Serial Physical Examinations Research Articles

Fever of Unknown Origin in Children

Fever is a common symptom in children and fever of unknown origin (FUO) is not uncommon in paediatric age group. The FUO remains a challenging clinical problem and is an important cause of morbidity and mortality in children. These undifferentiated prolonged fevers need step-wise approach for diagnosis. Details and proper history taking, thorough serial physical examination, critical analysis of sign-symptoms diary and investigation reports are crucial to get a clue that led to the diagnosis. Though in some aspect more concerned with developing countries data, this article is based on reviewing of published papers from both developed and developing countries. Worldwide infection remains the most common cause of FUO in children, followed by collagen vascular diseases, neoplasm, miscellaneous diseases and undiagnosed illnesses. Indiscriminate use of antimicrobials and other medications may mask the real diagnosis. Awareness of primary-level healthcare providers about the cause and logical management approach of pediatric FUO is important for better outcome. Journal of Monno Medical College December, 2023; 9 (2):78-84

Motor Examination of the Brachial Plexus.

Serial physical examination is often required in the evaluation of brachial plexus injuries. (Noland, 2019) A comprehensive evaluation that includes a thorough history, electrodiagnostic evaluation, and imaging studies, in addition to physical examination, can provide valuable information about the location of the lesion, prognosis for recovery, and whether surgical intervention is necessary. After brachial plexus reconstruction, physical examinations are also performed to document clinical improvement and identify any residual issues. The videos included in this clinical examination techniques section demonstrate the muscle strength examination testing for the brachial plexus and offer best practices for documentation.

Serial injections of 4% polyacrylamide hydrogel have no detrimental effects in equine joints following clinical, histologic, and synovial biomarker evaluation.

Polyacrylamide hydrogel (4% PAHG) is an inert viscoelastic supplement used to manage osteoarthritis in horses. Even with a prolonged clinical effect, horses may be administered multiple doses during their performance career. The effect of the serial 4% PAHG treatments is not known. The objectives of this study were to evaluate the clinical, histologic, and synovial fluid biomarker effects following serial administration of 4% PAHG in normal equine fetlock joints. 8 healthy horses. In a blinded, controlled in vivo study, horses received serial intra-articular injections of 4% PAHG (Noltrex Vet; Nucleus ProVets LLC) and contralateral 0.9% saline control on days 0, 45, 90, and 135. Treatment and control joints were randomly assigned. Synovial fluid was collected before administration of 4% PAHG or 0.9% saline on day 0 and at study completion for cellular and biomarker evaluation. Serial physical and lameness examinations were performed throughout the study. On day 240, gross examination and harvest of cartilage and synovial membrane for histology were completed. There were no histologic changes in articular cartilage or synovial fluid biomarkers. The 4% PAHG was seen on the surface of the synovium in 5 of 8 treated joints 105 days after the last treatment. There are minimal effects following serial injections of 4% PAHG on normal joints in horses following administration at 0, 45, 90, and 135 days, with final evaluation on day 240. Serial administration of intra-articular 4% PAHG in horses may provide long-term joint lubrication with no detrimental effects.

The Role of Serial Physical Examinations in Diagnosis of a Tension Pneumothorax Secondary to Alveolopleural Fistula

The Role of Serial Physical Examinations in Diagnosis of a Tension Pneumothorax Secondary to Alveolopleural Fistula

Pityriasis lichenoides presented with skin rash mimicking Urticaria: A case report.

Acute urticaria is urticaria with or without angioedema that is present for less than six weeks, while chronic urticaria is present for more than six weeks. Pityriasis lichenoides (PL) is a benign cutaneous inflammatory disease of unknown etiology. Acute PL typically resolves within a few weeks, while chronic PL lasts several months. The skin rash of PL may resemble the rash of other conditions, so the distinction is essential and depends on history and physical examination and is confirmed by skin biopsy. A 64-year-old gentleman presented with seven days history of generalized itchy skin (hives). Individual lesions last 24-48 hours and do not leave pigmentation or scarring. No systemic involvement. No specific triggers, with two previous similar episodes 30 years and 20 years ago. Levocetirizine, 5 mg tablet, was prescribed, and he was instructed to increase the dose to 4 tablets daily if needed. On reassessing the patient after ten days, he did not respond well. The rash was different from the initial one, with individual lesions lasting for five days or more, so he was referred to a dermatologist for a skin biopsy. Basic investigations were normal. Performing skin biopsy is needed to exclude other pathologies. Skin biopsy showed pathological changes of lichenoid dermatitis compatible with pityriasis lichenoides et varioliformis acuta (PLEVA). He has been treated with azithromycin 250 mg daily for three weeks with rapid and complete resolution without scaring. Urticarial rash may mimic the skin rash of other conditions. Detailed serial history and physical examination are warranted to exclude other diagnoses. Skin biopsy is needed when diagnosing conditions other than urticaria are suspected.

Conservative management of newborns with 35 weeks or more of gestational age at risk for early-onset sepsis: a Brazilian cohort study

ObjectiveTo evaluate the conservative management of newborns born at ≥35 weeks of gestational age, at risk for early-onset neonatal sepsis (EOS). MethodsRetrospective, analytic cohort study (2016 to 2019), including newborns ≥35 weeks of gestational at risk of EOS, asymptomatic at birth, managed conservatively in full rooming-in: serial physical examination and clinical observation for at least 48 h. They were classified into three groups, according to the clinical course: asymptomatic (group A), symptomatic for other reasons (group B), and with sepsis (group C). Risk factors, clinical signs and differential diagnoses of sepsis, length of stay, and discharge conditions were evaluated. ResultsThe authors evaluated 769 asymptomatic newborns at risk of EOS. (mean birth weight 2999 ± 485 g and gestational age 37.6 ± 1.7 weeks, respectively) corresponding to 12.2% of rooming-in admissions. The most prevalent risk factors were colonization by Group B Streptococcus (29%), prolonged rupture membrane duration (21.9%) and preterm labor (21.4%). Most of all of them (53.9%) remained asymptomatic (group A). Group B corresponded for 45.3%, and the most common clinical signs were hypothermia (24.5%), tremors (8.7%) and vomiting (8%). Environmental dysthermia (50.7%), prematurity (20.0%), and feeding intolerance (15.7%) were common in Group B. Laboratory tests were performed in 3.5%. Five patients (one confirmed) comprised group C (0.8/1,000 live births). There were no deaths. The median length of stay was 64 h (IQR 50-93). ConclusionThe rate of clinical/confirmed EOS was low. Most of the symptomatic patients only needed clinical evaluation to rule out sepsis. Management was shown to be safe.

Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment.

Current neonatal early-onset sepsis (EOS) guidelines lack consensus. Recent studies suggest three different options for EOS risk assessment among infants born ≥35 wks gestational age (GA), leading to different behaviors in the sepsis workup and antibiotic administration. A broad disparity in clinical practice is found in Neonatal Units, with a large number of non-infected newborns evaluated and treated for EOS. Broad spectrum antibiotics in early life may induce different short- and long-term adverse effects, longer hospitalization, and early mother-child separation. In this single-center prospective study, a total of 3002 neonates born in three periods between 2016 and 2020 were studied, and three different workup algorithms were compared: the first one was based on the categorical risk assessment; the second one was based on a Serial Physical Examination (SPE) strategy for infants with EOS risk factors; the third one associated an informatic tool (Neonatal EOS calculator) with a universal extension of the SPE strategy. The main objective of this study was to reduce the number of neonatal sepsis workups and the rate of antibiotic administration and favor rooming-in and mother–infant bonding without increasing the risk of sepsis and mortality. The combined strategy of universal SPE with the EOS Calculator showed a significant reduction of laboratory tests (from 33% to 6.6%; p < 0.01) and antibiotic treatments (from 8.5% to 1.4%; p < 0.01) in term and near-term newborns. EOS and mortality did not change significantly during the study period.

Management of well appearing infants born to afebrile mothers with inadequate GBS prophylaxis: A retrospective comparison of the three approaches recommended by the COFN.

There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36-48 hours. The second approach recommends serial physical examinations and vital signs for 36-48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS. This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition. A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS. The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.

Factors, treatments, and outcomes associated with primary soft tissue malignancies of the forearm: A series of 31 cases

BackgroundPrimary soft tissue malignancies of the forearm constitute up to 24% of soft tissue extremity malignancies and present a difficult problem when attempting to preserve both life and forearm function. As described by Enneking, recurrence and metastasis are the two largest contributors to morbidity and mortality and therefore, the primary consideration must be to excise the entire tumor. However, since limb salvage is the preferred treatment over amputation in 95% of cases, many physicians elect to perform marginal resections over wide resections in the attempt to increase functional outcomes. Our study aimed to compare recurrence rates and forearm functional outcomes between these groups to better guide clinical decision making. Questions/purposes(1) What is the difference in recurrence rates between wide resection of the tumor and marginal resection? (2) Between wide and marginal resection groups, what is the functional difference as measured by MSTS functional outcome scores? The purpose of our study was to answer these two questions and better understand if marginal resection yielded better results compared to wide resection. Patients and methodsFollowing IRB approval, we conducted a retrospective case series between 1999 and 2019. Included in the study were patients with a primary malignancy in the predetermined borders of the forearm with a minimum of two-year follow up post-operatively. All patients in the study were operated on by physicians in the Southern California Kaiser Permanente system. Thirty-one patients met criteria for the study. Recurrence rates and metastatic disease was determined through serial history and physical examination, with patients undergoing magnetic resonance (MRI) imaging of the affected area and computed tomography (CT) of the chest every 6 months for the first 2 years, and every 12 months for the following 3 years. MSTS scores were obtained in subsequent follow-ups following the guidelines set by the MSTS scoring system. ResultsOf the 31 patients evaluated, 4 (12.9%) had recurrence and 2 (6.5%) had signs of metastasis. Between the marginal excision and wide excision groups, all 4 recurrences happened in the marginal excision group and none occurred in the wide excision group. In addition, in the pathology report, excisions with 0.1 cm margins or less on any side had 3 instances of recurrence (31%) whereas there was only 1 recurrence (4.8%) outside of this group. MSTS scores for both wide excision and marginal excision were within 1 point with average scores being 26 and 26.9, respectively. ConclusionsConsistent with the literature, our study found that closer surgical margins lead to higher rates of recurrence due to the increased likelihood of aberrant tumor. However, when looking at functional outcome scores, we found minimal benefit in marginal resections compared to wide resections. The lack of MSTS score difference between both groups highlighted that the perceived benefit of choosing a marginal resection over wide excision may be nominal at best. Therefore, we recommend performing an additional intraoperative resection on narrow margins to reduce the chance of recurrence. Of note, clinical discernment in the form of preserving valuable neurovascular structures such as the median nerve should still be an important consideration.

EP.TH.74An incidental finding of liver haemangioma on diagnostic laparoscopy for right sided abdominal pain in a young woman

Abstract Introduction Cavernous liver haemangiomas or hepatic haemangiomas are the most common benign neoplasm of the liver. They are more common in women with a male to female ratio of 2.5-5.1- likely due to estrogenic influence. They are composed of hepatic endothelial cells and are usually small in size (&amp;lt; 4 cm). They are asymptomatic in most of the cases and incidentally discovered on diagnostic tests. Occasionally haemangiomas can exceed a size of 5 cm where they can cause symptoms such as nonspecific abdominal pain. Their exact aetiology is not well understood; they are thought to be vascular malformations with hormonal or congenital background. Haemangiomas belong to ‘Incidentaloma’ tumours, since they can be found incidentally while investigating for other unrelated pathologies. Although rare, but rupture and hemorrhage of liver hemangiomas can be fatal. Case presentation A 33-year-old woman was presented with abdominal pain which was started in central abdomen and then shifted to right lower abdomen abdomen. No other significant symptoms at presentation or past medical history. On serial physical examination, the patient was more tender at the right lower quadrant of the abdomen. Although her inflammatory markers were normal the decision was made to proceed with diagnostic laparoscopy to rule out acute appendicitis. During laparoscopy normal appendix was found with multiple liver lesions. Appendix was not removed. Postoperatively CT Thorax, Abdomen and Pelvis with contrast and CT Liver Triple Phase was performed which confirmed benign liver haemangioma. The patient recovered well after surgery and was discharged home with no routine surgical follow up.

A Girl with Limp and Rash on the Palms and Soles.

A Girl with Limp and Rash on the Palms and Soles.

Antibiotic stewardship for early-onset sepsis

Antibiotics are administered to the vast majority of preterm newborns and to a substantial proportion of term infants in the hours after birth due to risk for early-onset sepsis. The approaches taken to determine which newborns should be evaluated for early-onset sepsis, and what type and duration of antibiotics are administered, are important elements of neonatal antibiotic stewardship. The use of multivariate prediction models for sepsis risk assessment among infants born ≥35 weeks' gestation can safely reduce the use of empiric antibiotic therapy. Approaches incorporating serial physical examination may also contribute to decreasing empiric antibiotic exposure among such infants. Among infants born <35 weeks' gestation, delivery characteristics can be used to identify preterm infants at low enough risk of early infection that empiric therapies are not required. Data informing the epidemiology, microbiology and antibiotic susceptibility patterns of early-onset sepsis pathogens can be used to optimize antibiotic choice for empiric and targeted antibiotic therapy to ensure that effective therapies are administered, while decreasing the risks associated with broad-spectrum antibiotic exposure. Optimal use of blood culture and time to positivity data can also contribute to decreasing the risks associated with prolonged antibiotic administration in the face of sterile cultures.

Predicting Growth Quantitatively Through Proximal Tibia Radiograph Markers.

The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity. From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996). We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia. This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.

OR11-01 Using Kisspeptin to Predict Pubertal Outcomes for Youth With Pubertal Delay

Background: The management of youth presenting with delayed puberty is challenging because it can be difficult to predict which children will eventually progress through puberty and which children will not. We have previously shown that exogenous administration of the neuropeptide kisspeptin, which stimulates GnRH release, can be used to probe the integrity of the reproductive endocrine axis. We hypothesized that responses to kisspeptin could predict outcomes for individuals with pubertal delay. Methods: We conducted a longitudinal study of 16 children (3 girls and 13 boys) with delayed or stalled puberty who had undergone stimulation testing with kisspeptin and GnRH. Participants were followed with serial physical examinations and laboratory studies every six months for evidence of progression through puberty. Inhibin B was measured in boys. A subset of participants underwent exome sequencing. Results: “Kisspeptin responders” who had responded to kisspeptin with a rise in LH of 0.8 mIU/mL or greater all subsequently progressed through puberty (n = 8). In contrast, “kisspeptin nonresponders” who had exhibited LH responses to kisspeptin ≤0.4 mIU/mL all reached age 18 years without developing physical signs of puberty (n = 8). Thus, responses to kisspeptin accurately predicted later pubertal outcomes (p = 0.0002), with sensitivity and specificity of 100% (95% CI 74-100%). Moreover, the kisspeptin-stimulation test outperformed overnight LH measurements, GnRH-stimulated LH, inhibin B, and genetic testing in predicting pubertal outcomes. Conclusion: The kisspeptin-stimulation test can be used to reveal future reproductive endocrine potential in prepubertal children and is a promising novel tool for predicting pubertal outcomes for children with delayed puberty. Trial registration: ClinicalTrials.gov NCT01438034

Reduced Antibiotic Exposure by Serial Physical Examinations in Term Neonates at Risk of Early-onset Sepsis.

Suspected early-onset sepsis (EOS) results in antibiotic treatment of a substantial number of neonates who are uninfected. We evaluated if an approach using serial physical examinations (SPEs) can reduce antibiotic exposure for suspected EOS in term neonates during the first 3 days of life, without affecting safety. Within a quality-improvement framework, SPEs for 24-48 hours for neonates with suspected EOS was implemented in the neonatal intensive care unit, Stavanger, Norway. The proportion of neonates ≥37 weeks gestation exposed to antibiotics, antibiotic therapy-days and the safety outcome time from birth to start antibiotics were compared between a baseline period (April 2014-February 2016), when a risk factor based approach was used, and a post-SPE-implementation period (January 2017-November 2018). We included all term live born neonates (n = 17,242) in the 2 periods. There was a 57% relative reduction in neonates exposed to antibiotics; 2.9% in the baseline and 1.3% in the post-implementation period, P < 0.001. There was a 60% relative reduction in mean antibiotic therapy-days/1000 patient-days; from 320 to 129, P < 0.001, and a 50% relative reduction in time to initiate antibiotics in suspected EOS-cases, from median (interquartile range) 14 (5-28) to 7 (3-17) hours, P = 0.003. The incidence of culture-positive EOS remained unchanged. There were no infection-attributable deaths. Implementing SPE to guide empiric antibiotic therapy in term neonates with suspected EOS more than halved the burden of antibiotic exposure, without delay of antibiotic treatment of infected neonates or increased sepsis-related mortality.

The efficacy of serial physical examination in management of penetrating abdominal trauma to avoid negative laparotomy in selected cases

Background: Patients with Penetrating Abdominal Injury (PAI) are at risk of harboring life-threatening injuries. Many patients are in need of emergency operative intervention. However, there are some patients who can be safely managed non-operatively. Every patient with an abdominal penetrating trauma should have a thorough clinical examination. Repeating the clinical examination at regular intervals is the cornerstone of selective management, as symptoms and signs that were initially absent may appear later.&#x0D; Objective: To see the efficacy of serial physical examination in patients with penetrating abdominal injury thus avoiding non-therapeutic laparotomy in the overall management of patients.&#x0D; Methods: Convenient and purposive 60 PAI patients admitted in casualty block of Dhaka Medical College &amp; Hospital were selected for selective non operative management (SNOM). On admission the abdominal wound was inspected and neither digital nor direct probing of the wound was attempted. Patients selected for admission had an intravenous line established, a thoracic and abdominal X-ray taken and urine and blood samples were taken. If necessary, a nasogastric tube was inserted. Asymptomatic haemodynamically stable patients were admitted for clinical observation in a single unit during which period the patient was examined by a senior surgeon for clinical re-assessment. Patients were discharged when feeding was normal and if there were clear signs of improvement. Results: Over a 6 month period 60 consecutive patients with penetrating abdominal wound were reviewed. In total 52 patients (86.67%) were managed with clinical re-assessment and discharged without laparotomy. Eight patients (13.33%) underwent laparotomy after observation. Small bowel, liver, mesenteric vessels were most frequently affected. Non-therapeutic laparotomy rate was 0%. After laparotomy the morbidity rates were 62.5% (p = 0.92). One local wound infection occurred without prior laparotomy. Average hospital stay after observation was 2.8 days, after laparotomy 9.8 days. Delayed laparotomy did not increase morbidity or hospitalization.&#x0D; Conclusion: Our experience with penetrating abdominal trauma supports the concept of selective conservatism based on repeated physical examination. In a well-established trauma center this has proven to be highly effective with remarkably low rates of non-therapeutic laparotomies and absence of missed diagnosis of visceral injuries.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (2): 76-79

91-Year-Old Man With Upper Extremity Ecchymoses

91-Year-Old Man With Upper Extremity Ecchymoses

Clinical Importance of Markers of Congestion over Time in Patients with Heart Failure with Preserved Ejection Fraction

Background In patients with heart failure, the physical examination is an important aspect of management. However, the prognostic significance of changes in physical examination markers of congestion (MOC) over time in patients with HFpEF is unclear. Objectives To describe the association of changes in physical examination MOC collected serially over time with outcomes in patients with HFpEF. Methods We analyzed serial physical examination data for 1,644 participants in the Americas cohort of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial. Multivariable adjusted proportional hazards models determined the association of serial physical examination MOC, including JVP ≥10 cm, edema, or rales, as a time-updated covariate with the primary composite endpoint of cardiovascular death, aborted cardiac death, or heart failure hospitalization. The prevalence and standard error of the physical examination MOC per month over 2 years before this event was additionally calculated. Findings At baseline, 304 patients (18%) had jugular venous pressure ≥10 cm, 1265 (78%) had edema, and 292 (17%) had rales. The probability of having JVP ≥10 cm or rales was relatively unchanged during each month preceding the primary composite endpoint. After multivariable adjustment, each physical examination MOC was independently associated with a higher risk of the primary composite endpoint (HR for JVP ≥10 cm 1.95, 95% CI [1.51-2.51], p Conclusions When assessed over a period of time, each of the physical examination MOC was closely associated with risk. Unlike JVP and rales, the probability of the presence of edema increased prior to the primary composite endpoint. These findings underscore the importance of a careful physical examination in HFpEF.

Congenital megalourethra with delayed obstructive symptoms

Abstract Congenital megalourethra is a congenital non-obstructive dilation of the male urethra often associated with VACTERL anomaly malformations. We report a case of TE fistula associated congenital megalourethra with symptoms presenting approximately 2 months postpartum. At the time of referral, patient had distal penile flaccidity and poorly developed corpora. Imaging and cystoscopy showed development of hydronephrosis with significant sediment in the bladder. Attempts at retrograde catheterization failed, thus a Blocksum vesicostomy was required. This demonstrates the importance of serial physical examinations and ultrasound surveillance in patients with megalourethra.

Undifferentiated epithelioid sarcoma presenting as a fever of unknown origin: a case report

BackgroundFever of unknown origin is often a diagnostic dilemma for clinicians due to its extremely broad differential. One of the rarer categories of disease causing fever of unknown origin is malignancies; of these, soft tissue sarcoma is one of the least common. Soft tissue sarcomas make up < 1% of all adult malignancies and often do not present with any systemic manifestations or neoplastic fevers.Case presentationA 73-year-old Caucasian woman presented with a 2-week history of fever and profound fatigue. The only other symptom she endorsed was a transient history of left knee pain, initially thought to be unrelated. There was no clear cause on initial examination and routine investigations, but her C-reactive protein was significantly elevated at 207 mg/L. Blood cultures and a urine culture were drawn. She was admitted to hospital for further investigation and placed on empiric antibiotics. Her blood cultures were negative, but she had one further fever in hospital. Computed tomography scans did not yield a cause of her fever. No vegetations were seen on echocardiography. Antibiotics were stopped as she did not seem to have an acute infectious cause of her fever. No new symptoms developed. She felt well enough to proceed with out-patient follow up and was discharged after 8 days in hospital. At 1-month post-discharge: no resolution of symptoms, but she endorsed a recurrence of her left knee pain. Ultrasound and magnetic resonance imaging revealed a 4.5 × 6.8 × 11.6 cm soft tissue mass, identified as a sarcoma on biopsy. She subsequently underwent a distal femur resection. Final staging was pT2bN0M0. She underwent adjuvant radiation therapy, but was found to have developed metastatic disease.ConclusionThis case revealed an atypical presentation of a rare soft tissue sarcoma as the cause of the illness. The etiology behind a fever of unknown origin can be difficult to elucidate, making the approach to investigation particularly important. Repeated history-taking and serial physical examinations can be crucial in guiding investigations and ultimately arriving at a diagnosis. In addition, we believe this case highlights the adage that no seemingly innocuous symptom should be left out when working up a condition with such an extensive and complex differential.