Sinus Tenderness Research Articles

Chinese experts consensus statement: diagnosis and treatment of cystic fibrosis (2023)

Chinese experts consensus statement: diagnosis and treatment of cystic fibrosis (2023)

Identification of provider and patient characteristics associated with antibiotic prescription in treatment of acute sinusitis.

Inappropriate antibiotic use contributes to the development of antibiotic resistance. Sinusitis is the fifth most common diagnosis responsible for antibiotic use. Appropriate antibiotic prescribing for acute sinusitis treatment is crucial to mitigate antibiotic resistance threats. The purpose of this study was to identify patient and provider characteristics associated with antibiotic prescription and to assess provider adherence to antibiotic prescribing guidelines for acute sinusitis treatment. Retrospective chart review including acute sinusitis cases diagnosed over 12 months, at two express care clinics in the Southwestern United States. Data extraction identified 371 cases meeting inclusion criteria (age >18 years). Descriptive statistical data analyses included Chi square test. A majority of cases received antibiotic prescriptions (90.8%, n = 337). Sociodemographic characteristics significantly associated with antibiotic prescription (p < .05) included race, ethnicity, insurance type, and smoking status. Patient-reported nature of symptoms, sinus tenderness, and erythema/edema nasal turbinates were also significantly associated with antibiotic prescription (p < .05). Antibiotic prescription and watchful waiting for acute sinusitis treatment were significantly associated with provider types (p < .05). A gap exists between current guidelines and clinical practice for acute sinusitis treatment in outpatient settings. Antibiotic prescription occurred, although not indicated, along with incorrect antibiotic choice, dose, and duration of therapy. Outpatient antimicrobial stewardship programs for acute sinusitis treatment with a focus on educational interventions for providers may reduce antibiotic overprescribing for acute sinusitis.

ATYPICAL PRESENTATION OF MUCORMYCOSIS IN A NONSEVERE COVID-19 PATIENT

ATYPICAL PRESENTATION OF MUCORMYCOSIS IN A NONSEVERE COVID-19 PATIENT

P288 Rhinocerebral mucormycosis due to Saksenaea vasiformis in a Sri Lankan patient: A rare fungal infection

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground: Rhizopus, Rhizomucor, and Mucor species are renowned agents causing rhinocerebral mucormycosis; a disease with a high mortality rate. Saksenaea vasiformis is extremely rarely observed in this clinical entity. Minimal sporulation in common laboratory media might be responsible for the under-reporting of this organism. Here we present an uncommon case of rhinocerebral mucormycosis due to S. vasiformis. in a Sri Lankan patient with diabetes mellitus.Case History: A 66-year-old female with diabetes mellitus was admitted with frontal headache, right-sided nasal block, anosmia, and right-side facial swelling. Examination revealed facial edema, maxillary sinus tenderness, and a white patch over the hard palate. Thick pus in postnasal space, growth in posterior tongue base, inflamed palate, and oropharynx, were revealed by rigid nasal endoscopy. She developed ophthalmoplegia along with right V and XII cranial nerve palsies irrespective of antibacterial therapy. Right side pansinusitis was observed in non-contrast computed tomography. She was subjected to right-side full house functional endoscopic sinus surgery with right orbital and optic nerve decompression. Irregular wide, ribbon-like, non-septate hyphae suggestive of Zygomycete fungi were observed in the direct microscopy of a deep surgical tissue sample and started with intravenous amphotericin B. After 5 days of incubation, the culture grew a zygomycetes-like mold with a lack of sporulation on Sabouraud dextrose agar, potato dextrose agar, and slide culture. However, the floating agar technique succeeded in producing flasks-shaped sporangium on a short sporangiophore with brown pigmented rhizoids after 14 days of incubation. The phenotypic features were suggestive of S. vasiformis. She was subjected to repeated debridement surgeries and treatment with amphotericin B was continued. She was clinically improving however, refractory hypokalemia along with hypernatremia interrupted her antifungal therapy resulting return of severe symptoms. Contrast-enhanced computed tomography of the brain revealed multiple micro-abscesses in the right temporal lobe. She clinically deteriorated and succumbed to the illness.Discussion: Saksenaea vasiformis, a member of Mucorales, is largely bounded to cutaneous and subcutaneous infections. Rhino-orbital-cerebral infection is relatively uncommon and most of the reported cases were fatal irrespective of optimal therapy. Prompt diagnosis through fungal investigations of deep biopsy is mandatory. The delayed identification of this organism is attributed to its nature of poor sporulation on routine media. Special culture techniques and nutritionally deprived media enhance sporulation. Saksenaea vasiformis is usually sensitive to amphotericin B, high minimum inhibitory concentration has been reported though.ConclusionSpecific culture techniques should be used to induce sporulation if non-sporulating mucormycetes are encountered. Rhinocerebral mucormycosis is associated with a high degree of mortality even with effective antifungal therapy.

Efficacy of Nirgundi Patra Swarasa Nasya in Suryavarta with Special Reference to Frontal Sinusitis- A Case Study

Suryavarta is one of the Shiro Rogas mentioned by Brihatrayis. Suryavarta is produced by Pitta and Vata as per Acharya Sushruta who mentioned that it is ldquoSarvatmakam Kastatamam Vikaramrdquo. Most of its clinical features can be correlated to the features of frontal sinusitis which is also known as vacuum headache or office headache as it affects routine and day-to-day activities of the people. Nasya Siravyadha Lepas etc. are the treatment options for Suryavarta. In the present case study a 27-year-old female patient complaining of Shirashoola Nasavarodha Shiroguruthwa and frontal sinus tenderness came to the outpatient department OPD. The patient was treated with Nasya Karma with Nirgundi Patra Swarasa added with Ghrita and Saindhava for 7 days and got relief from her symptoms.nbsp

A black intruder into the Pandemic: Rhino-Orbital Mucormycosis Complicating COVID-19

There is an increased incidence of rhino orbital mucormycosis during the Coronavirus Disease-2019 (COVID-19) pandemic attributed to diabetes mellitus, corticosteroid usage and immunocompromise caused by COVID-19. In this series, seven biopsy proven cases of mucormycosis (six male patients and one female patient) are presented from a tertiary care center in Eastern India from (May 2021 to June 2021). Empirical systemic liposomal amphotericin B, radical sinus surgery with orbital decompression and irrigation of sinus and orbit with amphotericin B was performed. The mean age of the patients were 42.71±7.34 years with a male preponderance (85.7%). Five patients had orbital involvement (71.42%), and two had cerebral involvement (28.6%). All of them had elevated blood glucose levels, though only three (42.85%) were known cases of type 2 diabetes. The most common manifestations were sinus tenderness (100%), paresthesia (100%), facial swelling (71.42%) and nasal discharge (28.57%). Follow-up at two months showed zero mortality. Timely diagnosis, appropriate management with intravenous amphotericin B and endoscopic radical sinus surgery, debridement of the necrotic tissue proved to be necessary for a good outcome in rhino-orbito-cerebral mucormycosis.

Maxillary sinus metastasis in breast cancer; a case report and review of the literature

Paranasal sinuses are an infrequent site for tumor metastasis, and breast cancer metastasis to these sinuses is very rare. To date, less than 20 cases of breast cancer metastasis to paranasal sinuses have been reported. This case study’s purpose was to describe a 69-year-old woman with a history of breast cancer treated 15 years ago who developed the symptoms of rhinosinusitis. Physical examination showed exophthalmos and maxillary sinus tenderness. Finally, breast cancer metastasis to paranasal sinuses was diagnosed using CT scan. She received hormone therapy, systemic chemotherapy, and maxillary sinus radiotherapy. The treatment was well tolerated, and lesions observed in CT scan improved and after more than a year the patient is still alive.

A ranomized open comparative clinical study of sharbat ustukhuddus and sharbat banafsha in the management of chronic rhinosinusitis

To compare the efficacy of sharbat ustukhuddus and sharbat banafsha in the management of nazlamuzmin (chronic rhinosinusitis). Study was conducted on 60 patients, divided in two groups i.e., test group A (sharbat ustukhuddus) and test group B (sharbat banafsha), 30 patients in each group having various subjective and objective parameters, confirmed by comprehensive general, systemic examination as well as the local examination of nose and paranasal sinuses and diagnosis was confirmed on the basis of X-ray PNS (water’s view), which was carried out before and after the termination of drug therapy. The study was designed as open, randomized-comparative clinical trial. Subjects were randomly allocated from Ajmal Khan Tibbiya College &amp; Hospital, either from IPD or OPD. The treatment period of test drug was six weeks. The study was divided into six visits (7 th , 14 th , 21 st , 28 th , 35 th , 42 th wks) with weekly follow up. Both test drugs were found to be effective on subjective as well as on objective parameters, these drugs significantly reduced sinus tenderness &amp; opacity after treatment which were the main objective parameters but sharbat banafsha was superior than sharbat ustukhuddus and better remedy for this illness as it effectively relieved most of the clinical features of chronic sinusitis .

Significance of Blood Eosinophil Count in Patients with Chronic Rhinosinusitis with Nasal Polyposis.

Chronic Rhino Sinusitis (CRS) is one of the most prevalent chronic illnesses across the globe, affecting persons of all ages. It is an inflammatory process that involves the paranasal sinuses with symptoms lasting longer than 12 weeks. To establish the significance of blood eosinophil (count) levels in CRS with nasal polyps and to compare blood eosinophil count with eosinophil count in the histopathology specimens of the polyps. This was a retrospective study done to review the medical records of 63 patients who underwent endoscopic sinus surgery for CRS with Nasal polyps. The patients were divided into two groups, 1 and 2 based on the number of patients suffering from non eosinophilic rhino sinusitis (Group 1) and those from eosinophlic rhino sinusitis (Group 2). The clinical examination findings, nasal endoscopy observations and MDCT-Paranasal sinuses were notified. Also, the mean Eosinophil Count (EC), Absolute Eosinophil Count (AEC), and Histopathology Eosinophil Count (HPE) was compared between two groups. This was aided by CT Scan Lund Mackay Scores (LMS). Among the patients from Group 1, the male to female ratio was found to be 1.14:1 with 53.3% males and in Group 2 the same were noted as 1.75:1 and 63.6% respectively and found a male preponderance. With regard to symptomatology, significantly higher number of patients in the Group 2 suffered from nasal block (97% vs. 46.7%; p<0.001), nasal obstruction (90.9% vs. 46.7%; p<0.001), nasal discharge (81.8% vs. 56.7%; p=0.030), hyposmia (97% vs. 30%; p<0.001) and asthma (69.7% vs. 3.3%; p<0.001). However, facial pain (66.7% vs. 81.8%; p=0.168) and para nasal sinus tenderness (53.3% vs. 54.6%; p=0.923) were comparable in Groups 1 and 2. Mean EC, AEC and HPE were significantly high in Group 2 compared to Group 1. The study demonstrated that there was a significant correlation between tissue and blood eosinophil counts with increased severity of symptoms in patients with Eosinophilic CRS with nasal polyps in the Indian population.

Case 1: Prolonged Nasal Discharge and Facial Pain in a 17-year-old Girl

1. Elizabeth Ninan, MD* 2. Stefan Hagmann, MD, MSc* 1. *Albert Einstein College of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY. A 17-year-old girl who has a history of asthma and chronic allergic rhinitis presents with a 12-month history of persistent nasal congestion, rhinorrhea, facial pain, and headache. The diagnosis of asthma had been established at age 8 years and chronic allergic rhinitis at age 12 years. Her routine home medications include albuterol, nasal corticosteroids, antihistamines, and topical nasal decongestants. Her symptoms worsened over the last several months, and an 8-week course of oral antibiotics followed by oral corticosteroids for 2 weeks did not lead to notable symptomatic relief. At initial presentation, she is afebrile (36.9°C [98.5°F]), with a heart rate of 96 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 96/62 mm Hg, and oxygen saturations of 99% in room air. On physical examination she is a BMI of 24.5 and appears uncomfortable. Head and neck examination reveals a nasal crease, allergic “shiners,” bilateral nasal polyps, and frontal and maxillary sinus tenderness. On auscultation, clear breath sounds without any added sounds are audible over both lungs. Findings of the remainder of the physical examination are unremarkable. Laboratory studies reveal a white blood cell count of 6,200/μL (6.2 × 109/L), with 8.4% eosinophils on the differential cell count. Computed tomography (CT) scan of …

Posaconazole: An Only Oral First-line Antifungal for Rhinocerebral Mucormycosis

ABSTRACT Introduction Mucormycosis is a rare opportunistic invasive fungal infection. The most commonly reported form of the disease is rhinocerebral mucormycosis. Early diagnosis of the disease and aggressive medical and surgical intervention prevent the high morbidity and mortality associated with mucormycosis. Case report A 54-year-old diabetic and hypertensive male presented with severe frontal headache and retro-orbital pain of 4 days duration with high-grade fever. On examination, the patient was conscious and oriented with a blood pressure of 210/100 mm Hg. The pupils were anisocoric. Frontal sinus tenderness was present. Anterior rhinoscopy showed deviation of nasal septum to left without edema and nasal mucosal congestion. Eye examination revealed normal vision without any periorbital swelling and normal fundus. Plain axial computed tomography showed soft-tissue density material in sphenoid sinus with focal hyperdense component anteriorly. Cerebrospinal fluid study was negative for meningitis with a normal cerebrospinal fluid pressure. Axial T1-weighted image showed T1 intermediate to high signal soft tissue occluding the sphenoid sinus. Axial T2-weighted image showed T2 high signal soft tissue occluding the sphenoid sinus. Similar signal tissue was seen in the middle and posterior ethmoid air cells on both sides. Axial and coronal postcontrast T1-weighted fat-saturated images showed heterogeneously enhancing soft tissue in sphenoid and ethmoid sinuses. The patient underwent functional endoscopic sinus surgery and tissue sampling, following which antifungal therapy with posaconazole was initiated since biopsy from sinus mucosa was consistent with mucormycosis. The patient responded well to functional endoscopic sinus surgical evacuation of the fungal debris and posaconazole and is doing well on follow-up. Conclusion This report highlights the possibility of occurrence of this rapidly fatal condition even with normal-looking nasal mucosa. High index of suspicion is required to prevent the complications as the course of the disease is very rapid. This case report emphasizes the fact that posaconazole is the only available oral antifungal that can be used as a first-line agent in the management of mucormycosis, even in immunocompromised individuals. How to cite this article Jalal MJA, Fernandez SJ, Thomas RM, Kandathil JC, Menon MK, Kuruttukulam G. Posaconazole: An Only Oral First-line Antifungal for Rhinocerebral Mucormycosis. Clin Rhinol An Int J 2016;9(1):46-49.

A Rare Case of Spontaneous Pneumocephalus Associated with Nontraumatic Cerebrospinal Fluid Leak

Introduction. Spontaneous nontraumatic pneumocephalus (PNC) and cerebrospinal fluid (CSF) leaks are both very uncommon conditions. We report a rare case of spontaneous pneumocephalus associated with CSF leak secondary to right sphenoid sinus bony defect without history of trauma. Case Description. 51-year-old Hispanic female with past medical history of hypertension and idiopathic intracranial hypertension (Pseudotumor Cerebri) presented to the emergency room complaining of headache and clear discharge from the right nostril. Physical examination was significant for right frontal sinus tenderness and clear discharge from right nostril. Computed Tomography (CT) scan of the brain showed moderate amount of extra-axial air within the right cerebral hemisphere indicative of pneumocephalus. CT scan of facial bones showed bony defect along the right sphenoid sinus with abnormal CSF collection. The patient was started on intravenous antibiotics for meningitis prophylaxis and subsequently underwent transsphenoidal repair of cerebrospinal fluid leak with abdominal fat graft. CSF rhinorrhea stopped completely after the surgery with near complete resolution of pneumocephalus before discharge. Conclusions. Early identification of pneumocephalus and surgical intervention can help decrease the morbidity and avoid possible complications. Idiopathic intracranial hypertension, although rare, can lead to CSF leak and pneumocepahlus.

Cerebral Arterio Venous Malformation

Introduction: A brain arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain. An arteriovenous malformation can develop anywhere, but occurs most often in the brain or spine. Even so, brain AVMs are rare and affect less than 1 per cent of the population. The aetiology for AVM is not very clear. The most common presenting complaints of patients with AVM are headache or seizures. AVM are routinely diagnosed when CT scan is done for some other reason, not by suspecting AVM as the diagnosis. But this condition when it is classically diagnosed then can often be treated successfully to prevent complications that arise because of AVM malformations. This is a case report of a patient who presented with AVM malformation. The main presenting complaint of this patient was headache. Case Blog: 38 years old male patient attended ENT OP with complaints of severe headache. No aggravating or relieving factors. The headache was insidious in onset. The patient had consulted some local doctor and he was not relieved by taking medications. A thorough ENT examination was done. ENT causes of headache and migraine were ruled out. Also patient was not having any sinus tenderness. The patient was advised to do an emergency CT scan of brain. CT brain showed some abnormal finding. As it was plain CT scan of brain without contrast, the lesion could not be well delineated (Figure 1). The patient was immediately referred to neuromedicine department for further evaluation and opinion. In neuromedicine department patient was advised for MR angiogram. MRA study confirmed the presence of arterio venous malformation. Now the patient is followed up regularly in the neuromedicine department. Discussion: Arterio venous malformation can occur anywhere in the body. One among the most common sites of AVM is the Brain. The aetiology for AVM is not very clear. The most common presenting complaints of patients with AVM are headache or seizures.

Isolated Sinusitis of Lateral Recesses of Sphenoid Sinus

To the Editor: An 11-y-old boy presented with acute onset headache, eye pain and fever. There was no sinus tenderness, and symptoms did not resolve with oral antibiotics and antihistaminics. The CTscan of paranasal sinuses was done which revealed acute sinusitis with fluid only within lateral recesses of bilateral sphenoid sinuses (Fig. 1). This finding was also confirmed on MRI (Fig. 2). Rests of the sinuses, particularly bilateral frontal sinuses were clear (Fig. 3). No neurological complications were seen. The child was managed with intravenous antibiotics and endoscopic sphenoidotomy. Intraoperatively, hypertrophied inflamed polypoidal mucosa was seen involving the lateral recesses of sphenoid sinuses which were excised and curetted. On histopathological examination of the excised tissue, the lamina propria and epithelial layer showed extensive edema with infiltration of neutrophils and mononuclear cells, thrombophlebitis and necrotic foci suggestive of acute inflammatory pathology. Follow-up after one month showed near complete resolution with minimal soft tissue in right lateral recess (Fig. 4). Imaging finding of an isolated acute sinusitis of lateral recess of sphenoid sinus in a child is very uncommon and has not been described in the literature. The diagnosis is often delayed until there is a neurological complication. An important differential diagnoses with similar imaging findings that should be kept in mind while treating these cases is meningocele/meningoencephalocele of the lateral recesses, due to persistence of Sternberg’s canal. These patients usually present with spontaneous cerebrospinal fluid leaks and clinical meningitis. The anatomical location of Sternberg’s canal is medial to the superior orbital fissure Fig. 1 a Axial and b Coronal non-contrast CT scan of paranasal sinuses showing fluid within bilateral lateral recesses (arrow) of the sphenoid sinus (arrowhead) and clear bilateral ethmoid sinuses (asterisk)

Leukocytoclastic vasculitis: A window to systemic Churg Strauss syndrome

A twenty year old male presented with purpuric lesions with chronic painful ulcers over the lower extremities and a recurrent pruritic rash on the trunk for 10 years. He was diagnosed as idiopathic leukocytoclastic vasculitis (LCV) after investigations failed to reveal a systemic association. He was treated with immunosuppressants at each visit with partial remission. In 2004, he was diagnosed with bronchial asthma and allergic rhinitis. In his recent admission, he showed necrotic ulcers on legs and extensive shiny, truncal micropapules. Examination revealed maxillary sinus tenderness and loss of sensation on the medial aspect of the left lower limb. Biopsy of ulcer and the micropapules showed the presence of extravascular eosinophils, while hematological investigations showed peripheral eosinophilia of 18%, raised serum Immunoglobulin E (IgE), Anti nuclear antibody (ANA) positivity and negative antineutrophil cytoplasmic antibody (ANCA). Radiography confirmed maxillary sinusitis, nerve conduction studies revealed mononeuritis of the anterior tibial nerve and pulmonary function tests (PFT) were normal. Clinical examination and investigations pointed towards the diagnosis of Churg-Strauss syndrome (CSS). This report highlights the development of full-blown CSS over a period of 12 years in a patient initially diagnosed as idiopathic LCV, emphasizing the need for regular follow-up of resistant and recurrent cases of LCV.

Identifying and Managing Intracranial Complications of Sinusitis in Children

Of patients admitted to hospital with sinusitis, about 3% have an intracranial complication. We describe the clinical features, laboratory data, imaging findings, and outcomes of pediatric patients with intracranial complications of sinusitis. A retrospective chart review of all pediatric patients < 21 years of age admitted for intracranial complications of sinusitis to a tertiary hospital over a 10-year period. A total of 13 patients with a mean age of 13.3 ± 3.7 years presented with headache (92%), fever (85%), nausea/vomiting (62%), sinus tenderness (31%), and lethargy (23%). Physical examination findings included Pott puffy tumor (46%), orbital cellulitis (46%), altered level of consciousness (46%), new-onset seizure (31%), hemiparesis (23%), nuchal rigidity (23%), visual disturbance (23%), and slurred speech (15%). Computed tomography and magnetic resonance imaging demonstrated 16 instances of epidural and subdural empyema, and 1 brain abscess. One child had sagittal sinus thrombosis. Our findings suggest that acute sinusitis in combination with severe intractable headache, varying degrees of altered level of consciousness, focal neurologic deficits, and/or signs of meningeal irritation should raise clinical suspicion for potential intracranial complications of sinusitis. These signs and symptoms should prompt early and aggressive evaluation and management, including neuroimaging studies, neurologic and otolaryngologic consultations, and intravenous antibiotics.

28-Year-Old Woman With Rapidly Progressive Shortness of Breath

© 2010 Mayo Foundation for Medical Education and Research A 28-year-old female nurse at a skilled nursing facility with a medical history remarkable only for depression presented to an outside emergency department (ED) in October 2007 with maxillary sinus tenderness, tinnitus, and otalgia of 3 weeks' duration. She had been married for 5 years and had no history of foreign travel. Her family history was only remarkable for a maternal uncle with sarcoidosis. At the time of her evaluation, a physician noted that the patient had cervical lymphadenopathy and made a diagnosis of acute sinusitis and otitis media. The patient was prescribed amoxicillin-clavulanate and discharged home. After 1 week of antibiotic therapy, all of the symptoms had improved. In the following month, she developed intermittent flulike symptoms of cough, sore throat, fatigue, and night sweats. During the following 2 months, she unintentionally lost more than 30 lbs (13.6 kg). For these reasons, she was admitted to her local hospital. On admission, she was afebrile with marked cervical, supraclavicular, and axillary lymphadenopathy. Laboratory testing disclosed marked peripheral eosinophilia of 2300/ μL, which was 15% of the white blood cell differential. Computed tomography (CT) of the chest showed normal lung parenchyma but demonstrated substantial bilateral hilar adenopathy. A cervical lymph node biopsy revealed reactive hyperplasia but was negative for malignancy and granulomas. A week after hospitalization and supportive therapy, the patient was discharged without a diagnosis; her fever and sore throat spontaneously resolved. Two months after her hospitalization, the patient began experiencing a painful, asymmetrical, multifocal weakness that was worse in the lower extremities and more prominent on the right. According to the patient, her weakness was persistent and neither worsened with exercise nor improved with rest. Her initial neurologic examination was remarkable for a right foot drop and considerable right lower extremity weakness, but after 2 weeks she developed bilateral foot drop and symmetrical bilateral lower extremities weakness. In the next 2 months, she experienced symmetrical weakness in her lower extremities and became wheelchairbound. She was readmitted to the hospital. Findings on CT of the head were negative. Electromyography (EMG) and nerve conduction studies (NCSs) showed reductions in both conduction velocity and the amplitude of sensory and motor action potentials. Additional laboratory tests showed a fasting serum glucose level of 90 mg/dL (reference ranges provided parenthetically) (70-100 mg/dL) and were negative for Epstein-Barr virus IgM and IgG; cytomegalovirus IgG and IgM; extractable nuclear antigen panel (Sjogren syndrome antigen A, Sjogren syndrome antigen B, scleroderma-70 antigen, antihistidyl–transfer RNA synthetase, Smith antibodies, ribonucleoprotein); Lyme IgM and IgG; human immunodeficiency virus; hepatitis A, B, and C; perinuclear antineutrophil cytoplasmic antibody (ANCA); and cytoplasmic ANCA. However, she continued to have elevated levels of peripheral eosinophils (15%) and a mildly elevated antinuclear antibody level (5.1 U [≥3 U is positive]). A muscle biopsy was unremarkable for myositis. A lumbar puncture with cerebrospinal fluid (CSF) studies yielded the following results: erythrocyte count, 1/mm (0/mm); leukocyte count, 1/mm (0-3/ mm); glucose, 48 mg/dL (40-85 mg/dL); total protein, 95 mg/dL (15-50 mg/dL); and a normal level of angiotensinconverting enzyme.

Uncommon skin lesion in a patient with ataxia‐telangiectasia

A 20-year-old African-American man, with a history of ataxia-telangiectasia diagnosed at the age of one year, presented to the hospital with fever, cough, and headache of 2 days’ duration. The fever was of high grade, associated with chills and rigors. The headache was frontal in location, constant, pounding in nature, and associated with photophobia and phonophobia; there was no neck pain, no neck stiffness, and no blurring of vision. The patient complained of facial pain. There were no relieving or aggravating factors. The family denied any change in mental status. The cough was productive of yellowish sputum. There was associated rhinorrhea. The patient complained of nausea and vomiting with the headache. A review of other systems was negative. On presentation in the emergency room, the patient was tachypneic, febrile, and tachycardic. He was oriented to time, place, and person. His neck was supple and meningeal signs were negative. He had maxillary sinus tenderness. Neurologic examination revealed nystagmus, ocular telangiectasia (Fig. 1), ataxia, and globally decreased muscle strength. Skin examination showed hypopigmented areas on all four extremities, the face, and neck (Figs 1–4), without involvement of the trunk. The rest of the physical examination was unremarkable. Figure 1. Area of vitiligo on the neck with premature graying of the hair Download figure to PowerPoint Figure 2. Vitiligo on the hands Download figure to PowerPoint Figure 3. Vitiligo involving the legs Download figure to PowerPoint Figure 4. Ocular telangiectasia Download figure to PowerPoint The leukocyte count was elevated at 19,600/mcL, with a differential of neutrophils (84%), monocytes (11%), and lymphocytes (5%). Hemoglobin and hematocrit were normal. Chemistry and chest X-ray were normal. Computed tomography scan of the head showed acute sinusitis and cerebellar atrophy consistent with ataxia-telangiectasia. A lumbar puncture was performed, and cerebrospinal fluid findings were suggestive of aseptic meningitis. The patient was treated for aseptic meningitis and acute sinusitis with acyclovir and ceftriaxone. The leukocyte count normalized, the patient remained afebrile, and was asymptomatic after 2 days of treatment with antimicrobials. The rest of the hospital stay was uneventful.

Onset of symptom resolution in adults with acute bacterial rhinosinusitis treated with a single dose of azithromycin extended release compared with 10 days of levofloxacin: A retrospective analysis of a randomized, double-blind, double-dummy trial

Background: A previous study found that a single 2-g dose of azithromycin extended release (AZ-ER) was as efficacious as 10 days of levofloxacin (LFX) 500 mg QD in adults with acute bacterial rhinosinusitis (ABRS). The speed with which patients experience resolution of ABRS symptoms has not been reported. Objective: The purpose of this study was to evaluate the resolution of ABRS symptoms after a single 2-g dose of AZ-ER compared with 10 days of LFX. Methods: This was a retrospective analysis of data from a published international, randomized, double-blind, double-dummy clinical trial conducted between January 21, 2003, and February 20, 2004, that included 534 adult (age ≥18 years) outpatients with ABRS. All patients entering the study were required to have purulent nasal discharge, purulent drainage in the posterior pharynx, or purulent discharge from the maxillary sinus orifice and at least 1 of 3 other protocol-defined cardinal symptoms of ABRS (sinus pain, pressure, or tenderness) for ≥7 days. In addition, they were required to have at least 2 of the following 6 noncardinal symptoms at baseline: cough, fever, headache, nasal congestion, postnasal discharge, and leukocytosis. All patients who received medication were assessed for the occurrence of adverse events at study visits during and after therapy. At the ontreatment visit (between days 3 and 5), baseline symptoms were reassessed as resolved, improved, same, new, or worse. Resolution of symptoms was calculated as the proportion of patients with 3 or 4 cardinal symptoms either resolved (if present at baseline) or not new (if absent at baseline). Concomitant medications other than antibiotics were allowed as needed for symptomatic treatment. Results: Demographic characteristics were similar at baseline between the AZ-ER and LFX treatment arms (mean age, 38.4 and 39.5 years, respectively), although more women were randomized to receive LFX (62.9%) than AZ-ER (53.3%) ( P = 0.025). More than 90% of patients in both arms had ≥3 ABRS symptoms at baseline. At the on-treatment visit, resolution of ≥3 ABRS symptoms was achieved in 88 of 270 AZ-ER patients (32.6%) and 61 of 261 LFX patients (23.4%) ( P = 0.018). Resolution of individual symptoms in the AZ-ER and LFX groups at 3 to 5 days was as follows: sinus pain (92/253[36.4%] and 77/251 [30.7%]; P = NS), sinus pressure (97/243 [39.9%] and 68/244 [27.9%]; P = 0.005), sinus tenderness (83/218 [38.1%] and 73/214 [34.1%]; P = NS), and nasal discharge (57/270 [21.0%] and 49/264 [18.6%]; P = NS). Treatment-related adverse events were reported by 63 of 270 AZ-ER patients (23.3%) and 41 of 268 LFX patients (15.3%). Gastrointestinal disturbances were the most common adverse events, including nausea (4.4% and 3.4%) and abdominal pain (2.6% and 0.4%).

Sagittal Sinus Thrombosis as a Complication of Crohns Disease

Purpose: Thromboembolism is a frequently described complication of Inflammatory Bowel disease although few case reports exist in the literature of neurologic complications of Inflammatory Bowel Disease. We describe a rare case of sagittal sinus thrombosis as a complication of Crohns Diseae. Case Report: A 26-year old female who presented to the hospital with fever, diarhea and abdominal pain was diagnosed with Crohns disease. On a six months follow up she presented with worsening of her abdominal pain and diarrhea. At this office visit, she also had complaints of a sinus headache behind her left eye. About 2 weeks following this office visit, patient went to the emergency room with a throbbing headache radiating to her neck that she described as worst headache of her life. Her pain was aggravated by light and she had only mild improvement with OTC painkillers. She was also experiencing nausea, dizziness, weakness and blurry vision. Her exam was notable for maxillary and frontal sinus tenderness. Non-contrast CT of head showed no evidence of intracranial mass or bleed. An LP revealed no RBCs with normal glucose and protein, but there was an elevated lymphocyte count. She was discharged from the ER with pain medication. The patient returned to the GI clinic three days later electively for Crohns management, still having severe headaches with nausea and vomiting. The pain was still mostly frontal in location with associated pain behind her left eye. She was admitted to the hospital and a neurology consult was obtained. She underwent an MRA/MRV with findings suggestive of non-occlusive thrombus within the superior sagittal sinus with extension into the proximal transverse sinus. A work-up initiated to evaluate for an underlying hypercoagulable state was inconclusive. The patient denied cigarette use, and there was no record of oral contraceptives or other hormonal therapy use. The patient was subsequently started on IV heparin and coumadin. She was instructed to stay on coumadin for 6 months and repeat MRA/MRV to determine resolution of thrombosis in 4–6 months. Conclusions: Thromboembolism is a serious and not infrequent complication of Inflammatory Bowel Disease although case reports of CNS thrombosis in Crohns Disease are very rare in the literature. Clinicians need to have a high index of suspicion, especially for unusual presentations and should strongly recommend preventive measures against the risk factors described above in IBD patients in specific and all patients in general.