Recognition Of Such Cases Research Articles

Non-invasive imaging in acute decompensated heart failure with preserved ejection fraction.

Non-invasive imaging plays an increasingly important role in emergency medicine, given the trend towards smaller, portable ultrasound devices, the integration of ultrasound imaging across diverse medical disciplines, and the growing evidence supporting its clinical benefits for the patient. Heart failure with preserved ejection fraction (HFpEF) provides a compelling illustration of the impactful role that imaging plays in distinguishing diverse clinical presentations of heart failure with numerous associated comorbidities, including pulmonary, renal, or hepatic diseases. While a preserved left ventricular ejection fraction might misguide the clinician away from diagnosing cardiac disease, there are several clues provided by cardiac, vascular, and lung ultrasonography, as well as other imaging modalities, to rapidly identify (decompensated) HFpEF. Congestion remains the primary reason why patients with heart failure (irrespective of ejection fraction) seek emergency care. Furthermore, comprehensive phenotyping is becoming increasingly important, considering the development of targeted treatments for conditions exhibiting HFpEF physiology, such as cardiac amyloidosis. Timely recognition in such cases has lasting implications for long-term outcomes.

A Unique Case of Large Pelvic Non-Hodgkin Lymphoma

Introduction: Non-Hodgkin lymphoma (NHL) represents a diverse group of malignancies arising from lymphocytes and lymphoid tissues. It encompasses multiple subtypes, including the aggressive diffuse large B-cell lymphoma (DLBCL), which is the most common type of NHL in adults. DLBCL typically presents as a rapidly growing mass in the lymph nodes or extranodal sites. While DLBCL can affect various regions of the body, its occurrence in the pelvic region is infrequent and poses unique diagnostic and therapeutic challenges. Case Description: We present a rare and intriguing case of a 51-year-old female admitted for acute on chronic microcytic anemia, with accompanying symptoms of decreased oral intake due to nausea, and vomiting, significant weight loss, night sweats, and lower quadrant abdominal pain. Additionally, she reported decreased urinary frequency, urgency. CT imaging of the abdomen and pelvis revealed a large soft tissue mass measuring 7.6 x 4.6 x 5.7 cm in the posterior right pelvic region, resulting in severe hydroureteronephrosis, along with bilateral iliac chain adenopathy, retroperitoneal lymph node enlargement, and severe splenomegaly. CT chest revealed several small lung nodules indicating distant metastasis. Additionally, the patient exhibited elevated levels of LDH, CA 199, and CRP, and decreased hemoglobin levels, indicating the presence of systemic disease. A CT-guided biopsy of the right pelvic mass confirmed the diagnosis of non-Hodgkin malignant lymphoma, specifically of the diffuse large B-cell type. Immunohistochemistry and flow cytometry demonstrated CD20 positivity in the proliferating large cells, consistent with DLBCL, and revealed a kappa-restricted B-cell population expressing CD19, CD20, and kappa surface immunoglobulin light chains. The PET scan showed prominent splenomegaly, adenopathy, and retroperitoneal involvement, corroborating the lymphoma diagnosis. The patient was discharged for outpatient follow-up with oncology with a treatment plan of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) administered every 3 weeks, omitting rituximab during the first cycle. Discussion: This case stands out due to the unusual presentation of a large DLBCL in the pelvic region, which is a relatively rare occurrence. The localization of DLBCL in the pelvis poses a diagnostic challenge, as symptoms may overlap with various other conditions. Moreover, the extensive involvement of the retroperitoneal lymph nodes and splenomegaly added complexity to the management of the disease. The rarity of DLBCL in the pelvis highlights the importance of considering lymphoma in the differential diagnosis of patients presenting with non-specific pelvic symptoms and acute anemia. Early recognition of such cases is crucial for timely intervention and optimal treatment planning. Understanding the immunophenotypic characteristics of the tumor is essential for tailoring effective therapeutic strategies. This unique case sheds light on the need for further research and evidence-based guidelines for managing NHL in uncommon anatomical locations, promoting better patient outcomes and quality of life.

Pearls for the diagnosis and possible pathophysiological mechanisms of valproic acid-induced lupus erythematosus: A literature review.

Background: Drug-induced lupus erythematosus (DILE) accounts for 10-15% of systemic lupus erythematosus (SLE) cases, with more than 100 pharmaceutical agents implicated in its development. Depending on the offending drug, clinical and serological manifestations present great variability and, thus, DILE may be overlooked in clinical practice. Valproic acid (VPA) - induced lupus erythematosus has not been analytically reported in the literature, rendering the recognition of such cases even more difficult.Objective: The aim of this study was to analyze VPA - induced lupus features and to discuss possible pathophysiological mechanisms.Materials and Methods: This literature review was conducted in PubMed and Embase databases in June 2021, in search of DILE cases induced by VPA. We found 164 manuscripts, out of which 140 articles regarding other adverse effects or drugs were discarded. Finally, 15 cases fulfilled the eligibility criteria to be included in this review.Results: Although SLE is more common in females, VPA-induced lupus presented a male predilection. Patients developed DILE within the first three months of treatment with VPA at a percentage of 50%, whereas four patients from one to five years after VPA initiation. DILE frequently presented with mild symptoms. In most patients, serositis manifested with polyarthritis, pleural effusion or pericarditis. Notably, one patient presented with Rowell's syndrome, a rare subtype of lupus erythematosus with erythema multiforme and speckled pattern of antinuclear antibodies (ANAs). Central nervous system, renal and skin involvement was scarcely observed. Cytopenia was noted in 7 patients. Immunological findings included positive ANAs in the vast majority of the patients (86.7%), positive anti-histone antibodies in five, positive anti-dsDNA antibodies in three and hypocomplementemia in two patients. Despite the prompt resolution of clinical symptoms after VPA discontinuation, serological abnormalities persisted up to 18 months. Apart from the discontinuation of VPA administration for the resolution of DILE, treatment included corticosteroids in 8 cases.Conclusion: Valproic acid has been implicated in several cases of DILE. Clinicians should be aware of this entity and recognize it promptly to ensure a favorable outcome. Possible pathophysiologic associations may be extrapolated, but a clearer understanding of this syndrome is to be gained by further studies.

Stellate ganglion blockade as a treatment modality in ischemia and gangrene following insect bite

We describe the case of a 34-year-old female patient who had ischemia of the hand and fingers following insect bite and underwent stellate ganglion block as treatment. She was otherwise fit without any significant past history. We recommend an early recognition of such cases with prompt treatment for a better outcome.

Cumulative Harm in Child Protection: The Hidden Concern

ABSTRACTCumulative harm remains a significant child protection concern yet effective responses across the protective and legal domains in Australia are negligible. This article reports on a study of cumulative harm in the Victorian child protection system and the factors contributing to recognition of such cases for intervention and decision-making, and how they moved both through the child protection system, and were responded to by the courts. An audit of case files from Victorian child protection offices and a series of focus groups was conducted April to October 2017. Cumulative harm cases generally closed at intake because no immediate or significant risk to the child, in legal terms, could be established or support for ongoing statutory concern justified. Greater clarification around the definition and urgency of cumulative harm in legislation and best interest principles is suggested, to allow a more holistic understanding of harm and the impacts of long-term maltreatment, emphasising early intervention before there is cumulative impact.

Idiopathic hyperplasia of the sublingual gland in a partially edentulous individual; A case report

BackgroundSalivary glands swellings are frequently encountered in the dental clinic. Their causes include but not limited to neoplasm, infection, stone, and inflammation. Sublingual salivary gland enlargements are commonly caused by ranula, while neoplasms rarely occur and if found they tend to be malignant. Another cause is idiopathic hyperplasia of the sublingual gland (IHSG), which is characterized as asymptomatic swelling of unknown cause, protrude from the mouth floor with normal appearance of the overlying mucosa. The one factor found to be associated with these enlargements is the absence of mandibular posterior teeth. Although IHSG is a relatively frequent condition, to the authors’ knowledge only a few related studies were found in the literature. Case descriptionA 61 years old male patient presented with a complaint of a swelling at the floor of the mouth. It was painless, asymptomatic and noticed by the patient for two years with unremarkable size changes. Examination revealed a lobulated swelling, mobile, non-ulcerated, sessile and arising from the left sublingual gland. No lymphadenopathy was observed. The left side of the mandible presented with missing molars. Panoramic radiographs examination was unremarkable. Contrast-enhanced CT scan showed asymmetric hypodensity at the mouth floor, just lateral to the left geniohyoid muscle. With ranula as a tentative diagnosis, we planned to perform marsupialization and the procedure carried out under local anesthesia. Exposure of the tissue revealed a lobulated mass, mimics the appearance and texture of typical salivary gland tissue. An incisional biopsy was obtained. Microscopic examination of the tissue revealed a normal appearing mucous and serous salivary glandular lobules while part of the specimen was characterized by the presence of fibrosis and inflammation with preservation of the main ductal structure. On follow-up appointments, the swelling was asymptomatic without changes. After correlation between the histopathological and the clinical presentation, a decision made to keep the patient with no intervention unless symptoms arise or swelling progress then surgical excision is indicated. Clinical implicationThe present case was reported to highlight a variation in sublingual gland swellings. Recognition of such cases is vital to avoid unnecessary investigations and misdiagnosis or invasive surgical approaches.

Right MCA Lacunar Infarct with Concomitant Right Ventricular Myocardial Infarction

Concomitant acute myocardial infarction and ischemic cerebrovascular accidents has been rarely reported in the literature. In this report, we are describing a 74 year old male patient previous diabetic and hypertensive who presented to ER with a H/O sudden fall at home after which he had weakness of left leg, slurring of speech and left sided hemianopia after which a screening MRI revealed a Rt sided thalamic lacunar infarct. On further probing he revealed a vague epigastric pain and ECG revealed ST elevation in Lead II,III and AVF with atrial fibrillation & CVR. After that pt was urgently shifted to cath lab for percutaneous coronary intervention. This association can best be described as “cardio-cerebral infarction”. Early recognition of such cases is important and determines the patient’s further management and prognosis.

The Histopathological Spectrum of Pseudolymphomatous Infiltrates in Cutaneous Lupus Erythematosus.

The occurrence of pseudolymphomatous infiltrates in cutaneous lupus erythematosus (cLE) is described mainly in lupus panniculitis and lupus tumidus/lymphocytic infiltration of the skin (Jessner-Kanof). We collected 15 cases of pseudolymphomatous cLE other than lupus panniculitis and lupus tumidus (M:F = 4:11; age range: 23-79 years; mean age: 50.9 years; median age: 57 years). Of the 15 cases, 9 (60%) were characterized by dense nodular infiltrates. Three cases (20%) showed an angiocentric pattern with cytological atypia of lymphoid cells; 2 cases (13.3%) showed a band-like infiltrate mimicking mycosis fungoides, and 1 case had mixed features of the band-like and angiocentric patterns. Clues to the histopathological diagnosis of cLE were presence of interface dermatitis, clusters of plasmacytoid dendritic cells, and dermal mucin deposition. Our study shows that the spectrum of pseudolymphomatous presentations of cLE is broader than previously described, including band-like cases that may be misconstrued as mycosis fungoides, and angiocentric cases that may be misinterpreted as an aggressive lymphoma. Recognition of such cases is possible only on careful clinicopathologic correlation and requires a high level of histopathological suspicion to allow a correct diagnosis and the proper management of the patients.

Psychopathological approach of unsafe games among teenagers: A case report

IntroductionVoluntary asphyxiation by practicing unsafe games such as choking, hanging, strangulation or other means of inducing hypoxia/anoxia is not uncommun among adolescents and can lead to unintended death but it stills not very well-known so underestimated by parents and underdiagnosed by health professionals.ObjectivesStudy of clinical, psychological and psychopathological features in adolescent practicing unsafe games through a case report and a literature review.MethodsWe will present the case of a 14-year-old boy followed up in the Child and Adolescent Psychiatry Department of Mongi Slim Hospital (La Marsa, Tunisia) for behavioral disorders and recurrent syncope. This case report will be supported by a literature review.Case reportS.B., 14-year-old boy, unique child of two divorced parents, with precarious family socio-economic conditions, no apparent medical problems and no known history of drug or alcohol abuse, suicidal ideation or suicide attempts, consulted first time in the department for behavioral disorders. The diagnostic of dysthymia was made. Seven months later, he was hospitalized in the medical intensive care unit for postictal coma. All medical investigations were normal. In the following, S.B. revealed that he used to practice voluntary asphyxiation by compressing the two carotids using his fingers until loss of consciousness. The diagnosis of paraphilia (DSM-5) was established.ConclusionsEarly recognition of such cases and awareness of psychological and psychopathological motivations might prevent serious complications and lethal outcome for these “unsafe-young-players”.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Paraneoplastic Neurological Syndromes and Glutamic Acid Decarboxylase Antibodies.

Little is known of glutamic acid decarboxylase antibodies (GAD-abs) in the paraneoplastic context. Clinical recognition of such cases will lead to prompt tumor diagnosis and appropriate treatment. To report the clinical and immunological features of patients with paraneoplastic neurological syndromes (PNS) and GAD-abs. Retrospective case series study and immunological investigations conducted in February 2014 in a center for autoimmune neurological disorders. Fifteen cases with GAD65-abs evaluated between 1995 and 2013 who fulfilled criteria of definite or possible PNS without concomitant onconeural antibodies were included in this study. Analysis of the clinical records of 15 patients and review of 19 previously reported cases. Indirect immunofluorescence with rat hippocampal neuronal cultures and cell-based assays with known neuronal cell-surface antigens were used. One hundred six patients with GAD65-abs and no cancer served as control individuals. Eight of the 15 patients with cancer presented as classic paraneoplastic syndromes (5 limbic encephalitis, 1 paraneoplastic encephalomyelitis, 1 paraneoplastic cerebellar degeneration, and 1 opsoclonus-myoclonus syndrome). When compared with the 106 non-PNS cases, those with PNS were older (median age, 60 years vs 48 years; P = .03), more frequently male (60% vs 13%; P < .001), and had more often coexisting neuronal cell-surface antibodies, mainly against γ-aminobutyric acid receptors (53% vs 11%; P < .001). The tumors more frequently involved were lung (n = 6) and thymic neoplasms (n = 4). The risk for an underlying tumor was higher if the presentation was a classic PNS, if it was different from stiff-person syndrome or cerebellar ataxia (odds ratio, 10.5; 95% CI, 3.2-34.5), or if the patient had coexisting neuronal cell-surface antibodies (odds ratio, 6.8; 95% CI, 1.1-40.5). Compared with the current series, the 19 previously reported cases had more frequent stiff-person syndrome (74% vs 13%; P = .001) and better responses to treatment (79% vs 27%; P = .005). Predictors of improvement in the 34 patients (current and previously reported) included presentation with stiff-person syndrome and the presence of a thymic tumor. Patients with GAD-abs must be screened for an underlying cancer if they have clinical presentations different from those typically associated with this autoimmunity or develop classic PNS. The risk for cancer increases with age, male sex, and the presence of coexisting neuronal cell-surface antibodies.

Evolution of gamete attraction molecules: evidence for purifying selection in speract and its receptor, in the pantropical sea urchin Diadema.

Many free-spawning marine invertebrates, such as sea urchins, lack any courtship or assortative mating behavior. Mate recognition in such cases occur at the gametic level, and molecules present on the sperm and egg are major determinants of species-specific fertilization. These molecules must also coevolve in relation to each other in order to preserve functional integrity. When sea urchins release their gametes in seawater, diffusible molecules from the egg, termed sperm-activating peptides, activate and attract the sperm to swim toward the egg, initiating a series of interactions between the gametes. Although the compositions and diversity of such sperm-activating peptides have been characterized in a variety of sea urchins, little is known about the evolution of their genes. Here we characterize the genes encoding the sperm-activating peptide of the egg (speract) and its receptor on the sperm, and examine their evolutionary dynamics in the sea urchin genus Diadema, in the interest of determining whether they are involved in reproductive isolation between the species. We found evidence of purifying selection on several codon sites in both molecules and of selectively neutral evolution in others. The diffusible speract peptide that activates sperm is invariant across species, indicating that Diadema egg peptides do not discriminate between con- and hetero-specific sperm at this stage of the process. Speract and its receptor do not contribute to reproductive isolation in Diadema.

Extreme Growth Failure is a Common Presentation of Ligase IV Deficiency

Ligase IV syndrome is a rare differential diagnosis for Nijmegen breakage syndrome owing to a shared predisposition to lympho-reticular malignancies, significant microcephaly, and radiation hypersensitivity. Only 16 cases with mutations in LIG4 have been described to date with phenotypes varying from malignancy in developmentally normal individuals, to severe combined immunodeficiency and early mortality. Here, we report the identification of biallelic truncating LIG4 mutations in 11 patients with microcephalic primordial dwarfism presenting with restricted prenatal growth and extreme postnatal global growth failure (average OFC −10.1 s.d., height −5.1 s.d.). Subsequently, most patients developed thrombocytopenia and leucopenia later in childhood and many were found to have previously unrecognized immunodeficiency following molecular diagnosis. None have yet developed malignancy, though all patients tested had cellular radiosensitivity. A genotype–phenotype correlation was also noted with position of truncating mutations corresponding to disease severity. This work extends the phenotypic spectrum associated with LIG4 mutations, establishing that extreme growth retardation with microcephaly is a common presentation of bilallelic truncating mutations. Such growth failure is therefore sufficient to consider a diagnosis of LIG4 deficiency and early recognition of such cases is important as bone marrow failure, immunodeficiency, and sometimes malignancy are long term sequelae of this disorder.

Overlapping sound event recognition using local spectrogram features and the generalised hough transform

In this paper, we address the challenging task of simultaneous recognition of overlapping sound events from single channel audio. Conventional frame-based methods are not well suited to the problem, as each time frame contains a mixture of information from multiple sources. Missing feature masks are able to improve the recognition in such cases, but are limited by the accuracy of the mask, which is a non-trivial problem. In this paper, we propose an approach based on Local Spectrogram Features (LSFs) which represent local spectral information that is extracted from the two-dimensional region surrounding “keypoints” detected in the spectrogram. The keypoints are designed to locate the sparse, discriminative peaks in the spectrogram, such that we can model sound events through a set of representative LSF clusters and their occurrences in the spectrogram. To recognise overlapping sound events, we use a Generalised Hough Transform (GHT) voting system, which sums the information over many independent keypoints to produce onset hypotheses, that can detect any arbitrary combination of sound events in the spectrogram. Each hypothesis is then scored against the class distribution models to recognise the existence of the sound in the spectrogram. Experiments on a set of five overlapping sound events, in the presence of non-stationary background noise, demonstrate the potential of our approach.

Forensic sexological exam in children and adolescents: challenges of a practice

In order to analyze cases of sexual violence, the physical and behavioural signs of which very often go unperceived, 2031 forensic sexology reports at the Institute of Forensic Medicine (city...

Genomic and Gene Expression Profiling Defines Indolent Forms of Mantle Cell Lymphoma

Mantle cell lymphoma (MCL) is typically a very aggressive disease with poor outcomes, but some cases display an indolent behavior that might not necessitate treatment at diagnosis. To define molecular criteria that might permit recognition of such cases, we compared the clinicopathologic features, gene expression, and genomic profile of patients who had indolent or conventional disease (iMCL or cMCL). Patients with iMCL displayed nonnodal leukemic disease with predominantly hypermutated IGVH and noncomplex karyotypes. iMCL and cMCL shared a common gene expression profile that differed from other leukemic lymphoid neoplasms. However, we identified a signature of 13 genes that was highly expressed in cMCL but underexpressed in iMCL. SOX11 was notable in this signature and we confirmed a restriction of SOX11 protein expression to cMCL. To validate the potential use of SOX11 as a biomarker for cMCL, we evaluated SOX11 protein expression in an independent series of 112 cases of MCL. Fifteen patients with SOX11-negative tumors exhibited more frequent nonnodal presentation and better survival compared with 97 patients with SOX11-positive MCL (5-year overall survival of 78% versus 36%, respectively; P = 0.001). In conclusion, we defined nonnodal presentation, predominantly hypermutated IGVH, lack of genomic complexity, and absence of SOX11 expression as qualities of a specific subtype of iMCL with excellent outcomes that might be managed more conservatively than cMCL.

Concomitant acute right ventricular infarction and ischemic cerebrovascular stroke; possible explanations

Concomitant acute myocardial infarction and ischemic cerebrovascular accidents has been rarely reported in the literature. In this report, we are describing a 48 year old male patient who presented with acute infero-posterior and right ventricular transmural myocardial infarction followed within one hour with massive cerebral infarction and deep coma. The patient succumbed to cardiogenic shock and fatal ventricular arrhythmias resistant to aggressive resuscitative efforts. This association can best be described as "cardio-cerebral infarction". The authors suggest that there exist a possible relationship between both pathologies rather than being just a mere coincidence. Explanations for this association are thoroughly explored and discussed. Early recognition of such cases is important and determines the patient's further management and prognosis. This report aims to sensitize readers to this rare and critical scenario and highlights the necessity of further research for the ideal management of this situation.

A Neglected Posterior Fracture Dislocation of the Shoulder With Ipsilateral Distal Humeral Shaft Fracture

Cases of posterior dislocation or fracture-dislocation of the shoulder are rare. A combination of posterior dislocation and ipsilateral humeral shaft fracture, especially a distal third one, is even rarer. In such injuries, the diagnosis of shoulder dislocation may be missed because great attention is usually given to the fractured humerus. We present this case report to raise awareness among emergency physicians of this manner of injury. We present a case report of a 30-year-old woman who had posterior fracture dislocation of the right shoulder with ipsilateral distal humeral shaft fracture. The shaft fracture was initially evaluated, internally reduced, and fixed, whereas the posterior fracture-dislocation of the shoulder was not recognized. A belated diagnosis was established 1 month after the operation, when a computed tomography scan was performed because the patient reported continuous pain and limited range of motion of the shoulder. A second reduction was performed to reduce the dislocation. The patient had partial functional recovery 1 year later. Consideration of this condition, coupled with thorough and appropriate physical and radiological examinations, could lead to improved recognition of such cases.

Astrocytoma-like multiple sclerosis

Multiple sclerosis (MS) may sometimes mimic clinically and radiologically a brain tumor. The initial recognition of such cases is essential as it might avoid a surgical intervention and supplementary treatment. However, even in patients who underwent surgery, the appropriate preparation of the specimen is of crucial importance for the correct pathological diagnosis since tumors and non-neoplastic demyelinating lesions share some common histopathological features. We present such a case of multiple sclerosis presenting with features of an astrocytoma and was treated with surgery and additional radiotherapy.

Impulse testing of power transformers – a model reference approach

An objective classification of faults that can occur during impulse tests on power transformers is proposed. It includes nonlinear elements, breakdown, and partial discharge events. An analysis of a layer winding, in the time and frequency domains, with these faults shows that current assessment methods must be used with caution. A model reference approach is proposed to distinctly improve recognition in such cases. The method is immune to changes of wave shape and the instant of fault is available by observation.

Myocardial infarction coincident with cerebrovascular accidents in the elderly.

In a three-year prospective study of acute cerebrovascular accident patients admitted to a geriatric unit within 72 hours of the onset, 12.7% had what was considered to be an associated acute myocardial infarction. In the majority of cases, 71%, there was no clinical indication of an acute myocardial infarction and, had it not been for electrocardiographic and enzyme studies, the concurrence of these two conditions might not have come to light. The possible explanations for the concurrence of these two conditions are explored. Patients were followed-up for five years. The mortality rate for the combined acute myocardial and cerebral infarction cases admitted to hospital was 53% in six weeks, and 64% in one year, compared with 26% and 42%, respectively, in those strokes uncomplicated by a cardiac infarction. Only one patient has survived for five years. The recognition of such cases is important in terms of management and prognosis and this may be achieved by ECG recordings followed by enzyme studies in all cases of acute stroke admitted to hospital.