Severe Tenderness Research Articles

Management of Painful Vertebral Compression Fracture With Kyphoplasty in a Sever Cardio-Respiratory Compromised Patient

IntroductionVertebral body compression fractures due to osteoporosis, often lead to pain and disability which can be successfully treated by injecting cement into the vertebral body, a procedure known as Balloon Kyphoplasty. In this procedure, an inflatable balloon is used to restore vertebral body height before injection of the cement. Vertebral compression fractures have been treated conservatively with the bed rest, pain medications, and back bracing to decrease the patient’s pain, but the spine was left in its deformed state. Open surgical treatment can address the deformity, but it is usually reserved for patients with a neurological deficit. Kyphoplasty have been developed as an alternative to surgery for the treatment of painful vertebral compression fractures.Case PresentationA 65 year-old female had a compression fracture and decrease height of L1 due to falling down. She had a local severe pain (VAS 8) and tenderness over L1 to L4 vertebra and in her physical examination, there were not any neurologic deficits or bowel and bladder dysfunction. She had a severe cardiovascular disease with low ejection fraction (30%) and had a pace maker, hypertension, diabetes, Chronic obstructive pulmonary disease (COPD), and used about 15 drugs daily. The risk of anesthesia and open surgery was high, therefore she was nominated for the Balloon Kyphoplasty as an interventional procedure.ConclusionsAfter Kyphoplasty, her pain was immediately resolved, vertebral body height was restored to normal, and pain score was reduced from 8 to 1. She was discharged with a normal neurological examination and good general condition, and returned to her normal life. In this case, Balloon Kyphoplasty resulted in the restoration of the vertebral body height, decrease in pain, and returning to daily activity. Therefore, this technique can be an appropriate alternative for surgery in cardio-pulmonary compromised patients.

Factitious Panniculitis Induced by Cupping Therapy

Cupping therapy is an alternative medical procedure that has been widely performed in Asian countries to relieve pain. It is known that there is no complication to this therapy, so many non-health care professionals have performed this procedure. However, there have been few reports on complications, such as iron deficiency anemia, hemorrhagic bullae, kelloids, vasovagal syncope, and foreign body reactions. Masses associated with panniculitis induced by cupping are extremely rare, and they require a unique approach.A 56-year-old woman presented with a 10-month history of multiple masses in the posterior neck and right shoulder areas. The patient repeatedly attempted cupping therapy by herself, and multiple palpable masses developed in the posterior neck and right shoulder area where cupping therapy had been performed. The masses were enlarged by repeated cupping, and they decreased in size when cupping was stopped. Among all lesions, the 2 masses with tenderness were surgically excised. The remaining masses resolved after cupping therapy was ceased. When a patient with subcutaneous mass has a history of cupping or trace of cupping marks, panniculitis induced by cupping should be suspected. The lesion seems to spontaneously resolve unless they are repeatedly stimulated. However, surgical resection is considered in patients with infections or severe tenderness as a complication.

Large Bowel Obstruction in an Obese Woman

Question: A 60-year-old obese (body mass index of 50 kg/m2) woman was admitted through the emergency department with a history of severe colicky abdominal pain, abdominal distension, and constipation. She was known to have diverticular disease of sigmoid colon, hypertension, diabetes, and chronic obstructive pulmonary disease. There was no history of any previous abdominal operations. On examination, she was found to have distended abdomen with severe tenderness and guarding in the left iliac fossa.

Tumor-induced osteomalacia: The tumor may stay hidden!

We report the case of a patient with severe muscular and articular tenderness that caused almost complete immobility. This subject had severe hypophosphatemia due to hyperphosphaturia. Fibroblast growth factor 23 (FGF-23) was abnormally high and the diagnostic of tumor-induced osteomalacia was made. Despite multiple tests, the tumor was not localized. In this report, we discuss different possible investigations to localize the tumor. Lastly, we review the potential therapy available when tumor is not found and can thus not be excised.

Diabetic Myonecrosis of the Thigh

A46-yr-old man with a history of long-standing type 2 diabetes, hypertension, chronic atrial fibrillation, hemodialysis-requiring end-stage renal disease, and left below-the-knee amputation due to severe peripheral arterial disease presented with a 2-d history of atraumatic acute-onset and then progressively worsening right anteromedial thigh pain, which was constant, aching, and aggravated with motion. He was an ex-smoker and a social drinker, and he denied use of illicit drugs. Medications included sitagliptin, amlodipine, metoprolol, lisinopril, aspirin, simvastatin, erythropoietin, and warfarin. Physical examination was remarkable for weak distal pulses and severe tenderness, erythema, and edema of the affected thigh without paresthesia or focal weakness. He had a normocytic normochromic anemia without leukocytosis, serum creatinine of 12.4 mg/dl, normal alanine and aspartate aminotransferases, normal thyroid function, creatine kinase of 228 U/liter (normal range, 30– 200), and aldolase of 13.9 U/liter (normal range, 1.2–7.6). Blood cultures and tests for autoimmune myositis were negative. Magnetic resonance imaging showed extensive edema through the entire extent of vastus medialis (Fig. 1, A and B). A muscle biopsy was performed, which showed muscle fibers undergoing active necrosis with extensive perivascular and endomysial lymphohistiocytic infiltrate, consistent with a diagnosis of diabetic myonecrosis (Fig. 1, C and D). The patient was discharged on analgesics. Diabetic myonecrosis is a rare complication of diabetes with advanced microvasculopathy and presents most commonly with acute pain and swelling of the thigh (1). Other reported risk factors are antiphospholipid antibodies (2) and cirrhosis (3). Differential diagnosis includes pyomyositis, primary muscle lymphoma/sarcoma, necrotizing fasciitis, soft tissue abscesses, deep vein thrombosis, dermatomyositis, focal/proliferative/nodular myositis, and cellulitis (1). Pathogenesis involves muscle infarction due to arteriosclerosis or diabetic microangiopathy (4). Diabetic myonecrosis predicts a poor prognosis.

Myonecrosis of Paralumbar Spine Muscle

A case report. To report a case of myonecrosis in the paralumbar spinal muscle. Diabetic myonecrosis is an uncommon and often a missed complication of poor controlled diabetes. It usually occurs in the lower extremities with thigh pain and swelling. Occurrence in the paraspinal muscle is rare with no previous reports of this condition. A 45-year-old obese man came to the emergency department with one week history of sudden onset severe left sided low back pain. On physical examination, the left side of the lumbar area is swollen and tender to touch and quite tense with palpation. The right side is soft and non-tender. The patient is neurologically intact lower extremities. Magnetic resonance imaging (MRI) shows destruction and swelling of the muscles left paralumbar area from the thoracolumbar junction down to the sacrum. The patients pain had improved significantly with analgesics and bed rest. MRI images that were obtained 10 weeks later show remarkable diminish of abnormal signal in the posterior paraspinal muscles on the left side and a few tiny pockets of fluid were identified. Although there does remain some bright signal involving the muscle bundle, there has been much improvement in this regard. Diabetic myonecrosis is a reminder that aggressive diabetic control is essential in all patients to avoid end-organ damage. Diabetic myonecrosis may occur in paralumbar spinal muscle as well as thigh. When diabetic have severe back pain and tenderness with high signal intensity on T2 weighted MRI image, myonecrosis should be included in the differential diagnosis although one consider abscess or cellulitis primarily. The episode of myonecrosis in diabetic is marker of poor control and poor prognosis. Main strategy of treatment is pain control and immobilization, supportive care and diabetes control.

Prevalence and anatomical location of muscle tenderness in adults with nonspecific neck/shoulder pain

BackgroundMany adults experience bothersome neck/shoulder pain. While research and treatment strategies often focus on the upper trapezius, other neck/shoulder muscles may be affected as well. The aim of the present study is to evaluate the prevalence and anatomical location of muscle tenderness in adults with nonspecific neck/shoulder pain.MethodsClinical neck/shoulder examination at two large office workplaces in Copenhagen, Denmark. 174 women and 24 men (aged 25-65 years) with nonspecific neck/shoulder pain for a duration of at least 30 days during the previous year and a pain intensity of at least 2 on a modified VAS-scale of 0-10 participated. Exclusion criteria were traumatic injuries or other serious chronic disease. Using a standardized finger pressure of 2 kg, palpable tenderness were performed of eight anatomical neck/shoulder locations in the left and right side on a scale of 'no tenderness', 'some tenderness' and 'severe tenderness'.ResultsIn women, the levator scapulae, neck extensors and infraspinatus showed the highest prevalence of severe tenderness (18-30%). In comparison, the prevalence of severe tenderness in the upper trapezius, occipital border and supraspinatus was 13-19%. Severe tenderness of the medial deltoid was least prevalent (0-1%). In men, the prevalence of severe tenderness in the levator scapulae was 13-21%, and ranged between 0-8% in the remainder of the examined anatomical locations.ConclusionsA high prevalence of tenderness exists in several anatomical locations of the neck/shoulder complex among adults with nonspecific neck/shoulder pain. Future research should focus on several neck/shoulder muscles, including the levator scapulae, neck extensors and infraspinatus, and not only the upper trapezius.Trial RegistrationISRCTN60264809

Updates in neonatal gastrointestinal US

Sonography has come to play a significant role in imaging of the gastrointestinal (GI) tract in neonates. Although plain radiographs of the abdomen remain essential in some situations, the information obtained from radiographs regarding the bowel itself is often limited. US has several advantages over radiographs in that it can provide detailed information about the bowel wall regarding echogenicity (including intramural gas) and thickness; real-time images can provide information regarding peristalsis, and Doppler techniques can provide information regarding perfusion. US can also clarify whether a gasless area on a radiograph is the result of collapsed bowel, fluid-filled bowel, free fluid or a focal fluid collection. Separation of bowel gas on abdominal radiographs is a nonspecific appearance, and US might elucidate whether this is a result of true bowel wall thickening or fluid within the bowel lumen or in the peritoneal cavity. Furthermore, US can easily depict pneumoperitoneum caused by very small amounts of free gas at least as accurately as plain radiographs and probably even more accurately. To make the best use of US in the evaluation of the neonatal GI tract one has to optimize technique. The wider field of view obtained with vector or curved-array transducers is essential to evaluate the abdomen as a whole and to delineate the overall relationship of the bowel to other structures and free fluid or focal fluid collections. However, the features of the GI tract itself are often better depicted with the high-megahertz linear-array transducers. It is essential to magnify these images so as to depict only an individual or just a few bowel loops at any one time and to ensure that the focal zone is directed at the level of maximum interest in the GI tract. A relative limitation of US is the presence of large amounts of bowel gas but the technique of gentle graded compression can be useful in displacing the gas for better visualization. In neonates with severe abdominal tenderness, abdominal US might cause significant discomfort but the use of a large amount of gel on the abdominal wall can facilitate the examination by enabling images to be obtained without the transducer actually touching the abdomen. US should not be attempted in any neonate who is labile or unstable. There is a wide range of clinical situations in which abdominal US is invaluable for assessment of the neonate with known or suspected GI tract pathology. For example, in neonates with non-bilious vomiting, US can easily differentiate those with hypertrophic pyloric stenosis from those with gastric foveolar hyperplasia or other rarer causes of gastric outlet obstruction. In neonates with bilious vomiting US is the modality of choice to determine whether a midgut volvulus is present. In those neonates without a volvulus, US evaluation of the anatomical position of the entire duodenum (facilitated with intraluminal fluid) might elucidate the presence or absence of midgut malrotation. In the above examples US will obviate the necessity for an upper GI series. Another less common use of US is in the evaluation of the esophagus in neonates suspected of having an N-type tracheoesophageal fistula. Abdominal radiographs are still important in neonates suspected of having necrotizing enterocolitis (NEC). However, US can be invaluable in two clinical situations: first, in those neonates in whom the clinical and radiographic findings are nonspecific and the diagnosis remains indeterDisclaimer Dr. Daneman has no financial interests, investigational or off-label uses to disclose.

Painful myositis in the anti-synthetase syndrome with anti-PL12 antibodies

The idiopathic inflammatory myopathies (IIMs) are characterized by muscle weakness, electromyography (EMG), histological and biochemical features of muscle inflammation. Their classification is evolving due to the myositis-associated autoantibody panel. Anti-aminoacyl-tRNA synthetase (ARS) antibodies are detected in 25-30% patients and define the anti-synthetase syndrome (ASS), a spectrum of interstitial lung disease (ILD), arthritis, fever, Raynaud’s phenomenon and mechanic’s hands. Anti-Jo1 antibodies are most common (20%), whereas anti-PL12 antibodies (alanyl-tRNA synthetase) occur in <3% cases. We report a 58-year-old male with IIM associated with anti-PL12 antibodies, who presented with a three-week history of severe widespread muscle pain, without overt muscle weakness. He also reported polyarthralgia, exertional dyspnoea, dry cough and weight loss. Examination revealed low-grade pyrexia, bi-basal crepitations and exquisitely tender muscles. Notably, there was no proximal muscle weakness or neurological deficit. Investigations revealed marked acute phase response (CRP 121 mg/l, ESR 79 mm/hr), polyclonal hypergammaglobulinaemia and raised ALT 276 U/l (0-40). Serology demonstrated high-titre anti-nuclear antibodies (1:1280, speckled). Serum Western blotting revealed anti-PL12 antibodies. No other autoantibodies were detected. Creatinine kinase was elevated 936 U/l (0-200), EMG was consistent with myositis. MRI thighs demonstrated high signal within the semitendinosis muscle. Muscle histology confirmed a florid inflammatory myopathy with disruption, oedema and considerable macrophage and lymphocytic infiltrate of perimysial connective tissue – typical features of ASS. Spirometry was restrictive with reduced corrected gas transfer. CT chest showed non-specific interstitial pneumonia. Prednisolone 60mg daily, resulted in improvement of dyspnoea and normalisation of CRP and CK. Significant muscle pain (requiring morphine) was steroid-responsive, but only to high doses, with recurrence on dose reduction. Pulsed cyclophosphamide was commenced, with improvement in muscle pain after the first dose. Severe muscular pain and tenderness in the absence of weakness, is atypical of ASS and has not been previously reported. Anti-PL12 antibodies are rare, therefore their associated clinical features are not well-described, unlike the Jo-1 syndrome. ILD is common, usually precedes muscle involvement and may occur in isolation. Previous reports suggest that muscle involvement is uncommon and mild (often subclinical). Further reports and prospective studies will help refine the clinical phenotype of anti-PL12 antibody-positive ASS subtype.

Acute abdomen caused by both acute appendicitis and epididymitis

Acute appendicitis often presents as right lower quadrant (RLQ) pain, severe tenderness at the point of McBurny or Lanz, and Blumberg's sign. Scrotal events with appendicitis are very rare. In our case, a 63-year-old Japanese man presented with severe RLQ pain and high fever. Physical examination revealed severe tenderness (including both points of McBurny and Lanz) and Blumberg's sign. The scrotum was slightly swollen and showed local heat with severe testicular pain. Abdominal computed tomography revealed ascites in a pelvic space and the right side of the spermatic cord was swollen. Emergency operation was performed and the final diagnosis was catarrhal appendicitis and acute epididymitis. This is the first report of acute appendicitis concomitant with acute epididymitis.

A 14-Year-Old Girl Treated for Pyelonephritis

A 14-year-old girl was being treated for pyelonephritis and had been on ceftriaxone for 2 days as an inpatient. She presented with mild fever of 99.4°F, dysuria, suprapubic and fl ank tenderness, and costovertebral angle tenderness, which was consistent with pyelonephritis. Genital exam was normal. She was empirically started on ceftriaxone, and subsequently, the urine culture grew Escherichia coli, which was susceptible to ceftriaxone. Her dysuria resolved, and she had been afebrile for 24 hours before having lower back pain. The pain was excruciating, 10/10 in severity, non-radiating, aggravated by movement, and relieved somewhat by rest and analgesics. She denied having any tingling, numbness, or weakness in the lower extremities. She denied any trauma to the back before being admitted. Because the patient experienced pain, her suprapubic and costovertebral angle tenderness resolved. However, there was severe tenderness noted on the

Imatinib Combined with Chemotherapy and Allogeneic Stem Cell Transplantation Results In Long Time Survival In Patients with De Novo Ph+ AML

AbstractAbstract 4368De novo Philadelphia chromosome-positive acute myeloid leukemia is a rare condition with a poor prognosis. Allogeneic stem cell transplantation (allo-SCT) is always recommended to treat this disease although its results are not always satisfactory even in young patients. Imatinib is a protein tyrosine kinase inhibitor that has now been shown to be active in Ph+ chronic myeloid leukemia and Ph+ acute lymphoblastic leukemia, however its role in Ph+ AML has not been extensively investigated. We present two patients with de novo Ph+ AML who received Imatinib combined with chemotherapy and allogeneic stem cell transplantation (allo-SCT), followed by Imatinib maintainance treatment after allo-SCT. These patients achieved long-term disease-free survival for 34 and 44 months respectively. Patient 1: A 19-year-old woman was admitted in October 2007 with fever and fatigue for one week. Physical examination showed pallor and severe sternal tenderness. Blood routine showed WBC 93.7×109/L, Hb 80.7g/L, platelets 42×109/L, 60% blast cells. Flow cytometry analysis of marrow mononuclear cells showed 84.41% blast cells positive for CD34, 80.49% for HLA-DR, 34.63% for CD13, and 5.71% for MPO. Karyotype at diagnosis was 46, XX, t (9; 22) (q34; 11) in 10 analyzed metaphases. Major BCR/ABL rearrangement (M-BCR-ABL, P210) was positive tested by real-time quantitative polymerase chain reaction(RQ-PCR). She was diagnosed with Ph+ AML (FAB M0). The patient was treated with 2 courses of DA chemotherapy then achieved bone marrow remission after the first course and achieved Complete Hemotology Response (CHR) after the second course. Then another 2 courses of high dose cytarabine were given. The status of minimal residual disease (MRD) was monitored by RQ-PCR for BCR-ABL/ABL ratio. After that BCR-ABL/ABL ratio was 68%, and then oral treatment with Imatinib 300mg/d×14d was started 4 months after diagnosis. Then 2 more cycles of Imatinib (300 mg/day for 14 days) following IA consolidation chemotherapy were taken and the patient maintained CHR and achieved statuses Complete Molecular Response (CMR) by her BCR-ABL/ABL ratio reducing to 0.4% 8 months after diagnosis. Then she took another course of Imatinib 400mg×4w therapy before allo-SCT. The patient underwent allo-SCT from a HLA-identical unrelated donor 9 months after diagnosis. STR analysis showed completely donor phenotype 1, 3 and 6 months after SCT. Imatinib (300 mg/day) was continued 74 days after SCT and the patient remains continuous CHR with Complete Cytogenetic Response (CCyR) and CMR till now. Patient 2: A 46-year-old man was admitted in Dec. 2004 with fever, cough and fatigue. Physical examination showed pallor and a small submaxillary lymphnode on the right. Blood Routine showed Hb 59g/L, platelets 115×109/L, WBC 3.1×109/L, and 24% blast cells. Bone barrow immunophenotype was CD34+, CD13+, CD117+, HLA-DR+ and MPO-. Karyotype analysis showed 46, XY, t (9; 22) (q34; 11) in 10 analyzed metaphases. Major BCR-ABL rearrangement was positive. He was diagnosed as Ph+ AML (FAB M0). The patient received induction chemotherapy as MA/VP plus Imatinib (400 mg/day×4w) and achieved CHR. Imatinib combined chemotherapy continued for another 7 more cycles. Imatinib was taken as 400 mg/day×2 w during the intermission period of chemotherapy. He had a bone marrow relapse with 18% blasts 48 days after the last chemotherapy, although CCyR and CMR were still maintained. Imatinib was added in a dose of 600mg/day and CHR achieved again 1 month later. The patient then took continuous Imatinib (400mg/day) until he received allo-SCT 26months after diagnosis. STR analysis showed completely donor phenotype 1, 3 and 6 months after SCT. Imatinib (400 mg/day) administration was continued and the patient maintained CHR and CMR in the following clinical course. However, he developed interstitial pneumonia 11 months after SCT and died from severe respiratory failure 30 months after SCT with CHR and CMR still maintained at that time. Our cases indicate that Imatinib combined with daunorubicin based chemotherapy followed by allo-SCT and Imatinib maintenance treatment appears to be the best way to treat Ph+ de novo AML, especially when Imatinib is used in an early phase of AML and when a complete molecular response is achieved before allo-SCT. Disclosures:No relevant conflicts of interest to declare.

Painful myositis in the anti-synthetase syndrome with anti-PL12 antibodies

The idiopathic inflammatory myopathies (IIMs) are characterized by muscle weakness, electromyography (EMG), histological and biochemical features of muscle inflammation. Their classification is evolving due to the myositis-associated autoantibody panel. Anti-aminoacyl-tRNA synthetase (ARS) antibodies are detected in 25-30% patients and define the anti-synthetase syndrome (ASS), a spectrum of interstitial lung disease (ILD), arthritis, fever, Raynaud’s phenomenon and mechanic’s hands. Anti-Jo1 antibodies are most common (20%), whereas anti-PL12 antibodies (alanyl-tRNA synthetase) occur in <3% cases. We report a 58-year-old male with IIM associated with anti-PL12 antibodies, who presented with a three-week history of severe widespread muscle pain, without overt muscle weakness. He also reported polyarthralgia, exertional dyspnoea, dry cough and weight loss. Examination revealed low-grade pyrexia, bi-basal crepitations and exquisitely tender muscles. Notably, there was no proximal muscle weakness or neurological deficit. Investigations revealed marked acute phase response (CRP 121 mg/l, ESR 79 mm/hr), polyclonal hypergammaglobulinaemia and raised ALT 276 U/l (0-40). Serology demonstrated high-titre anti-nuclear antibodies (1:1280, speckled). Serum Western blotting revealed anti-PL12 antibodies. No other autoantibodies were detected. Creatinine kinase was elevated 936 U/l (0-200), EMG was consistent with myositis. MRI thighs demonstrated high signal within the semitendinosis muscle. Muscle histology confirmed a florid inflammatory myopathy with disruption, oedema and considerable macrophage and lymphocytic infiltrate of perimysial connective tissue – typical features of ASS. Spirometry was restrictive with reduced corrected gas transfer. CT chest showed non-specific interstitial pneumonia. Prednisolone 60mg daily, resulted in improvement of dyspnoea and normalisation of CRP and CK. Significant muscle pain (requiring morphine) was steroid-responsive, but only to high doses, with recurrence on dose reduction. Pulsed cyclophosphamide was commenced, with improvement in muscle pain after the first dose. Severe muscular pain and tenderness in the absence of weakness, is atypical of ASS and has not been previously reported. Anti-PL12 antibodies are rare, therefore their associated clinical features are not well-described, unlike the Jo-1 syndrome. ILD is common, usually precedes muscle involvement and may occur in isolation. Previous reports suggest that muscle involvement is uncommon and mild (often subclinical). Further reports and prospective studies will help refine the clinical phenotype of anti-PL12 antibody-positive ASS subtype.

An Unusual Case of Aortoduodenal Fistula Associated With Acute Pancreatitis: A Case Report

Purpose: Aortoduodenal fistula is a direct communication between the aorta and duodenum, most often secondary to surgery. We present a case of aortoduodenal fistula associated with acute pancreatitis. A 50-year-old lady presented with 2 episodes of massive hematemesis and severe epigastric pain of 12 hour duration. Past medical history was significant for left renal cell carcinoma with metastasis to para-aortic lymph nodes treated by left nephrectomy and chemotherapy 5 yrs prior to presentation. There was no history of alcohol or tobacco abuse. Vital signs showed blood pressure 80/50 mm Hg and heart rate 110/min. Physical examination was significant for pale mucous membranes, severe epigastric tenderness and positive bowel sounds. Lab data showed hemoglobin 8 gm/dl; WBC 20,000/ul; serum creatinine 2 mg/dl; serum amylase and lipase were elevated at more than 6 times and 20 times the upper normal limits of the lab values respectively. Patient was diagnosed with acute pancreatitis and was started on intravenous fluid boluses with bowel rest. Endoscopy showed friable, delicate 4x3 cm blood clot, adherent to the underlying mucosa in the proximal duodenum. Without disturbing it, epinephrine was injected in to the duodenal mucosa surrounding the blood clot. As an effort to stop the bleeding, patient underwent laparotomy, which showed fistula in the aorta communicating with the duodenum at the site of ligament of Trietz. Necrotic debris was found at the aortic end of the fistula. There was mild edema of the pancreas but no evidence of pancreatic necrosis. Patient succumbed to massive blood loss during attempted surgical correction of aortoduodenal fistula. Aortoduodenal fistula is one of the rare and dreaded causes of upper gastrointestinal bleeding. The most common site is the third or fourth part of duodenum. The most common cause of primary aortoenteric fistulas in the U.S. is an atherosclerotic aortic aneurysm. The classic triad of gastrointestinal bleed, pain and a pulsatile mass is present only in 11% of the cases. Endovascular repair and stent graft implantation have important role in the treatment of the aortoenteric fistula. After thorough English literature search, no case report of aortoduodenal fistula associated with acute pancreatitis was found. In our case, aortoduodenal fistula with necrotic debris at the aortic end was most likely secondary to metastasis from renal cell carcinoma. As the other causes of pancreatitis were ruled out, the presence of blood clot in the duodenum and massive blood loss could have triggered intense ischemia and pancreatic inflammation leading to acute pancreatitis in this case.

Acute Compartment Syndrome in a Patient on Extracorporeal Support: Utility of Near-Infrared Spectroscopy

ACUTE COMPARTMENT SYNDROME is a surgical emergency. Its diagnosis is based on a clinical suspicion that includes a swollen extremity with severe pain and tenderness, loss of distal pulses, and decreased sensation. The confirmation of this diagnosis is based on the direct invasive measurement of the pressure inside this compartment. A delay in the diagnosis often is associated with a poor prognosis and puts the viability of the affected tissue in jeopardy.1 Critically ill patients supported with extracorporeal membrane oxygenation (ECMO) have several conditions that potentially may delay this diagnosis.

Necrotizing fasciitis: a surgical emergency

Accurate assessment and timely interventions are critical in the treatment of patients affected with necrotizing fasciitis, a rare, fulminating, potentially life-threatening, infectious process of the soft tissues. Understanding the natural history and unique characteristics of this disease is crucial to achieve early recognition, effective management and a favorable patient outcome. Classic symptoms include severe pain, erythema, mottling, crepitus, skin anesthesia, warmth, tenderness, bullous formations and edema in the affected area and fever. This article aims at reviewing the information known about this disease, collected from various sources. Radical surgical debridement, broad-spectrum antibiotics, negative pressure wound therapy and hyperbaric oxygen therapy are considered to be the cornerstones of treatment.

Protracted febrile myalgia in two children with familial Mediterranean fever

1FMF is associated with several types of vasculitis, including polyarteritis nodosa (PAN), Henoch‐ Schonlein purpura (HSP) and Behcet’s disease. The clinical spectrum of FMF has recently been expanded and protracted febrile myalgia (PFM) is now a frequently recognized component in these patients. 2‐4 PFM is characterized by severe paralyzing myalgia, high fever, abdominal pain, arthritis/arthralgia, and transient vasculitic rashes mimicking HSP. PFM develops usually in patients with known FMF, even under colchicine prophylaxis. Sometimes, FMF can be diagnosed with PFM as a first manifestation. 2‐4 We describe here two children with FMF-associated protracted febrile myalgia. The first patient presented with PFM and was subsequently diagnosed as having FMF based on clinical features and genetic analysis. The second was a patient with known FMF. Case Reports Case 1 An 8-year-old boy was admitted with abdominal pain, high fever, arthralgia and myalgia for two weeks. He was unable to walk without help due to the myalgia. His medical history revealed abdominal pain attacks with fever and/or recurrent febrile episodes every three to four months for the last two years. His parents were not relatives and there was no family history of autoimmune or rheumatic diseases. Physical examination showed normal anthropometric development, normal blood pressure (100/60 mmHg), fever (38.7°C), tachycardia, diffuse abdominal tenderness and severe muscular tenderness in all extremities. The rest of the physical examination was normal. Laboratory investigations revealed normal urine analysis, leu

A 1955 clinical trial report that changed my career

A 1955 clinical trial report that changed my career

Methicillin-Resistant Staphylococcus aureus as a Cause of Lumbar Facet Joint Septic Arthritis

Hematogenous septic arthritis of the lumbar facet is a well-recognized although rare1-5 primary infectious entity of the spine. Traditionally, the most commonly implicated organism has been Staphylococcus aureus1,2,6 . Although there have been reports of methicillin-resistant Staphylococcus aureus (MRSA) spondylodiscitis7, methicillin-resistant Staphylococcus aureus as a cause of hematogenous facet joint septic arthritis has not been described, to our knowledge. We report our experience with the treatment of two cases of facet joint septic arthritis due to methicillin-resistant Staphylococcus aureus . The patients were informed that data concerning these cases would be submitted for publication, and they consented. Case 1. A fifty-three-year-old man presented with an eighteen-day history of severe back pain radiating to the left lower limb. He was unable to walk because of the intensity of pain. He had retention of urine, for which he required catheterization. Apart from being a chronic smoker, he had no medical comorbidities. Clinical examination revealed severe tenderness over the left side of the lower back. Neurological examination of the left lower extremity revealed grade-2 (of 5) strength of the extensor hallucis longus and tibialis anterior muscles. Lower extremity sensation and deep tendon reflexes were normal. Rectal examination revealed a lax anal sphincter and an absent bulbocavernosus reflex. Hematological examination showed an erythrocyte sedimentation rate of 77 mm/hr (normal, 6 to 12 mm/hr), a total white blood-cell count of 17.4 × 109/L (normal, 4.3 to 10.8 × 109/L), and a C-reactive protein level of 60 mg/L (normal, <6 mg/L). Plain radiographs were unremarkable. Magnetic resonance imaging demonstrated altered signal intensity in the left L4-L5 facet joint, with fluid causing widening of the joint and extending into the adjacent left paraspinal and psoas muscles (Fig. 1-A). The paraspinal muscle fluid …

Sonozaki syndrome: case report and review of literature

Sonozaki syndrome--pustulotic arthro-osteitis (PAO) is a relatively rare, chronic illness. This disease belongs to the group of psoriatic arthritis (psoriasis arthropatica, artropatia psoriatica) which in turn belongs to the group of seronegative arthritis. Sonozaki syndrome includes palmoplantar pustulosis, PPP as well as arthro-osteitis. Clinically, symmetrically localised pustulae are observed on feet and hands. Effected joints are painful, swollen with a visible inflammation. Here, we describe a case of a woman aged 55 with a diagnosis of Sonozaki syndrome and hyperthyroidism. At the moment of admission multiple changes in the form of pustulae were observed on hands and soles, filled with pus and blood of the erythemal basis. Oral and genital mucosa were free from changes. The oedema within clavicle and sternum joints was without features of the severe inflammation and tactical tenderness. In additional tests, increased BSR 36/62 was found. Bone scintigraphy-focuses of increased accumulation of MDP-Tc-99 m were found in the sternal projection of the clavicle ends at both sides, and the left-side change is bigger and more strongly saturated and can probably progress to the sternum's manubrium. As a result of the used treatment during hospitalisation, (cyclosporine 3 mg/kg and steroid external therapy upon the skin changes) the improvement of the local changes was observed as well as no progression in the joints' changes. At the moment, the patient is treated in the dermatological and rheumatological out-clinic. Early and correct diagnostics allows for efficient treatment of Sonozaki syndrome and decreases the risk of potential complications, such as the described systemic amyloidosis.