation, poor discriminant symptoms featured in diabetes and obesity, and low clinical index of suspicion. Even if initial tests are recommended to screen CS, divergent results are not infrequent. As global prevalence of type 2 diabetes and obesity increases, CS may not be frequent enough to back routine screening to avoid false-positive results. This represents a greater challenge in countries with limited health resources. The development of indexes incorporates clinical features and biochemical data that are largely used to provide a tool to predict the presence of disease. In clinical endocrinology, indexes have been used in Graves' ophthalmology, hirsutism, and hypothyroidism. The use of clinical risk scoring system may assist clinicians in discriminating CS in the context of at-risk populations and, thus, may provide a potential intervention to decrease time to diagnosis. Development and validation of clinical model to estimate pre-test probability of CS in different geographic source population may help to establish regional prediction model for CS. Here, we review on the latest progress in clinical risk scoring system for CS and attempt to raise awareness for the use, validation, and/or development of clinical risk scores in CS.

Secondary Hemophagocytic Lymphohistiocytosis in Adults: Experience from a Safety Net Hospital Serving an Underserved Population

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition, driven by an overactivation of the immune system, which causes inflammatory tissue damage potentially leading to organ failure and death. Secondary HLH in adults is a rare clinical entity and diagnosis often is delayed due to low index of clinical suspicion or limited availability of sophisticated testing. Therefore, evidence related to overall outcomes in underserved populations remains scarce. Methods: After institutional review board approval, we retrospectively reviewed charts of patients 18 years or above, with a diagnosis of hemophagocytic lymphohistiocytosis at our institution between 2015-2021. Data on baseline characteristics, cause of HLH and overall outcomes were collected and analyzed. SAS v9.4 was used for statistical analysis. Results: A total of 17 patients were included for the analysis. Majority patients were males (10/17, 58.8%) and mean age was 41.1 ± 17.1 years. Most patients lacked insurance coverage (12/17, 70.6%); in patients with insurance coverage, Medicaid was the most common primary payer (5/6, 83.3%). 8/17 (47.1%) patients were African Americans, similarly Caucasians (8/17, 47.1%), followed by Hispanics (1/17, 5.9%). Fever was noted to be the most common presentation (12/17, 70.6%), followed by abdominal pain, vomiting and cough which were present only in 3/17 (17.6%) patients. Splenomegaly/ hepatosplenomegaly was the most common finding on imaging (7/17, 41.2%). Laboratory investigations were consistent with with cytopenias (16/17, 94.1%) and transaminitis (13/17, 76.5%) in majority of the patients. Bone marrow biopsy was performed to aid in diagnosis in 8/17 (47.1%) patients, out of which, hemophagocytosis was noted only on 4/17 (23.5%). NK- cell activity was tested in 8/17 (47.1%) patients and was noted to be low. Soluble interleukin-2 receptor-alpha/CD25 was tested in 7/17 (41.2%) patients and ranged from 345-6,029 units/ml and was helpful in diagnosis (>2400 units/ml) only in 3/7 (42.9%) patients. Underlying infection was the most common cause of HLH (8/17, 47.1%), out of which, majority had HIV (5/8, 62.5%). 4 out of 5 patients with HIV had disseminated histoplasmosis (80%). 4/17 (23.5%) patients were noted to have underlying rheumatologic disease; the cause of HLH was deemed to unknown in 4 patients (4/17, 23.5%)). One patient was diagnosed with an underlying malignancy, i.e., acute myeloid leukemia (1/17, 5.9%). Majority patients were managed in intensive care unit setting (10/17, 58.8%). Patients managed in ICU setting had a lower median platelet count nadir than those managed on the floor (40,000 cells/cu. mm vs 52,000 cells/ cu. mm, p=0.04). However, no significant difference in the median platelet count, white blood cell count or median hemoglobin levels on presentation was noted between the two groups (p>0.05). Majority patients were managed with steroids alone (9/17, 52.9%), followed by steroids+steroid-sparing agents (4/17,23.5%), anti-fungal agents alone (2/17, 11.8%) and steroids+intravenous anti-globulin and anti-fungal agent (1/17, 5.9%). One patient (1/17, 5.9%) was only conservatively managed. Complete recovery was noted in majority of the patients (13/17, 76.5%), while 4/17 (23.5%) patients died during their hospital stay. 2 out of the 4 patients (50%) who died had underlying rheumatological disease, while the remaining two patients had acute myeloid leukemia and cellulitis respectively. Conclusion: Majority of the cases of secondary HLH in our cohort of underserved adults were noted to be related to infectious causes. Contrary to existing literature, HIV was noted to be the predominant cause in these patients (as opposed to Epstein-Barr virus). HLH in patients with HIV should prompt investigation for underlying histoplasmosis. Patients with a lower platelet nadir appear to be at greater risk of escalation of level of care. HLH related to infections is associated with a relatively favorable outcome, which may explain the relatively lower overall mortality in our study population. Clinical presentation was widely non-specific, warranting a high index of suspicion for secondary HLH, to allow prompt diagnosis in these patients. Investigations such as bone marrow biopsy and interleukin-2 receptor-alpha/CD25 may not aid in diagnosis in many patients and may not be included in initial evaluation for HLH in resource-limited settings.

HEMATOLOGIC MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IN A TERTIARY CARE CENTRE

Background: Systemic lupus erythematosus (SLE) can present with hematologic manifestations alone or with features of systemic involvement. Diagnosis may be delayed or missed at presentation time, especially in those with hematologic abnormalities as the initial manifestation, with low index of clinical suspicion or inadequate follow-up. Aim And Objectives: To study the prevalence and the type of hematologic manifestations in SLE from pathologist's perspective. Setting And Design: Retrospective observational study. Material And Methods: Study was done in 63 SLE patients in a tertiary care hospital in Secunderabad for duration of one and half years, from January 2018 to June 2019. Hematological parameters of the same were retrieved. Results :It was observed that anemia was the most common hematologic nding with iron deciency anemia (IDA) being the commonest cause followed by hemolytic anemia. Leucopenia with predominant lymphopenia was the most common WBC abnormality and thrombocytopenia was seen in majority of the patients. Bi and pancytopenia was also observed. Raised erythrocyte sedimentation rate (ESR) was a common nding. Deranged coagulation prole was seen due to secondary anti-phospholipid antibody (APLA) syndrome, hemolysis and sepsis on anticoagulant. Bone marrow studies showed varied ndings including hypocellularity, dyspoiesis in the erythroid, myeloid and megakaryocytic series and abnormal localisation of immature precursors (ALIP) aggregates. Conclusion: This study was conducted to estimate the proportion of patients with hematological abnormalities as the manifestation of SLE and to study the nature of hematological problems, so that the empirical treatment can be started.

Study on rickettsial diseases evidenced by Weil-Felix test among febrile patients visiting a tertiary care hospital in Mymensingh

Background: Rickettsial diseases are neglected, re-emerging vector borne zoonosis & increasingly considered as one of the most important causes of pyrexia of unknown origin (PUO). They are grossly underdiagnosed due to wide range of non-specific symptoms, low index of clinical suspicion, lack of widely available specific diagnostic tools, leading to significant morbidity & mortality. Appropriate diagnosis in early stages is therefore necessary to prevent fatal complications associated with this disease. Objective: Present study was attempted to assess the burden of rickettsial illness by Weil-Felix agglutination test, among the suspected febrile patients, visiting a tertiary care hospital as well as to analyze the demographic profile & clinical manifestations of the seropositive cases. Methods: This was a cross-sectional study, conducted at department of microbiology, Mymensingh Medical College from March 2018 to February 2019. A total of 453 febrile patients of suspected rickettsial illness, irrespective of age and sex, were enrolled in this study. Serum sample from all the enrolled cases were then analyzed for rickettsial antibodies by Weil-Felix slide agglutination test. Results: Out of 453 cases, a total of 260 (57.39%) showed significant agglutination by Weil-Felix test, of which 101 (38.84%) were reactive to OX2 (spotted fever group rickettsiae), 65 (25%) were reactive to OXK (Scrub typhus) & 13 (5%) showed significant titers to OX19 (typhus fever). Remaining 81 (31.15%) sera were reactive to more than one antigens (mixed reactivity). Seropositivity was higher among female subjects (142; 54.61%) & age group >15-30 accounted for highest number of cases (95; 36.53%). Positive cases showed diverse clinical manifestations like headache (55.76%), myalgia (50.76%), skin rash (10.38%), eschar (9.23%), oliguria (7.3%), jaundice (10.76%), splenomegaly (6.81%), hepatomegaly (7.30%) etc. Conclusion: Rickettsial diseases should be considered as an important etiology of PUO & early diagnosis should be done to initiate proper treatment to prevent fatal complications. Though it lacks sensitivity & specificity, in a resource constraint area like Bangladesh, Weil-Felix test still serves as the cheapest initial diagnostic tool for rickettsial illness to guide the physician for further approaches. Mediscope 2021;8(2): 112-121

High prevalence and mortality due to Histoplasma capsulatum in the Brazilian Amazon: An autopsy study.

BackgroundHistoplasmosis is acquired by inhalation of spores of the dimorphic fungus Histoplasma spp. Although this pathogen is distributed worldwide, it is more prevalent in the Americas. However, the real burden of histoplasmosis remains undefined in many endemic regions.MethodologyWe conducted a series of 61 autopsies to individuals who died in a hospital in the Brazilian Amazon focused on infectious diseases. We performed a detailed histological and microbiological evaluation with genetic characterization of Histoplasma strains with the aim to evaluate the contribution of histoplasmosis to morbidity and mortality. Additionally, we assessed the clinicopathological correlation.Principal findingsEvidence of Histoplasma infection was detected in 21 patients (34%). Eight cases were disseminated infections, all of them occurred in HIV-positive patients. Six cases were localized histoplasmosis, limited to the lungs. In seven patients Histoplasma DNA was detected by PCR in patients with no histological lesions. Histoplasma infection was detected in 38% of HIV-positive patients and was a major contributor to death in 22% of them. Lungs, liver and spleen were affected in all cases of disseminated histoplasmosis. Phylogenetic analysis of the strains suggested a high diversity of Histoplasma species circulating in the Brazilian Amazon. Histoplasmosis was clinically missed in 75% of the disseminated infections.ConclusionsThe high incidence of histoplasmosis, the low index of clinical suspicion, and the severity of the disseminated disease highlight the need of proactively implementing sensitive routine screening methods for this pathogen in endemic areas. Antifungal prophylaxis against Histoplasma should be encouraged in the severely immunocompromised HIV patients in these areas. In conclusion, substantial mortality is associated with disseminated histoplasmosis among HIV-positive patients in the Brazilian Amazon.

Case of squamous cell carcinoma of the tongue in a pregnant woman, with literature review.

Oral squamous cell carcinoma (OSCC) is an extremely rare occurrence during pregnancy. OSCC accounts for less than 2% of all malignancies in pregnant women, with an average mortality rate of 36%. Understanding the features of this tumor during pregnancy is important; however, the paucity of reports in the literature makes this challenging. Case presentation: The following is a case presentation of a woman who was diagnosed with SCC of the tongue (TSCC) at 13 weeks gestation. The article also provides a review of the literature of TSCC affecting pregnant women aged 30 years and under. Conclusion: Although OSCC in young women of reproductive age is rare, recent literature suggests an increased risk for this age group. The rarity of OSCC in pregnancy may potentially lead to low clinical index of suspicion, misdiagnosis, and delay in treatment. Additionally, treatment modalities, prognosis, and the long-term impact on the developing fetus are not well established, due to rarity of OSCC in pregnancy. Further studies to identify specific etiologic factors are needed to establish the association of OSCC with pregnancy, aid in prevention, and improve treatment and outcome.

Histoplasmosis overlapping with HIV and tuberculosis in sub-Saharan Africa: challenges and research priorities.

Histoplasmosis, tuberculosis and HIV are all highly prevalent in sub-Saharan Africa (SSA). Co-occurrence of two or more of these infections has been reported in several populations of patients, especially those with advanced HIV infection where these opportunistic infections contribute to a significant morbidity and mortality. With a high burden of pulmonary tuberculosis (PTB) secondary to HIV in SSA, histoplasmosis is commonly misdiagnosed as smear-negative PTB in HIV patients due to similar clinical and radiological presentations. This is also partly the result of the lack of trained clinical and laboratory personnel to make a definite diagnosis of histoplasmosis. There is a low index of clinical suspicion for histoplasmosis, and cases are mostly discovered accidently and documented through case reports and case series. Similarly, the high cost and lack of fungal diagnostics in most SSA countries makes it difficult to make a diagnosis. There is a need to build local capacity for mycology so that patients are managed to improve on the index of clinical suspicion and diagnostic capabilities. Moreover, simple accurate point-of-care diagnostic tests and first-line antifungal treatment for histoplasmosis are not available in many SSA countries. This review describes the existence of co-infections of histoplasmosis, tuberculosis and HIV in SSA, highlighting the challenges and research priorities.

Myocarditis in admitted patients with dengue fever.

Cardiac involvement in dengue fever is underdiagnosed due to low index of clinical suspicion and its contribution to hemodynamic instability in severe dengue is not well known. A prospective observational study was conducted among admitted patients ≥ 14years of age having confirmed dengue fever. Patients on medications affecting heart rhythm/rate, pre-existing heart disease and electrolyte abnormalities were excluded. A baseline electrocardiography (ECG), Trop-I and NT-proBNP were done for all patients. The biomarkers were measured using enzyme-linked fluorescent assay and recommended cut-off were used. Patients with elevated biomarkers underwent 2-dimensional echocardiography. Diagnosis of myocarditis was as per European Society of Cardiology (ESC) 2013 criteria. A total of 182 patients were recruited with mean age of 30 ± 12.6years and 31% were females. Dengue with warning signs was present in 85 (47%) and severe dengue in 60 (33%) patients. ECG abnormalities were observed in 44 (24%) patients, biomarkers were elevated in 27 (15%) patients and 11 (6%) patients had echocardiographic abnormalities. According to ESC 2013 criteria, dengue fever with myocarditis was diagnosed in 13 [7.1% (95% CI 3.4-10.9)] patients. The patients with myocarditis were more likely to have shortness of breath, bleeding manifestations and higher respiratory rate at baseline. Clinical features of fluid overload were more common (69% vs. 1.7%, p < 0.01) and the duration of hospital stay longer in myocarditis group (7 ± 4.3 vs. 4.8 ± 1.9days, p < 0.01). Myocarditis among admitted dengue patients is not uncommon and may lead to increased morbidity.

Small Bowel Neoplasms: A Pictorial Review.

Small bowel tumors are rare and account for approximately 3% of all gastrointestinal tumors in the United States. The incidence of small bowel neoplasms is rising-in particular, there is a rising incidence of small bowel carcinoid tumors. This may in part be due to small bowel lesion identification in an increasing number of cross-sectional imaging studies performed for other indications as well as increased use of advanced imaging techniques to assess specifically for small bowel disease. Diagnosis is a challenge owing to nonspecific clinical manifestation, rare occurrence, and low index of clinical suspicion. Yet, various small bowel neoplasms have characteristic imaging features at CT and MRI when optimal distention of the small bowel is achieved, correlating well with features seen in gross specimens. Understanding the imaging features of small bowel neoplasms is important to improve the radiologist's ability to diagnose and characterize small bowel neoplasms. Most small bowel tumors are clinically silent for long periods, and nearly half of the benign tumors are found incidentally during surgery or at cross-sectional imaging performed for other reasons. The authors review the imaging features of common benign and malignant small bowel neoplasms to aid the radiologist in diagnosis of small bowel tumors. ©RSNA, 2020.

Angioedema Masqueraders.

Angioedema is a common reason for referral to immunology and allergy specialists. Not all cases are in fact angioedema. There are many conditions that may mimic its appearance, resulting in misdiagnosis. This may happen when a clinician is unfamiliar with conditions resembling angioedema or when there is a low index of clinical suspicion. In this article, we explore a list of differential diagnoses based on body parts, including the lips, the limbs, periorbital tissues, the face, epiglottis and uvula, as well as the genitalia, that may pose as a masquerader even to an experienced eye.

Current state-of-play in spontaneous coronary artery dissection

For over 80 years, spontaneous coronary artery dissection (SCAD) has been recognised as a cause of myocardial infarction. SCAD is described as a non-iatrogenic, non-atherosclerotic coronary artery dissection, resulting in formation of a false lumen or intramural haematoma in the coronary artery wall that compresses the true lumen, often compromising myocardial blood flow. In early literature, the incidence of SCAD in acute coronary syndrome (ACS) was underestimated. Recent advances in awareness and widespread early angiographic investigation in ACS has led to important shifts in our understanding of the prevalence, predisposing causes, natural history, aetiology, clinical and angiographic features, management, and prognosis of SCAD. It is now well understood that SCAD predominantly affects women and is responsible for around 20% of ACS presentations in females below the age of 60. Despite this, SCAD is still often overlooked and misdiagnosed as atherosclerotic disease. Misdiagnosis is multifactorial; with contributing factors including a low clinical index of suspicion, particularly in young females, a lack of clinician familiarity with angiographic variants, and limitations of angiography. Although increasing evidence suggests that optimal management is distinct from atherosclerotic coronary artery disease, many questions remain unanswered regarding the pathogenesis and optimal treatment of SCAD, heralding prospective research to answer these questions. This review aims to give a current clinical perspective on SCAD and highlight the importance of familiarity and vigilance with this condition when diagnosing and treating ACS.

Extranodal NK/T cell lymphoma: diagnostic challenges in a resource-constrained setting

Introduction: Extranodal natural killer/T-cell lymphoma (NKTCL)- nasal type is a rare form of non-Hodgkin lymphoma. It mainly affects the midfacial structures (the nose, oropharynx, and hypopharynx). Prognosis is generally very poor and diagnosis is often delayed in Africans because of low index of clinical suspicion and resource constraints. Case report: The patient was a 30-year-old man who presented with a 5-month history of rhinorrhea associated with blockage of the left nasal cavity. Examination revealed a fleshy left nasal mass. Incisional biopsy of the mass was reported as nonspecific chronic inflammation but the diagnosis was reviewed to non-Hodgkin lymphoma after histologic examination of the excised mass. Subsequent immunohistochemical studies established a diagnosis of NKTCL 6 months after initial presentation. The patient was placed on chemotherapy and radiotherapy. He did not have access to radiotherapy because of financial constraints and defaulted from care after he has had three cycles of chemotherapy. The patient died 4 months after defaulting. Conclusion: It is very common to miss the diagnosis of the early phase of NKTCL before the appearance of the destructive facial lesion. Low index of suspicion and constraints of resources also play a role in the delayed diagnosis and poor outcome in Africa.

Assessment of Lassa fever sample and case management preparedness in Nigeria 2017: challenges and way forward

Introduction: Lassa fever remains an important cause of morbidity and mortality in West Africa. In Nigeria, Lassa fever (LF) is endemic with an annual cycle of incident cases across the country. Despite seasonal epidemic preparedness and response efforts, there is still evidence of low clinical index of suspicion, poor sample management and delay in treatment resulting in nosocomial transmission, long turnaround time (TAT) for laboratory diagnosis and high case-fatality-rates (CFR).

Dermatofibrosarcoma Protuberans, análisis clínico e histopatológico de los últimos 14 años en población consultante del Hospital Clínico Universidad de Chile

Introducción: El Dermatofibrosarcoma Protuberans (DFSP) es un sarcoma cutáneo infrecuente y poco descrito en la literatura regional. En este trabajo se describió y analizó las características clínicas e histopatológicas de los DFSP tratados en nuestro centro. Métodos: Estudio retrospectivo de todos los casos de DFSP primarios, confirmados con biopsia entre los años 2002 y 2016 en el Servicio de Anatomía Patológica del Hospital Clínico Universidad de Chile (HCUCh).Resultados: La muestra contó con 18 casos, 67% de sexo femenino, la edad promedio de diagnóstico fue 45,5 años. El 28% de los DFSP se localizaron en tronco, 22% extremidades inferiores, 22% extremidades superiores, 22% región inguino-genital y 6% cervical. Un 22% de las biopsias fueron enviadas con diagnóstico clínico presuntivo de DFSP. En la histopatología, todos los DFSP estaban compuestos por células fusiformes, distribuidas en patrón estoriforme que infiltraban hasta el tejido adiposo subcutáneo. La inmunohistoquímica se realizó en 7 casos, siendo positivo para CD34 en todas estas muestras y negativo para el factor XIIIa. En el 50% de los casos se observó compromiso de márgenes quirúrgicos.Conclusiones: Nuestros resultados fueron similares a publicaciones internacionales. Se observó mayor frecuencia en mujeres y diagnóstico clínico más tardío. Se constató un bajo índice de sospecha clínica de DFSP, confundiéndose con patologías benignas, lo que podría incidir en la frecuencia de márgenes positivos del estudio. Este trabajo constituye uno de los reportes de series de casos más extensos desarrollado a nivel nacional.

Ankle tuberculosis. A case in childhood

Articular tuberculosis of the ankle joint is a rare presentation of skeletal tuberculosis (10% of cases). This unusual location and the low index of clinical suspicion leads to delays in diagnosis and treatment. Radiographic and analytic studies are unspecific in the first stage. CAT and MRI are useful in diagnosis. Chemotherapy is the mainstay of treatment and surgery is often required to establish the diagnosis and in the treatment.We report a case of ankle tuberculosis in a 22 month-old child. The diagnosis was confirmed by synovial biopsy. There was no patient or family contact with tuberculosis patients. There was no risk factor. There was no lung disease. Diagnosis was made 1 year after onset of symptoms. The treatment was with chemotherapy and surgery was performed as preventive treatment of equinus deformity and osteoarthritis. Good clinical and functional outcome was achieved after 20 years of follow up.

Tuberculosis de tobillo. A propósito de un caso en la infancia

Articular tuberculosis of the ankle joint is a rare presentation of skeletal tuberculosis (10% of cases). This unusual location and the low index of clinical suspicion leads to delays in diagnosis and treatment. Radiographic and analytic studies are unspecific in the first stage. CAT and MRI are useful in diagnosis. Chemotherapy is the mainstay of treatment and surgery is often required to establish the diagnosis and in the treatment.We report a case of ankle tuberculosis in a 22 month-old child. The diagnosis was confirmed by synovial biopsy. There was no patient or family contact with tuberculosis patients. There was no risk factor. There was no lung disease. Diagnosis was made 1 year after onset of symptoms. The treatment was with chemotherapy and surgery was performed as preventive treatment of equinus deformity and osteoarthritis. Good clinical and functional outcome was achieved after 20 years of follow up.

Neuroleptic malignant syndrome following catatonia: Vigilance is the price of antipsychotic prescription

Objectives:To describe a case of neuroleptic malignant syndrome following antipsychotic treatment of catatonia, highlighting the potentially serious complications of this rare adverse drug reaction.Methods:We present a case report of a patient who developed this syndrome with various sequelae.Results:The patient developed neuroleptic after being treated with lorazepam and olanzapine for catatonia. He subsequently developed the complications of rhabdomyolysis, acute kidney injury, pulmonary embolism, urinary retention and ileus. He received high-dose lorazepam, anticoagulation and intravenous fluids. Antipsychotic medication in the form of haloperidol was reinstated with no adverse effect, and he went on to make a full recovery.Conclusions:This case illustrates the potential life-threatening complications of neuroleptic malignant syndrome and the need for a low index of clinical suspicion. It also highlights the lack of evidence for treatment of catatonia, including the use of antipsychotics.

Pathogenesis, Diagnosis, and Treatment of Venous Thromboembolism in Older Adults

Older adults have a significantly greater risk of venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, than younger adults. The cause of this greater risk is thought to be multifactorial, including age-related changes in hemostatic factors and greater comorbid conditions and hospitalizations, but is not completely understood. Moreover, VTE remains underrecognized in older adults and may present atypically. Thus, a low index of clinical suspicion is essential when evaluating older adults with possible VTE. Despite this underrecognition in older adults, the diagnostic approach remains similar for all age groups and includes estimation of pretest probability, measurement of the D-dimer, and imaging. Antithrombotic agents are the mainstay of VTE treatment and, when used appropriately, substantially reduce VTE recurrence and complications. The approval of novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, provide clinicians with new therapeutic options. In some individuals, NOACs may offer advantages over warfarin, including fewer drug interactions, more-predictable anticoagulation, and lower risk of bleeding. Nevertheless, anticoagulation of VTE in older adults should always be performed cautiously, because age is a risk factor for bleeding complications. Identifying modifiable bleeding risk factors and balancing the risks of VTE recurrence with hemorrhage are important considerations when using anticoagulants in older adults.