Significant Physical Findings Research Articles

THU201 Atypical Presentation Of Kallmann Syndrome With A Rare Genetic Mutation

Abstract Disclosure: E.L. Montgomery: None. B. Thrasher: None. S. Watson: None. Kallmann Syndrome presents as idiopathic hypogonadotropic hypogonadism with additional findings of hyposmia or anosmia and midline facial defects, including cleft lip/palate. We present a case of Kallmann Syndrome due to a rare genetic mutation with absent Mullerian structures. A 15 year, 6 month old female with history of cleft lip and palate and short stature was referred for primary amenorrhea. Clinical history was notable for limited sense of smell and no signs of puberty, including thelarche or adrenarche. Family History unknown (adopted). Significant physical exam findings include tanner 1 breast, no pubic or axillary hair, normal external female genitalia without clitoromegaly, unestrogenized vaginal introitus. Height 147cm (0.88%ile for age). Lab evaluation consisted of: LH 0.66 mIU/ml (2.4-12.6 mIU/ml), FSH 1.63 mIU/ml (3.5-12.5 mIU/ml), prolactin 11.30 ng/ml (4.79-23.30 ng/ml), BhCG negative, testosterone 8 ng/dl (2-17 ng/dl), free testosterone 1.1 pg/ml (<2.2 pg/ml), estradiol 3.0 pg/ml (9.0-249.0 pg/ml), AMH 2.46 ng/ml (1.05-12.86 ng/ml), thyroid function testing and growth factors normal. Imaging included pelvic ultrasound that showed no uterus or gonads. An MRI was obtained that confirmed these findings and also a blind-ending vaginal canal. While the presentation is suggestive of Kallmann Syndrome, the lack of Mullerian structures on imaging has not previously been described. Further evaluation included karyotype (46, XX) and hypogonadotropic hypogonadism genetic panel that identified a mutation in the FGFR1 gene with c.2172C>G (p.Asn724Lys), heterozygous, variant of uncertain significance. Estrogen replacement therapy was initiated with subsequent expected pubertal progression. Repeat imaging after seven months of treatment demonstrated presence of normal developing uterus and bilateral ovaries. Clinical Lesson/Conclusion: 1.Rare mutation with now 3 reports suggesting it is a true pathologic variant2.Unique presentation with hypoplastic Mullerian structures not detected on imaging.This patient’s particular variant has previously been described in in 2 individuals (mother/son) with features of Kallmann Syndrome (PMID: 16606836) with normal and partial puberty respectively, increasing the suspicion that this variant is pathogenic. Newly described FGFR1 variant associated with Kallmann Syndrome / hypogonadotropic hypogonadism. Kallmann Syndrome is not associated with lack of Mullerian structures, however this patient presented with features of Kallmann Syndrome and imaging that did not demonstrate presence of Mullerian structures. Since initiating estrogen therapy, she has had appropriate development of uterus and ovaries. This case demonstrates that prior to estrogen therapy, patients with Kallmann Syndrome may have underdeveloped Mullerian structures that not recognized on imaging prior to estrogen replacement therapy. Presentation: Thursday, June 15, 2023

Virchow-Troisier's Node: A Review

Virchow-Troisier's node is an eponymous term referring to the enlargement of the left supraclavicular lymph node. It is a significant physical finding that generally indicates the late manifestation of a variety of malignancies. This review article briefly revisits the historical background, epidemiology, anatomical routes of metastasis, clinical presentation, differential diagnosis, and clinical significance of Virchow-Troisier's node.

Diagnosis and Treatment Planning of Developmental Hip Dysplasia: Evaluation of Care Practices of the Members of the Turkish Pediatric Orthopedics Association.

Developmental dysplasia of the hip is one of the most important causes of childhood disabilities. Although there are accepted treatment algorithms for developmental dysplasia of the hip, diagnosis and treatment approaches can show variations in the management among physicians. This study aimed to develop a diagnosis and treatment algorithm for developmental dysplasia of the hip according to the preferences of members of the Turkish Pediatric Orthopedics Association. An interview by telephone call was made with 76 orthopedists (group 1: more experienced 39 physicians, group 2: less experienced 37 physicians) who are members of the Turkish Pediatric Orthopedics Association. Participants were q uesti onnai red ab out their demographic information, experiences, diagnostic criteria that they use for developmental dysplasia of the hip, and treatment approaches to patient scenarios of different ages. Most of the participants recommended universal screening at the age of 4 weeks. It was observed that the most significant physical examination finding was limited hip abduction, and the most frequently used radiographic evaluation on x-ray was acetabular index measurement. The most frequently used description for dysplasia was found as acetabular index >30°. Although there are some differences among orthopedists in the diagnosis, treatment, and follow-up approach of developmental dysplasia of the hip, there was no significant difference according to the experience-based grouping. The treatment algorithm, which was created with the most frequently given answers, was designed, which we think may be beneficial for pediatricians and orthopedists.

P271 A masquerading case of Cryptococcus neoformans

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMIntroductionCryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutaneous tropism is not uncommon. Here we describe an HIV-negative immunocompromised patient who developed disseminated cryptococcosis with the predominant presentation being painful thigh lesions.Case DetailsA 56-year-old lady presented with skin lesions and burning pain over both thighs for 1 month and a high-grade fever for 15 days. Her thigh lesions were initially treated elsewhere as tinea corporis. Her previous medical history was significant for poorly controlled diabetes, and chronic liver disease (secondary to autoimmune hepatitis or AIH). Her ongoing medications included prednisolone, anti-diabetics, and tenofovir. At presentation, the only significant physical findings were large irregular areas of central hypo-pigmentation with peripheral hyper-pigmentation and superficial small blisters over both thighs. These areas showed signs of inflammation. The empiric antimicrobial therapy included piperacillin-tazobactam and fluconazole (in view of prior urine culture growing Candida species). Over the next 48 h, fever continued, thigh pain worsened and the lesions on thighs blistered with violaceous discoloration. Her blood cultures sent at admission grew Candida kruzei, resistant to fluconazole, sensitive to voriconazole, amphotericin and echinocandins. Beta-D Glucan was also elevated. Fluconazole was discontinued, and anidulafungin was initiated. A repeat culture (prior to the start of anidulafungin) was still positive for C. krusei, but a subsequent blood culture (after the start of anidulafungin) was negative. Echocardiography did not show features of endocarditis. After a transient improvement, she worsened again with breakthrough fever, hypotension, and worsening of thigh lesions with eschar formation. Wound debridement was done, and antibiotics were escalated to carbapenem and polymyxins. Tissue cultures (sent during wound debridement) grew carbapenem-resistant klebsiella pneumonia. With these, the fever and her wounds were better; but the fever still persisted and she described a persisting severe burning pain over both the thigh wounds which did not respond to several analgesics.A few days later, the fever worsened, and she had hypotension and disorientation. Blood and urine cultures were repeated. Repeat Serum beta D glucan levels were elevated. CSF examination was not possible in view of severe coagulopathy. The blood and wound cultures both grew C. neoformans (confirmed on MaldiTOFF). Antibiotics and anidulafungin were discontinued; liposomal amphotericin and flucytosine were started. Patient had significant improvement in sensorium, fever, and thigh pains within the next 72 h. Later, liposomal amphotericin was switched to conventional amphotericin because of financial constraints. This was followed by acute kidney injury and a flare of AIH. Amphotericin and flucytosine were withheld for a few days; a pulse of methylprednisolone was needed for AIH. Following resolution of acute kidney injury and AIH flare, conventional amphotericin B and flucytosine were restarted (and given for cumulative 3 weeks). This was followed by fluconazole consolidation. At hospital discharge, although there were raw areas over the thighs, these were healthy and she was otherwise well. A total of 3 months later, skin grafting was successfully performed.Conclusions Cryptococcus can be a great masquerader, and can mimic a variety of conditions. A high index of suspicion is required to clinch the diagnosis.

Low-Risk Foot and Ankle Stress Fractures in The Pediatric Population: A Case Series

Background: Stress fractures are a common overuse injury in the pediatric population. Distal fibular and calcaneal stress fractures are considered low-risk stress fractures. Due to their rarity, they have not been studied as thoroughly as other stress fractures. Purpose: To present a descriptive case series of distal fibular and calcaneal stress fractures in the pediatric population and elaborate on demographics, mechanism of injury, management and outcomes. Methods: IRB-approved retrospective study included patients under 18 years at a tertiary children’s hospital who were diagnosed with a distal fibular or calcaneal stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, and outcomes were collected. Descriptive statistical analysis was conducted. Results: 11 patients, 6 distal fibula (4 female, 2 male) and 5 calcaneus (2 female, 3 male) with stress injury on clinical exam and on X-ray or MRI were included. Mean age was 11 years (1-15) and average BMI of 23.5 (16-30.7). The common presenting complaint was pain aggravated by activity that began an average of 3 weeks prior. 7/11 (63.6%) participated in competitive sports: 4/6 with fibular stress fractures were runners (cross country, soccer and sprinting) compared to 0/5 patients with calcaneal involvement. Typical radiographic findings (periosteal reaction, cortical thickening) and a corresponding physical exam was sufficient to diagnose fibular stress fractures in 5/6 patients, with one requiring MRI for definitive diagnosis. 4/5 patients with calcaneal stress fractures required an MRI for a definitive diagnosis, delaying the diagnosis by an average of 3 weeks. 5/6 patients with fibular stress fractures had no other associated pathology, such as additional stress fractures, bone cysts, or osteoid osteomas, whereas 3/5 with calcaneal injuries had at least one of these associated pathologies. Patients with isolated fibular or calcaneal stress fractures (7/11) improved with conservative management, including a controlled ankle motion (CAM) boot, PT, and full activity rest over an average of 6.5 weeks. Out of the remaining 4 patients with associated pathologies, 3/4 improved with conservative management alone after an average of 20 weeks; however, one patient required surgical removal of a bone cyst before complete recovery. Conclusion: A history of pain with significant running, X-ray findings, and physical exam findings were sufficient for diagnosis of fibular stress fractures; however, calcaneal stress fractures were often occult, requiring MRI for definitive diagnosis, and were associated with other pathologies. Conservative management was sufficient for treatment of 91% of patients, regardless of additional fractures or pathology. [Figure: see text][Figure: see text]

Abusive Head Trauma in Infants and Children in Japan

Subdural hematoma in infants can be caused by abuse, and is thought to be more likely if subdural hematoma is associated with retinal hemorrhage and cerebral edema. In Japan, few doctors disagree that cases of subdural hematoma with retinal hemorrhage and cerebral edema with multiple findings on the body are more likely to have been caused by abuse rather than by household accident. On the other hand, in cases where there are no other significant physical findings, only subdural hematoma and retinal hemorrhage, there is a difference of opinion as to whether the injury was caused by an accident or abuse. The reason for this is that neurosurgeons in Japan promoted the concept that infants can develop subdural hematomas and retinal hemorrages due to minor trauma at home before the concept of abusive head trauma became known. In addition, the age distribution of subdural hematomas in Japan differs from that in other countries, with peaks at around 8 months, and the reason for this remains unclear. Therefore, the etiology of infant subdural hematoma in Japan needs to be investigated in greater detail.

Streptococcus\xa0gallolyticus endocarditis on a prosthetic tricuspid valve: a case report and review of the literature

BackgroundStreptococcus gallolyticus subspecies gallolyticus is a known pathogen that causes infective endocarditis, and most cases involve the left heart valves. We present the first reported case of prosthetic tricuspid valve endocarditis caused by this microorganism. Relevant literature is reviewed.Case presentationA 67-year-old Jewish female with a history of a prosthetic tricuspid valve replacement was admitted to the emergency department because of nonspecific complaints including effort dyspnea, fatigue, and a single episode of transient visual loss and fever. No significant physical findings were observed. Laboratory examinations revealed microangiopathic hemolytic anemia and a few nonspecific abnormalities. Transesophageal echocardiogram demonstrated a vegetation attached to the prosthetic tricuspid valve. The involved tricuspid valve was replaced by a new tissue valve, and Streptococcus gallolyticus subspecies gallolyticus was grown from its culture. Prolonged antibiotic treatment was initiated.ConclusionsBased on this report and the reviewed literature, Streptococcus gallolyticus should be considered as a rare but potential causative microorganism in prosthetic right-sided valves endocarditis. The patient’s atypical presentation emphasizes the need for a high index of suspicion for the diagnosis of infective endocarditis.

STREPTOCOCCUS AGALACTIAE ENDOCARDITIS: AN UNUSUAL COMPLICATION OF GOOD'S SYNDROME

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Good's Syndrome is a rare disorder characterized by thymoma associated with hypogammaglobulinemia resulting in combined B and T cell immunodeficiency in adults. We present a case of Good’s syndrome manifesting as infective endocarditis. CASE PRESENTATION: A 66-year-old female without significant medical history presented with a 14-day history of fevers, malaise, myalgias, anorexia, night sweats, and weight loss. She denied chest pain, cough, and dyspnea, syncope or orthopnea. On arrival, vitals were stable. She appeared cachectic without any other significant physical exam findings. Initial blood work was unremarkable. Further testing revealed low immunoglobulin levels IgA <5, IgM <5 and IgG <37. Blood cultures remained negative. Chest CT showed an anterior mediastinal mass and small bilateral pleural effusions. Transesophageal echocardiogram showed aortic valve vegetation (1.5x0.5 cm2) with moderate aortic regurgitation. She was empirically started on broad-spectrum antibiotics. She underwent aortic valve replacement and mediastinal mass removal with pathology confirmed as thymoma on biopsy. Valve tissue PCR was positive for Streptococcus Agalactiae. Flow cytometry of CD45+ lymphoid gate showed normal T cells with an absent B cell population. She was given a dose of intravenous immunoglobulins (IVIG) resulting in the normalization of IgG levels. She was discharged with close clinic follow-up for IVIG infusions. Her repeat IgG levels after 6 months remained in a normal range. DISCUSSION: Hypogammaglobinemia seen in Good's syndrome leads to increased susceptibility to opportunistic infections with predominance for encapsulated bacteria, viruses and fungi. Diagnosis is often challenging as the initial presentation can vary. As noted in our case, It should be suspected after an incidental finding of thoracic mass is seen on imaging in an appropriate clinical context. It can also present with symptoms due to local compressive effects of thymoma including cough, chest pain, hoarseness of voice, Horner syndrome, Superior vena cava syndrome, and dysphagia. When Good Syndrome is suspected, further investigation with measurement of T-cell subsets, B-cell and immunoglobulin levels is warranted. Treatment requires surgical resection of thymoma and immunoglobulin replacement in addition to the treatment of opportunistic infections. It is associated with worse outcomes as compared to X-linked agammaglobulinemia and combined variable immunodeficiency. It is reported that survival at 5-years following diagnosis is around 70%. CONCLUSIONS: Good’s syndrome should be considered in adults with thymoma with unexplained hypogammaglobulinemia. Its diagnosis is often challenging due to variable symptomatology and lack of awareness of this condition. However, due to high mortality and morbidity associated with it, early recognition and timely intervention are essential to improve prognosis. Reference #1: Kelleher P, Misbah SA. Review: What is Good's syndrome? Immunological abnormalities in patients with thymoma. J Clin Pathol Jan. 2003;56(1):12–16. Reference #2: Kelesidis T, Yang O. Review: Good's syndrome remains a mystery after 55 years: A systematic review of the scientific evidence. Clinical Immunology Jun. 2010;135(3):347–363 Reference #3: Ohuchi M, Inoune S, Igarashi T, et al. Good Syndrome Coexisting With Leukopenia. Ann Thorac Surg. 2007;84:2095–2097 DISCLOSURES: No relevant relationships by Shahrukh Arif, source=Web Response No relevant relationships by Firas Jafri, source=Web Response

P837 Isolated cleft posterior mitral valve leaflet

Abstract A 78-year-old man with a history of hypertension and diabetes mellitus was referred to the ER of our hospital due to an episode of shortness of breath of new onset, associated with dizziness and central thoracic pain of 5 minutes duration. Significant physical examination findings included a V/VI holosystolic murmur at fourth intercostal space with radiation to the axilla. ECG showed no significant abnormalities and cardiac enzymes were within normal ranges The TTE and 3D TOE showed dilated left atrial with normal ventricular size and function with an isolated cleft posterior mitral valve leaflet that bisected into two separate leaflets of identical morphology. Concomitant posterolateral leaflet prolapse was also present with two eccentric, posteriorly, and interatrial septum directed regurgitant jets visualized with colour flow Doppler. Cleft mitral valve leaflet (CMVL) is an uncommon congenital cause of mitral regurgitation. Clefts are slit-like holes or defects hypothesized to be a result of incomplete expression of an endocardial cushion defect and most commonly involve the anterior mitral valve leaflet with a paediatric incidence of 1:1340. Clefts affecting only the posterior mitral valve leaflet are extremely rare . Important co-existing anomalies with either posterior and/or anterior CMVL include counterclockwise rotation of the papillary muscles, the presence of an accessory papillary muscle or mitral valve leaflet, atrial septal defects, and mitral valve prolapse. Acquired causes of clefts include infective endocarditis or trauma from surgical exploration. Regurgitation in CMVL results from blood flow directly through the cleft itself or from malcoaptation from accessory chordae with or without papillary muscle distortion. Early detection through 3D TEE echocardiography can provide accurate anatomical images of the mitral valve structure and identify associated congenital anomalies. Conclusion Posterior CMVL is an extremely rare cause of mitral insufficiency. 3D TEE early recognition of this rare clinical entity and co-existent anomalies can identify afflicted patients who can be closely monitored for the progression of symptoms as well as ventricular dysfunction. 3D TEE permits a personalized medicine tailoring the medical treatment to the individual characteristics of each patient. Abstract P837 Figure. Isolated cleft posterior mitral valve

RASH PROVOKES CATASTROPHIC ANTIPHOSPHOLID SYNDROME

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Catastrophic Antiphospholipid Syndrome (CAPS) is a rare life-threatening condition characterized by acute thrombosis in multiple organ systems leading to ischemia and/or organ failure in the presence of positive antiphospholipid antibodies. Approximately fifty percent of patients who present with CAPS do not initially have a prior diagnosis of antiphospholipid syndrome. We present a case of a patient who was found to have CAPS after originally presenting to the hospital for a drug induced rash. CASE PRESENTATION: A 55-year-old male with psoriasis presented to the hospital with a painful diffuse erythematous and pustular rash covering his entire body two days after receiving general anesthesia and cefazolin for an elective circumcision. He was admitted to the burn unit and punch biopsy revealed Acute Generalized Exanthematous Pustulosis (AGEP). Two days after his initial presentation, he lost vision in his right eye and was found to have an acute branch retinal artery occlusion. Throughout the next day, he became hypotensive, somnolent, and confused and he was found to have a dilated right pupil. Imaging revealed a left middle cerebral artery stroke. He developed acute renal failure and a non-ST-elevation myocardial infarction. He was started on pressor support for shock and ultimately required intubation due to increased work of breathing. Autoimmune and vasculitis workup were unremarkable. Repeat MRI was performed which revealed three new infarcts in the right frontal lobe and basal ganglia. Due to concern for endocarditis, a transesophageal echocardiogram was performed and was negative for vegetation. Bilateral lower extremity ultrasound was negative for deep venous thrombosis. Thrombotic workup was remarkable for a positive lupus anticoagulant, hexagonal phase phospholipid, and dilute Russell’s viper venom time screen. He was treated with methylprednisolone, plasma exchange, and a heparin infusion for suspected Catastrophic Antiphospholipid Syndrome. His overall condition began improving within 24 hours and he was eventually extubated. DISCUSSION: CAPS is difficult to diagnose with a need for high clinical suspicion especially in the setting of concomitant illnesses. For this patient with AGEP after cefazolin use, clinical diagnosis became even more difficult as the patient had such significant physical exam findings. Fortunately, the patient was diagnosed quickly enough to receive proper treatment and have significant improvement. CONCLUSIONS: This case demonstrates the importance of a high clinical suspicion to facilitate and receive prompt treatment with plasma exchange and a heparin infusion in order to improve a patient's chances of survival given the increased morbidity and mortality associated with CAPS. Reference #1: Nayer A, Ortega LM. Catastrophic antiphospholipid syndrome: a clinical review. J Nephropathol. 2014;3(1):9-17. DISCLOSURES: No relevant relationships by Nathan Brewster, source=Web Response No relevant relationships by Aaron Czysz, source=Web Response No relevant relationships by Kareem Godil, source=Web Response No relevant relationships by Breanna Goldner, source=Web Response No relevant relationships by Alaynna Kears, source=Web Response

Miliary Tuberculosis with Tubercular Uveitis Presenting as Fever of Unknown Origin: A Case Report

Miliary tuberculosis is a form of disseminated tuberculosis, which is more frequent in immunocompromised patient. Ocular involvement of mycobacterium tuberculosis is also an uncommon presentation of disseminated tuberculosis. Tubercular uveitis is most frequent form of ocular tuberculosis. If treatment is delayed, it may cause loss of vision. In many case of the systemic TB with ocular involvement, there may be no eye symptoms in early stage. On the other hand, many cases of ocular TB may not have any evidence of systemic TB. Here we have described a case of miliary tuberculosis with ocular uveitis who initially presented with fever without any significant physical findings and later developed eye symptoms including diminished vision.&#x0D; Bangladesh J Child Health 2019; VOL 43 (2) :126-130

ANAPHYLAXIS TO COFFEE FROM A SPECIFIC GEOGRAPHIC REGION

Introduction We present anaphylaxis to coffee from one region with tolerance to coffee from elsewhere. This is relevant, as foods from various geographic regions are widely available. Case Description 28-year old Saudi Arabian male presented with throat closing, chest tightness, wheezing with airborne exposure to Arabic coffee. When drinking Arabic coffee, he has immediate lip swelling. Denies hives, pruritis, breathing issues. Drinks black Starbucks coffee (House blend, Latin America) without symptoms. Arabic coffee (Yemen) is brewed with cardamom, ginger, milk. Patient tolerates cardamom, ginger, dairy. He has nasal allergies triggered by cats, trees (skin testing, 2016). Significant physical exam findings: dark circles, Dennie's folds, moderate nasal turbinate edema. Skin testing Positive to bell pepper (7/10), walnut (7/10), hazelnut (7/20), brewed Arabic coffee containing cardamom, ginger, milk (13/30). Negative to brewed Starbucks coffee (0/0); cow's milk (0/0). Histamine 7/20 Saline 0/0 Discussion This patient has history consistent with anaphylaxis to Arabic coffee, but not to Latin American coffee. He tolerates the components of Arabic coffee (cardamom, ginger, milk) in other foods. Skin test was positive to brewed Arabic coffee and negative to Latin American coffee. We recommended avoidance of Arabic coffee, self-injectable epinephrine, Albuterol inhaler. To our knowledge, this is the first description of a patient being sensitized to coffee from one region but not another, perhaps due to inherent differences in coffee from disparate regions or to variations in processing. This patient also has tree nut allergy. We were unable to determine whether the Arabic coffee was cross contaminated with any tree nuts.

Adolescent Female with Jaundice and Edema

An 18-year-old female presented to the emergency department at Texas Children's Hospital with intermittent symptoms of fever, nausea, poor food intake, fatigue, and shortness of breath in the past 3 months. The patient reported excessive weight loss of 10 lbs in the last month. On physical examination, her weight was 40.6 kg (89 lbs, 8.1 oz) and height was 153.4 cm, with a body mass index of 17.30 kg/m2. Other significant physical examination findings included scleral icterus, edema (4+ in bilateral lower extremities), and tachycardia. Abdominal examination was remarkable for the presence of distension and ascites, with tenderness in the left lower quadrant. Patient had a history of Crohn disease with several failed therapies and at presentation was on Cimzia®, an antitumor necrosis factor α (TNF-α) monoclonal antibody therapy, and prednisone. Initial laboratory results at the emergency department showed concentrations of sodium of 130 mmol/L, potassium of 3.4 mmol/L, chloride of 101 mmol/L, and albumin of 1.7 g/dL. She was then admitted to the intensive care unit (ICU)3 for intensive monitoring and correction of her electrolyte abnormalities. Further laboratory tests demonstrated hyperbilirubinemia (mainly conjugated bilirubin) and increased liver enzymes, including aspartate aminotransferase, alanine aminotransferase, and γ-glutamyltransferase, and increased prothrombin time and partial thromboplastin time (Table 1). Her …

Making use of high index of suspicion in diagnosing intra-abdominal abscess

More than 80% of intra-abdominal abscesses occur in the postoperative period and the majority after pancreatico- biliary or colorectal surgery. Over 30% of abscesses are associated with clear evidence of anastomotic leak. There are no reliable signs or symptoms of intra-abdominal abscess. Huge abscesses containing more than 1 L of pus may occur without any significant physical finding. This case report describes a patient with generalized abdomen pain and abdominal distension after 2 weeks of headache and fever. After undergoing laparotomy for dealing with perforated typhoid ulcer of the ileum and 2nd operation for bowel leakage ,the patient health two weeks later was fair, but unexplained tiredness while leukocytosis was the only finding which encouraged 3rd operation during which intraabdominal abscesses were found and Corrugated drain was left. We may conclude that unexplained postoperative leukocytosis indicate hidden sepsis. Placing Intraabdominal corrugated drain may be invaluable in preventing recollection.

Ovarian Hyperstimulation Syndrome: A Rare Case of Unilateral Pleural Effusion

Introduction: Ovarian hyperstimulation syndrome (OHSS) is a rare, usually self-limiting, life-threatening iatrogenic complication. Pleural effusion is usually bilateral and seen in severe forms. Unilateral pleural effusion in OHSS is extremely rare. Here, we present a patient with unilateral pleural effusion due to OHSS.Case Report: A 30-year-old woman with a history of infertility for 5 years and no significant past medical history or physical findings applied to an in vitro fertilization (IVF) center. Ovarian stimulation was initiated. She was admitted with complaints of dyspnea on the second day that she was β-human chorionic gonadotropin (β-hCG)-positive. She had tachypnea and decreased breath sounds. All laboratory tests were within the normal range. Ultrasonography evaluation demonstrated right pleural effusion without intraperitoneal fluid. Thoracentesis was performed, and 3000 cc exudative fluid was drained. Conclusion: The number of patients who undergo infertility treatment at IVF centers has been increasing. Although OHSS is considered as if it is a syndrome that belongs to gynecology and obstetrics clinics or IVF units, the chances of clinicians who work in the emergency service and thoracic diseases and thoracic surgery centers encountering these patients have increased. Therefore, it should be kept in mind that there may be unilateral pleural effusion without peritoneal fluid in OHSS

Right-sided Pleuritic Chest Pain in a 36-year-old Male.

A 36-year-old male was admitted with right-sided pleuritic chest pain that had lasted five days. There was no fever or chills, but he reported shortness of breath and long-standing coughing and wheezing. The cough was intermittently productive of brown sputum. The patient was diagnosed with bronchial asthma 10 years prior. He was managed by a pulmonologist until he lost his job and insurance three years before his presentation to the hospital. In those three years he continued to treat himself with 20 to 60mg prednisone daily to control his coughing and wheezing. His medical history was otherwise unremarkable. He was married with two healthy sons, and he had no history of smoking. On examination, the patient was thin and in mild respiratory distress. Vital signs were as follows: temperature 37.6oC, heart rate 104beats/min (regular), blood pressure 127/76mmHg, respiratory rate 28breaths/min, and oxygen saturation 94% while on 2L/min of oxygen via a nasal cannula. Significant physical examination findings included the following: right-sided pleural rub and shallow inspirations, regular heart sounds without murmurs or gallop, and no lymphadenopathy or rash. Pertinent laboratory findings included the following: white blood cells count 12,200/μL (79% neutrophils and 15% lymphocytes), hemoglobin level 11.8g/dL, platelet count 276,000/μL, and human immunodeficiency virus (HIV) test was negative. Liver enzymes, kidney function tests, and coagulation studies were within normal limits. Chest X-ray (CXR) on admission and computed tomography (CT) scan are shown in Figures 1 and 2. Figure 1 Chest X-ray on admission of a 36-year-old male with right-sided pleuritic chest pain. Figure 2 Computed tomography scan cross-section on admission. The patient underwent CT guided biopsy and histopathology [Figures 3 and 4]. Figure 3 Hematoxylin and eosin stained lung biopsy, magnification=200×. Figure 4 Gomori methenamine silver stained lung biopsy, magnification=200×.

Anticoagulant rodenticide toxicity in six dogs presenting for ocular disease.

To describe cases of suspected anticoagulant rodenticide toxicity manifesting with predominantly ocular signs. Six canine cases that presented to veterinary referral hospitals for ocular abnormalities and were diagnosed with suspected or confirmed anticoagulant rodenticide ingestion were reviewed for commonalities in presentation and outcome. Five dogs had unilateral ocular signs and one dog had bilateral manifestations. Signs included subconjunctival hemorrhage, exophthalmos, and commonly orbital pain without other significant physical examination findings. Prothrombin time was measured in 5 of 6 dogs and was prolonged in all. Partial thromboplastin time was measured in 4 of 6 dogs and was prolonged in all. Complete blood cell count and serum chemistry profiles demonstrated mild, if any, abnormalities. Five dogs had known anticoagulant rodenticide exposure, and rodenticide ingestion was suspected in 1 additional case based on clinical signs, clinical pathologic abnormalities, and response to treatment. Five of 6 cases were hospitalized overnight for plasma transfusions along with oral or injectable vitamin K1 , and all dogs were treated with oral vitamin K1 for 30 days. All dogs experienced complete resolution of clinical signs within 6 weeks of initiating treatment. Anticoagulant rodenticide toxicity can present with predominantly ocular manifestations. Rodenticide ingestion should be considered in dogs with unilateral or bilateral subconjunctival hemorrhage, exophthalmos, and orbital pain.

Milestones for Internal Medicine Sub-interns

BackgroundAs residency programs move toward measuring milestones for competency-based education assessment, medical schools will need to collaborate with residencies to determine competencies for graduating students. The objective of this study is to define the educational milestones for fourth-year medical students during an Internal Medicine sub-internship. MethodsA cross-sectional Internet-based survey (with attention to validity evidence) was developed in early 2013 and administered to Internal Medicine attendings and Internal Medicine sub-interns working on an inpatient team at 3 academic medical centers. With the purpose to determine the milestones for sub-interns, items asked respondents what responsibilities a sub-intern could be entrusted to perform without direct supervision. ResultsFaculty responded that behaviors sub-interns could perform with indirect supervision were mostly at the “reporter” level, including completing a history and physical examination and collecting data such as test results. Other skills such as venipuncture and some communication skills such as calling consults, providing patient counseling, responding to pages, and creating discharge instructions were examples of tasks in which the majority of faculty felt that students were progressing toward unsupervised practice. Behaviors where the majority of faculty would always supervise a medical student performance included performance on the “interpreter” level, including interpreting electrocardiograms, significant physical examination findings, and laboratory results. Medical students less commonly noted needing supervision on the majority of the items when compared with faculty. ConclusionTasks in the reporter domain such as taking a history, collecting medical records, and reporting results can be characterized as medical student milestones.

Lessons in creating a rewarding career.

Lessons in creating a rewarding career.

Pyrethroid as a substance of abuse.

This is a case of a 22-year-old Hispanic male with a history of bipolar disorder and methamphetamine dependence who was admitted after presenting with suicidal ideations by slashing his throat with a machete. The patient had been smoking and inhaling “processed” pyrethroid for about eight weeks as an inexpensive methamphetamine substitute. He reported experiencing a “rush” similar to methamphetamine after using pyrethroid from liquid insecticide that had been heated (electrocuted) or sprayed on hot metal sheets until it crystallized. The patient presented with no significant physical markings or findings but claimed to have his suicidal ideations precipitated by concerns of ill effects of pyrethroid on his health. He also had positive urine drug screen for methamphetamine, which he admitted to using on the day of admission. We conclude that it is important for physicians to maintain a high level of suspicion for alternate and uncommon substances of abuse as well as risks for suicidal tendencies in these patients.