Paraclinical Findings Research Articles

Postictal pulmonary oedema: a review of the literature

Postictal neurogenic pulmonary oedema is an infrequent condition of varying severity, probably related to sudden unexpected death in epilepsy (SUDEP). It is more frequent in patients with generalised tonic-clonic seizures of long duration or with status epilepticus. Based on a review of the literature, the aim is to describe the clinical characteristics, pathophysiology, radiological findings, treatment and prognosis of patients with postictal pulmonary oedema. A search of the literature was performed in the PubMed, Embase, Cochrane Database of Systematic Reviews and BVS databases using a combination of free terms. The limits of the search applied were: papers published between 1 January 2000 and 26 April 2018, and papers for which the abstract was available. Altogether 23 papers were found, most of which were clinical cases, and used to extract the information needed to carry out the review. In postictal pulmonary oedema, generalised tonic-clonic seizures are the most frequently reported type. The most common clinical manifestations were dyspnoea and tachycardia appearing within a few minutes after the seizure. Among the paraclinical findings the most frequent was leukocytosis. In general terms, a good prognosis was found in most cases, with improvement of the oedema within a period of between 12 and 96 hours. Only two of the 21 patients reported died. In addition, in a clinical pathology study in patients with SUDEP, pulmonary oedema appeared in most cases.

Paraclinical cardiac findings of children with breath-holding Spells in Taleghani Hospital of Gorgan, Iran, during 2014–2016

Context: Breath-holding spells (BHSs) are episodes of brief, involuntary cessation of breathing that occur in children in response to stimuli such as anger, frustration, fear, or injury. It occurs in about 0.1%–4.6% of healthy children. Although the etiology is not known, autonomic dysfunction and increased vagal tonus leading to cardiac arrest and cerebral anoxia are considered to play a role. Increase of QT dispersion increases the risk of sudden death. Because of this, children are always referred to cardiac clinics. Aims: Our aim was to evaluate According to these problems, our aim was the evaluation of ECG and Echocardiography findings in children diagnosed with BHSs in Taleghani Hospital in Gorgan. Settings and Design/ Methods and Material: All patients diagnosed with BHSs were enrolled in this study. In the first step, demographic characteristics and echocardiography and electrocardiogram (ECG) findings were obtained from the patients. Statistical Analysis Used: For statistical analysis, the demographic variables and ECG and echocardiography information of the patients were analyzed using frequency, percentage, and statistical tests such as Chi-square. Results: Sixty-three (9%) children were male and 36 (1%) children were female. Thirty-eight (9%) children were aged between 1 and 2 years, and this group was the most common age group. The most common type of attack was cyanotic (68/5%); 24 (1%) children had a positive family history, 78 (8%) had incomplete or absent iron supplementation, and 68% of children had anemia. Five (6%) children had long QT in ECG and five (6%) had abnormal echocardiography. There was a significant correlation between echocardiography findings and age, whereas there was no significant relationship between ECG findings with age, echocardiography findings with sex, and type of attack with age and sex. Conclusions: Although BHS among children with LQTS are relatively rare and occur at similar frequency as the general population, they can be the presenting symptom for a heart rhythm disorder.

Value of urinary carbohydrate antigen 19–9 to predict failure of conservative management in children with ureteropelvic junction obstruction

ObjectiveTo assess the role of urinary carbohydrate antigen 19–9 (CA19–9) measurement in determining optimal management of ureteropelvic junction obstruction (UPJO) and predicting failure of conservative management. Patients and methodsChildren with UPJO diagnosed between December 2012 and April 2015 were included. Depending on clinical and para-clinical findings, patients were divided into three groups: Group 1 consisted of patients who were considered for non-operative management with improvement of the condition during the course of follow-up. Group 2 were suitable for observation; however due to deterioration of condition pyeloplasty was indicated after a period of observation. Group 3 patients required immediate pyeloplasty. Urinary CA19–9 was measured in all patients at baseline and compared between the study groups. ResultsA total of 112 children (115 affected kidneys) with UPJO and mean age of 18.6 ± 3.3 months were assessed. Group 1, 2, and 3 consisted of 54(48.2%), 24(21.4%), and 34(30.4%) patients, respectively. Mean baseline urinary CA19–9 was 37.83 ± 5.20, 145.45 ± 18.38 and 244.62 ± 41.42 in groups 1, 2 and 3, respectively. Multivariate analysis showed that both CA19–9 and APD are independent predictors of need for surgery in patients on observation. ROC curve analysis revealed that urinary CA19–9 level at cut off value of 52.6 U/mL had sensitivity of 92.0% and specificity of 70.9% in predicting failure of non-operative management. ConclusionHigher urinary CA19–9 level is associated with failure of non-operative management in patients with UPJO. Such patients may require close follow-up and assessments to prevent irreversible damage to the kidney. Type of StudyStudy of Diagnostic Test. Level of EvidenceLevel II.

New MS diagnostic criteria in practice

The diagnostic criteria for multiple sclerosis (MS), first developed in the 1950s, have since undergone several revisions, all focused on three main requirements for a diagnosis of MS: 1. Objective...

Epidemiology of Causes of Fever of Unknown Origin in an Academic Center: A Five-Year Evaluation from 2009 to 2014

Background: Fever of unknown origin (FUO) remains a clinical challenge in both emergency and infectious diseases departments. Being clinically updated on probable etiologies helps physicians to narrow their diagnostic and treatment approach. Objectives: This study aimed to assess the causes of FUO in an academic setting in the recent 5 years to update the clinicians. Methods: In a cross-sectional study, the files all patients with the primary diagnosis of FUO were extracted and evaluated. The records were assessed with regard to patients & rsquo; age, gender, days of fever before admission, time of admission and discharge, clinical course of the disease, laboratory and other para-clinical findings were documented. The patients were then classified based on the etiology of the disease and the type of test utilized for the diagnosis. Median and frequencies were used for descriptive variables; chi-square test was performed for correlation analysis. Results: From March 2009 to April 2014, 101 patients were admitted and their files were recruited for the purpose of this study. The median age of our patient population was 39. Infections (23.1%) and non-infectious inflammatory diseases (21.1%) constituted the most common known causes of fever in our patient population. Invasive tests had been documented for 41.1% while non-diagnostic in 20%. Non-invasive tests leading to final diagnoses were performed for 48.4%. There was a significant association between the type of the utilized test for diagnosis and different etiologies of FUO (P = 0.001). Conclusions: Similar to global trends, non-infectious inflammatory diseases comprised an increasing share of the causes of FUO. However, tuberculosis remains an important infectious cause that may present with FUO or simply be overlooked in primary patient visits. Updating a local database for the causes of FUO in hospitals at certain time intervals may facilitate the diagnostic approach.

Retrospective analysis of children with myelin oligodendrocyte glycoprotein antibody-related disorders

BackgroundKnowledge has been expanding on myelin oligodendrocyte glycoprotein (MOG) antibody-associated central nervous system disorders. We delineate the clinical and paraclinical findings and outcome of our pediatric patients with MOG antibody seropositive disease. MethodsWe retrospectively analyzed the clinical presentation, cerebrospinal fluid findings, magnetic resonance imaging (MRI) studies, course and outcome of children seropositive for anti-MOG IgG. ResultsTotal 20 children with neurological symptoms and serum anti-MOG IgG were identified from six centers in Turkey. Median age at onset was 9 years (mean 8.8 ± 5.0 years, range: 1.5–16.5 years). Final diagnoses were acute disseminated encephalomyelitis (ADEM) (n = 5), ADEM + optic neuritis (n = 4), neuromyelitis optica spectrum disorder (NMOSD) (n = 3), myelitis (n = 2), relapsing optic neuritis (n = 2), multiphasic DEM (n = 3), and unclassified relapsing demyelinating disease (n = 1). Seven/20 (35%) children experienced a single episode while 13/20 (65%) had a least one relapse during follow-up. On MRI, subcortical white matter, brainstem, and corpus callosum were preferentially involved regions. Full recovery was observed in 15/20 (75%) children. ConclusionMOG autoimmunity in children has a wide clinical spectrum, tendency to relapse, and a favourable outcome compared with other relapsing demyelinating diseases.

Clinicopathological Stratification and Long-term Follow-up of Patients with Periampullary Carcinomas.

Periampullary carcinomas generally confer a poor outcome. Choosing the most effective treatment regimen for each sub-entity proves challenging and is usually based on experience from pancreatic adenocarcinoma (PDAC). The long-term follow-up is presented of 472 patients with periampullary tumors [PDAC, distal cholangiocarcinoma (dCC) and ampullary carcinomas (AC)] who underwent radical resection considering clinical characteristics, paraclinical findings and histopathological features in order to define factors of prognostic relevance. Patients with PDACs presented with larger tumor sizes, more frequent R1 resection, higher rate of nodal and perineural invasion, higher tumor stage according to the classification of tumors of the Union Internationale contre le Cancer when compared to those with dCCs and ACs. In a multivariate analysis, age >65 years, postoperative complications and higher grading of the tumor proved to be independent prognostic factors for survival. Patients suffering from PDAC have the worst prognosis and greatest benefit from radical resection of all patients with periampullary tumors. More detailed studies are warranted to better distinguish between the different entities.

Clinical and laboratory findings of patients with the possible diagnosis of influenza hospitalized in affiliated hospitals of Babol University of Medical Sciences, 2015-2016

Abstract The clinical and para clinical manifestations of influenza in various patients have range from an autoimmune disease to a life-threatening respiratory infection. In addition, the severity of the disease is influenced by factors such as demographic factors, underlying diseases, and immune response. Therefore, in this study, we evaluated the clinical, laboratory and epidemiological characteristics of patients with this type of influenza in Babol (north of Iran). This study was conducted as a descriptive cross-sectional study from October 2015 to March 2016. Subsequently, in this study, records of 123 patients with clinical signs of the influenza-like disease who have undergone the clinical sign in hospitals affiliated to Babol University of Medical Sciences were reviewed. Of 123 patients admitted to a possible diagnosis of influenza, 58 patients (47.2%) were PCR positive for H1N1, while seventy nine (64.2%) participants were women and 21 (17.1%) had diabetes or underlying lung disease. Most of the involved age groups were of individuals above the age of 50. These were followed by the 21-35 years-old. Fever (78%), cough (65.9%), shivering (58.5%) and myalgia (56.1%) were the most common clinical symptoms. Increased levels of transaminases (43.1%), leukocytosis (35.8%) and thrombocytopenia (34.2%) were as well reported in patients as the most frequently reported para clinical findings. In the present study, the most usual clinical symptoms were fever, cough, chill, and myalgia, while gastrointestinal symptoms were also noticeably observed in patients. In an experimental study, a significant number of patients showed leukocytosis and thrombocytopenia and increased transaminases.

Evaluation of Clinical and Paraclinical Findings for the Differential Diagnosis of Autoimmune and Infectious Encephalitis.

Background: The differential diagnosis of autoimmune and infectious encephalitis is notoriously difficult. For this study, we compare the presenting clinical symptoms and paraclinical test results of autoimmune and infectious encephalitis patients. A clinical algorithm for the diagnosis of autoimmune encephalitis has recently been published. We test these Graus criteria on our cohort for diagnostic sensitivity and specificity within the first week of presentation.Methods: We included all patients seen at our department within a 10-year-period who were diagnosed with encephalitis. The discharge diagnoses served as the reference standard for testing the clinical algorithm for two conditions: use of all the clinical information available on a patient during the first week of hospital admission assuming undefined autoantibody status and microbiological test results (C1) vs. consideration of all the information available on a patient, including the results of serological and microbiological testing (C2).Results: Eighty-four patients (33 autoimmune, 51 infectious encephalitis) were included in the study. Fifty-one (17 autoimmune, 34 infectious) had a definite clinical diagnosis. The two groups differed significantly for the presence of headache, fever, epileptic seizures, and CSF cell-count at presentation. Application of the clinical algorithm resulted in a low sensitivity (58%) and very low specificity (8%) for the diagnosis of possible autoimmune encephalitis. The latter increased considerably in the subgroups of probable and definite autoimmune encephalitis. Whereas the sensitivity of the individual diagnostic categories was clearly time-dependent, the specificity rested foremost on the knowledge of the results of microbiological testing. Anti-CASPR2- and -LGI1-associated autoimmune encephalitis and tick-borne virus encephalitis presented particular diagnostic pitfalls.Conclusions: We define clinical symptoms and paraclinical test results which prove valuable for the differentiation between infectious and autoimmune encephalitis. Sensitivity and specificity of the clinical algorithm clearly depended on the amount of time passed after hospital admission and knowledge of microbiological test results. Accepting this limitation for the acute setting, the algorithm remains a valuable diagnostic aid for antibody-negative autoimmune encephalitis or in resource-poor settings. The initiation of immune therapy however should not be delayed if an autoimmune etiology is considered likely, even if the diagnostic criteria of the algorithm are not (yet) fulfilled.

Prevalence of muscular dystrophy in patients with muscular disorders in Tehran, Iran.

Muscular dystrophy is a group of diseases that is characterized by progressive muscle wasting and the weakness of variable distribution and severity. On the basis of the distribution of predominant muscle weakness, there are many different kinds of muscular dystrophy. Some dystrophies are especially frequent in certain populations. There are no studies on the prevalence of muscular dystrophy in Iran. This study was aimed to survey the prevalence of muscular dystrophy among Iranian patients with muscular disorders. This analytical cross-sectional study was conducted on 1000 patients with musculoskeletal disorders who visited the dystrophy association of Bou-Ali Hospital (Tehran) from June 2014 to June 2016. Patients’ data were extracted using a checklist that included age, gender, age of onset, family history, findings from clinical diagnostic tests and types of muscular dystrophy. The clinical findings were the results of genetic tests; EMG-NCV; para-clinical findings, including LDH and CPK; and pathological findings. All data were analyzed by SPSS V.22 (IBM Inc., NY) with Chi Square and One way ANOVA tests. All analyses were performed with P = 0.05 considered as the threshold of statistical significant. Out of the 337 patients studied, 262 (77.7%) were male and 75 (22.3%) were female. Subjects had a mean (± SD) age of 26.08 (± 11.86) years with an age range of 3 to 59 years. The most common types of muscular dystrophy were found to be Duchenne dystrophy (131 cases, 38.9%), limb-girdle dystrophy (91 cases, 27%), Becker dystrophy (58 cases, 17.2%), FSHD dystrophy (31 cases, 9.2%), and SMA (26 cases, 7.7%), respectively. The results showed that a statistically significant relationship between dystrophy types and gender, age, family history, age of diagnosis, CPK and LDH levels (P < 0.001). There were no statistical relationship between dystrophy types and pathological findings (P = 0.57), EMG-NCV test results (P = 0.062), and genetic findings (P = 0.06). Since muscular dystrophies often appear during the first decade of life, any information in regard to their prevalence can contribute to better planning and provisioning of required services, as well as better treatment or control of the condition. The results also showed that genetic tests, para-clinical tests, pathology analysis, and EMG-NCV tests can serve as good diagnostic tools for different varieties of dystrophy. Thus, facilitation of these diagnostic tests, particularly the genetic tests, can lead to a faster and more accurate diagnosis of dystrophy, especially in people with a family history of the disease.

Contribution of diagnostic tests for the etiological assessment of uveitis, data from the ULISSE study (Uveitis: Clinical and medicoeconomic evaluation of a standardized strategy of the etiological diagnosis).

ULISSE is the only study that prospectively assessed the efficiency of a standardized strategy, compared to an open strategy for the etiologic diagnosis of uveitis. Our aim was to evaluate the diagnostic yield of the tests prescribed in the ULISSE study to clarify their relevance. ULISSE is a non-inferiority, prospective, multicenter and cluster randomized study. The standardized strategy is a two-steps strategy: in the first step, common standard tests were performed, and in the second step, tests were guided by the clinical and anatomic type of uveitis. We reported the relevance of the diagnostic tests used in the standardized strategy, as well as the profitability of the tests that were prescribed to more than twenty patients in each group. Based on diagnostic criteria, either an ophthalmologist, or an internist, established the profitability of a test by considering whether the test lead to a diagnosis or not. Among the 676 patients included (standardized 303; open 373), a diagnosis was made for 152 (50.4%) in the standardized group and 203 (54.4%) in the open group. The most common entities were HLA-B27 associated uveitis (22%), spondyloarthritis (11%), sarcoidosis (18%), tuberculosis (10.7%) and herpes virus infections (8.5%). Among the first step's systematic tests, tuberculin skin test was the most contributive investigation (17.1%), followed by chest X-ray (8.4%), C reactive protein and ESR (6.6% and 5.1%), complete blood count (2.2%) and VDRL (2.0%). The second step's most often contributive tests were: HLA B27 (56.3%), chest-CT (30.3%) and angiotensin converting enzyme (ACE) (16.5%). HLA B27 and ACE were significantly more contributive in the standardized group than in the open group. Immunological tests were never contributive. Among the free investigations, or among the investigations guided by clinical or paraclinical findings, the most often contributive tests were: Quantiferon® (24%), electrophoresis of serum protein (7.8%) and sacroiliac imagery (46.4%). Intracellular serologies (1.7%), serum calcium (2.1%) and hepatic tests (3.3%) were exceptionally contributive. Among the third intention tests, labial salivary gland biopsies were contributive in 17.9% of cases, but the profitability of other invasive investigations (anterior chamber tap, vitrectomy, bronchoscopy and lumbar puncture) or specialized imagery (18F-FDG PET, Brain MRI) could not be determined since these test were rarely performed. Only a few diagnostic tests are useful for the etiological assessment of uveitis. They are often cheap, simple, more often guided by the clinical findings, and lead to an etiological diagnosis in most patients. On the other hand, some tests are never or exceptionally contributive, such as immunological tests or intracellular serologies. Further studies are required to evaluate the profitability of third intention imagery and invasive investigations.

Multiple sclerosis in pediatric patients in Slovenia

AimThe purpose of this study is to review the Slovenian experience with the diagnostics, treatment and outcome in pediatric multiple sclerosis (MS) patients. MethodsChildren and adolescent diagnosed with MS and followed by Department of Child, Adolescent and Developmental Neurology, University Childrens' Hospital Ljubljana, between 1 January 2000 and 31 December 2012 were included. Data from patients' documentation were analyzed retrospectively to record demographic data, clinical presentation, paraclinical findings, disability progression, relapse rate and treatment strategies. ResultsThe study includes 38 patients up to 18 years with MS diagnosis, with female: male ratio 2.8:1 and the incidence of 0.81 per 100.000 children of 0–18 years. The mean age at the time of diagnosis was 15 years 4 months. Most frequent presenting symptoms were sensory, motor, brain-stem, visual and ataxia and 65% of patients had a relapse in the first year. The value of paraclinical findings was asessed. 74% of patients with definite MS and 36% of those with clinically isolated syndrome received disease modifyng therapy and 68% of them was not affected at the follow-up. InterpretationThe characteristics of pediatric MS patients in Slovenia disclose higher annual relapse rates than in adults but also favorable impact of disease modifying treatment on a clinical course. Our data suggest a good treatment tolerance but also the influence of the formulation on a decision to start or switch the treatment.

Cystitis Glandularis: A Rare Benign Condition Presenting as Bladder Tumor

Cystitis glandularis or glandular metaplasia of the urinary bladder, is a benignreactive metaplasia of the urothelium, which occurs in the context of chronic irritation, in less than 2% of the general population. It is a condition in most casesasymptomatic, but also characterized by nonspecific symptoms and paraclinical findings, which is why this condition is underdiagnosed. Its evolution is mainly focused on the risk of malignant degeneration. This condition affects men much more commonly than women. Two forms of cystitis glandularis are recognized: typical and intestinal form. They differ in their histology, incidence, difficulty of diagnosis, and possible association with adenocarcinoma of the bladder. Diagnosis of certainty is histological by careful analysis of chips from bladder endoscopic resection. This rare pathology is managed by endoscopic bladder resection, with repeated cystoscopy as a monitoring tool. Extensive surgical is needed in severe or recurrent cases. We present here-in a case of a female patient having cystitis glandularis presenting with lower urinary tract symptoms. We review equally data reported in literature. To the best of our knowledge our case represents the fourth case of cystitis glandularis affecting a female patient reported in the English literature so far.

Late-onset Hereditary Transthyretin Amyloidosis in Two Patients with Acquired Demyelinating Features

Autosomal-dominant transthyretin (TTR)-related amyloidosis usually manifests in the third to fifth decade with a length-dependent axonal neuropathy and prominent involvement of the small diameter nerve fibers.Objectives:To describe the clinical and para-clinical findings in patients with hereditary transthyretin amyloidosis (hATTR), formerly known as transthyretin-related familial amyloid polyneuropathy (TTR-FAP).Methods:Electrodiagnostic, cerebrospinal fluid (CSF), and TTR gene findings in two patients misdiagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP).Results:A 78-year-old, right-handed, Caucasian male (patient 1) and a 69-year-old, right-handed, Japanese male (patient 2) were referred for late-onset sensory symptoms of the hands and feet as initial manifestations. The first patient, after several years, developed progressive leg weakness affecting his gait and balance, as well as dysautonomic complaints. The second patient had relatively rapid progression with bilateral foot drop and ambulation difficulty after a few months. In both patients, CSF findings were unremarkable. Lumbar spine magnetic resonance imaging did not reveal abnormal thickening or enhancement of the lumbar plexus and exiting nerve roots. Both patients were initially diagnosed with CIDP before being referred to our institution. Patient 2 was started on intravenous immunoglobulin by his primary neurologist, which was maintained for a year without a meaningful response. Repeat electrodiagnostic study at our institution revealed non-length-dependent axonal sensory loss and features of acquired demyelinating neuropathy. TTR gene testing identified pathogenic variants p.Val30Met or V30M, and p.Ala 117Ser or A117S, in the first and the second patient, respectively.Conclusion:hATTR can mimic CIDP clinically and electrodiagnostically. The presence of significant sensory axonal loss, rapid course, and lack of response to immunomodulation therapy should prompt consideration of this diagnosis and TTR gene testing.

Purulent pericarditis as a complication of pneumonia in an infant. Clinical case report

Introducción. La pericarditis purulenta es un proceso inflamatorio del pericardio producto de una infección bacteriana. De no lograrse un diagnóstico oportuno, se convierte en una patología con alta mortalidad en la infancia.Presentación del caso. Lactante de 10 meses de edad que ingresó a un hospital pediátrico de alta complejidad en Bogotá D.C., Colombia, por un cuadro clínico dado por tos, dificultad respiratoria y fiebre. Se tomó una radiografía de tórax donde se observó cardiomegalia y compromiso neumónico multilobar. El ecocardiograma mostró un derrame pericárdico global que requirió pericardiotomía, en la cual se obtuvo 50 mL de líquido turbio con membranas blanquecinas. En la prueba citoquímica se encontraron 2 600mm3 leucocitos, polimorfonucleares del 90% y elevación de proteínas. Con los hallazgos de imagenología y laboratorio se hizo el diagnóstico de pericarditis purulenta, por lo que se inició tratamiento con ceftriaxona y clindamicina por 4 semanas, obteniendo una resolución clínica y ecocardiográfica efectiva.Discusión. La presentación clínica y los hallazgos imagenológicos, paraclínicos y electrocardiográficos sugirieron como primera posibilidad pericarditis purulenta, lo cual se confirmó por las características de líquido pericárdico, que era compatible con un exudado. La resolución clínica, apoyada por el manejo antibiótico y a pesar de no obtener aislamiento microbiológico en los cultivos, corroboró el diagnóstico.Conclusiones. La pericarditis purulenta es una enfermedad poco frecuente en pediatría pero con alta mortalidad. Realizar un diagnóstico oportuno sumado a un tratamiento tempano se relaciona con un mejor pronóstico de esta patología.

AREA POSTREMA SYNDROME – A CHALLENGE FOR DIFFERENTIAL DIAGNOSIS BETWEEN MULTIPLE SCLEROSIS AND NEUROMYELITIS OPTICA SPECTRUM DISORDERS

Area postrema syndrome (APS) manifested with hiccups, nausea and vomiting is one of the core clinical findings in neuromyelitis optica spectrum disorders (NMOSD). We report the case of a 41-year-old woman, with no significant prior medical history, who presented with left upper limb paresthesias. The patient revealed two prior episodes, one 5 years ago, with paresthesias and mild paresis on the right side of the body and the other a few month ago, with right peripheral facial palsy, right facial anesthesia, headache, nausea and emesis. This led us to suspect area postrema syndrome and, possibly, NMOSD. Brain MRI did not show typical lesions for NMOSD, apart from a left periaqueductal lesion. Other potential diagnoses were excluded through laboratory workup. Serum anti-AQP4 antibody were negative, while CSF analysis was positive for oligoclonal bands. Based on clinical and paraclinical findings, a diagnosis of MS was made. This case illustrated that APS may also be present in MS and not only in NMOSD.

Hyphema – from the effect to the cause

The purpose of this review is to describe the etiology (traumatic, iatrogenic, spontaneous causes), clinical and paraclinical findings and the management of hyphemas. The clinical appearance of hyphema is variable and is influenced by the volume of blood and the amount of time erythrocytes are present in the anterior chamber. When hyphema is evident, a complete history should be obtained and a thorough physical examination performed to direct the initial selection of diagnostic tests. Secondary complications of hyphema include glaucoma, synechiae, cataract formation, blood-staining of the cornea, and blindness. Early diagnosis and treatment can minimize or prevent the installation of secondary complications and improve the prognosis.

Post-partum pathological conditions in the bitch - Part II

Various disorders, some of which are life-threatening, can occur in bitches during the Puerperium. In this series of two articles, a detailed review of the literature on puerperal pathological conditions, along with excerpts from the authors' clinical experience and photographs, is presented. Initially, a brief account of the physiological processes during the Puerperium is presented. The hormonal changes, the changes in the genital system and the behavioural changes taking place as the genital system progressively returns to the non-pregnant state, are described. Subsequently, the various disorders, which are distinguished into systemic diseases, diseases of the mammary glands and diseases of the uterus, are reviewed. Systemic disorders that are manifested during the Puerperium are the puerperal hypocalcaemia and the abnormal maternal behaviour. Hypocalcaemia occurs usually after whelping, as calcium requirements of the bitch are increased due to milk production. The disease is due to the increased calcium requirements coupled with either a decreased intake of calcium (primary) or an inability to absorb it from the intestine or mobilise it from the bones (secondary). Abnormal maternal behaviour can be the consequence of factors causing nervousness, pain or disturbance of the bitch. Factors, such as genetic predisposition, caesarian section, young age or even the puppies themselves, may also trigger this condition. The puerperal mammary diseases are mastitis, agalactia and galactostasis. Mastitis is a disease of bacterial aetiology {Escherichia coli, Staphylococcus spp. Streptococcus spp.) occurring with acute or subacute-chronic form. Agalactia is the inability for milk production and can be either primary or secondary; it is defined as full agalactia or hypogalactia. Galactostasis refers to the abnormal passage and expression of milk from the teats, resulting in increased accumulation into the mammary glands. The pathological conditions of the uterus include post-partum metritis, uterine prolapse, retention of foetal membranes, foetal retention, subinvolution of the placental sites and uterine haemorrhage. Post-partum metritis is caused by bacteria (mainly E. coli) invading the uterus during or immediately after whelping and occurs with systemic and genital signs. Uterine prolapse (full or partial) is usually the consequence of vigorous embryo manipulations or intense tenesmus of the bitch. Foetal retention is the consequence of dystocia or of misuse of long-acting progestagens. Subinvolution of the placental sites is the consequence of the erosion of the uterine wall by trophoblast-like cells; often, this erosion extends down to involve the entire mucosa and may even invade the myometrium. Puerperal haemorrhage occurs more frequently in bitches with pre-existing disorders of blood coagulation factors. All the above pathological conditions may cause serious problems to the affected bitches. For a successful treatment, early and correct diagnosis is important. For each condition, the clinical signs and the paraclinical findings are described and the procedure for accurate diagnosis is described. Finally, the recommended conservative or surgical treatment for each condition is presented. It should be noted that in every case, appropriate measures for the welfare of puppies need also to be taken. Measures for a frequent and efficient post-partum monitoring of bitches and puppies are proposed, in order to prevent the development of the various pathological situations.

Post-partum pathological conditions in the bitch - Part I

Various disorders, some of which are life-threatening, can occur in bitches during the Puerperium. In this series of two articles, a detailed review of the literature on puerperal pathological conditions, along with excerpts from the authors' clinicalexperience and photographs, is presented. Initially, a brief account of the physiological processes during the Puerperium is presented. The hormonal changes, the changes in the genital system and the behavioural changes taking place as the genital system progressively returns to the non-pregnant state, are described. Subsequently, the various disorders, which are distinguished into systemic diseases, diseases of the mammary glands and diseases of the uterus, are reviewed. Systemic disorders that are manifested during the Puerperium are the puerperal hypocalcaemia and the abnormal maternal behaviour. Hypocalcaemia occurs usually after whelping, as calcium requirements of the bitch are increased due to milk production. The disease is due to the increased calcium requirements coupled with either a decreased intake of calcium (primary) or an inability to absorb it from the intestine or mobilise it from the bones (secondary). Abnormal maternal behaviour can be the consequence of factors causing nervousness, pain or disturbance of the bitch. Factors, such as genetic predisposition, caesarian section, young age or even the puppies themselves, may also trigger this condition. The puerperal mammary diseases are mastitis, agalactia and galactostasis. Mastitis is a disease of bacterial aetiology {Escherichia coli, Staphylococcus spp. ήStreptococcus spp.) occurring with acute or sub acute-chronic form. Agalactia is the inability for milk production and can be either primary or secondary; it is defined as full agalactia or hypogalactia. Galactostasis refers to the abnormal passage and expression of milk from the teats, resulting in increased accumulation into the mammary glands. The pathological conditions of the uterus include post-partum metritis, uterine prolapse, retention of foetal membranes, foetal retention, subinvolution of the placental sites and uterine haemorrhage. Post-partum metritis is caused by bacteria (mainly E. coli) invading the uterus during or immediately after whelping and occurs with systemic and genital signs. Uterine prolapse (full or partial) is usually the consequence of vigorous embryo manipulations or intense tenesmus of the bitch. Foetal retention is the consequence of dystocia or of misuse of long-acting progestagens. Subinvolution of the placental sites is the consequence of the erosion of the uterine wall by trophoblast-like cells; often, this erosion extends down to involve the entire mucosa and may even invade the myometrium. Puerperal haemorrhage occurs more frequently in bitches with pre-existing disorders of blood coagulation factors. All the above pathological conditions may cause serious problems to the affected bitches. For a successful treatment, early and correct diagnosis is important. For each condition, the clinical signs and the paraclinical findings are described and the procedure for accurate diagnosis is described. Finally, the recommended conservative or surgical treatment for each condition is presented. It should be noted that in every case, appropriate measures for the welfare of puppies need also to be taken. Measures for a frequent and efficient post-partum monitoring of bitches and puppies are proposed, in order to prevent the development of the various pathological situations.

Chronic Recurrent Multifocal Osteomyelitis: A Case Report

Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare migratory skeletal disorder with non-infectious inflammatory etiology which usually causes bone pain in children and adolescents. Intermittent periods of exacerbation and remission are usually noted during the course of the disease. It is a multifocal bone disease usually involving the metaphyses of long bones. The clinical and Paraclinical findings are non-specific, and indeed CRMO is a diagnosis of exclusion based on multiple criteria. Case Presentation: We present a 6-year-old boy with multiple periods of fever, systemic inflammation and bone pain since he was 2 years old, hospitalized multiple times, received antibiotics and finally diagnosed as a CRMO case. Conclusions: CRMO should be diagnosed according to a variety of clinical and paraclinical findings. In children and adolescents with multiple bone lesions and lytic lesion, one of the differential diagnoses that should be considered is CRMO.