Solitary Symptom Research Articles

External auditory canal metastasis leading to peripheral facial paralysis as first manifestation of de novo stage IV invasive lobular carcinoma of the breast: a rare case report

Facial nerve (FN) palsy, as a solitary symptom resulting from a metastatic tumor, is uncommon, and metastases to the external auditory canal (EAC) are even more infrequent. In this article, we report a unique case of the de novo stage IV invasive lobular breast carcinoma (LBC) presenting as an EAC metastasis and leading to FN palsy as the first symptom, highlighting the importance of considering a broad differential diagnosis.

Infra-low frequency neurofeedback and insomnia as a model of CNS dysregulation.

This paper will review what is conventionally known of sleep homeostasis and focus on insomnia as a primary manifestation of brain dysregulation, whether as a solitary symptom or as part of a larger syndrome such as post-traumatic stress disorder, PTSD. It will discuss in brief behavioral/mindfulness treatments that have been used to treat neurologic diseases, as this is germane to the phenomenology of neurofeedback (NF). It will explore how neurofeedback may work at the subconscious level and cover the current clinical experience of the effectiveness of this technique in the treatment of insomnia. It will conclude with a case presentation.

Intracranial pressure, lateral sinus patency, and jugular ultrasound hemodynamics in patients with venous pulsatile tinnitus.

The clinical and hemodynamic characteristics of venous pulsatile tinnitus (PT) patients with normal or elevated cerebrospinal fluid pressure (CSFP) have not been clearly differentiated. This study aimed to explore CSFP among patients with PT as the solitary symptom, as well as quantitatively and qualitatively assess the role of the degree of transverse sinus (TS) stenosis and jugular hemodynamics in venous PT patients. A total of 50 subjects with venous PT with or without sigmoid sinus wall anomalies (SSWAs) were enrolled in this study. In addition to radiologic assessments for TS stenosis and invagination of arachnoid granulation (AG) in TS, CSFP and jugular hemodynamics were measured via cerebrospinal fluid (CSF) manometry and Doppler ultrasound. Apart from group comparisons and correlation analyses, multivariate linear regression, and receiver operating characteristic (ROC) models were used to identify the sensitivity and specificity of the index of transverse sinus stenosis (ITSS) and hemodynamic variables with inferential significance. The mean CSFP of all cases was 199.5 ± 52.7 mmH2O, with no statistical difference in CSFP between the diverticulum and dehiscence groups. Multivariate linear regression analysis demonstrated that CSFP was linearly correlated with ITSS and pulsatility index (PI). ROC analysis showed that the area under the ROC curve of PI was 0.693 at 200 mmH2O threshold, and the best PI cut-off value was 0.467, with a sensitivity of 65.7% and specificity of 81.8%. For 250 mmH2O threshold, the area under the ROC curve of PI was 0.718, and the best PI cut-off value was 0.467 with a sensitivity of 68.4% and specificity of 75.0%. Additionally, the area under the ROC curve of ITSS was 0.757, and the best ITSS cutoff value was 8.5 (p = 0.002, 95% CI = 0.616–0.898) with a sensitivity of 72.4% and specificity of 75.0% at 200 mmH2O threshold. In conclusion, patients with venous PT as the only presenting symptom should be suspected of having borderline or increased CSFP when they present with high ITSS, BMI and low PI. Further, AG in TS without encephalocele and empty sellae are not limiting findings for differentiating the level of CSFP in patients with venous PT.

Primary Esophageal Tuberculosis

Developing countries such as India, harbor almost a quarter of global tuberculosis (TB) burden. Esophageal involvement in TB, itself is a rare entity with primary esophageal TB reported only as isolated case reports. We report a case of an immunocompetent young adult who presented with dysphagia as the solitary symptom. Upper GI endoscopy and barium swallow showed a midthoracic esophageal stricture. He was subsequently diagnosed with “primary” esophageal TB based on histological examination of endoscopic biopsy showing features consistent with TB and demonstration of normal adjacent pulmonary parenchyma and lymph nodes on a computed tomography scan of the thorax. He showed marked symptomatic improvement with temporary esophageal dilation and stenting which helped in the effective administration of antituberculous therapy as well as attaining nutritional recovery. Our case report emphasizes on this rare scenario of “primary” involvement of esophagus in an otherwise common disease such as TB and its management strategy.

Primary hyperparathyroidism with Browns Tumour-A case report

Parathyroid adenoma is the commonest cause of primary hyper-calcaemia and usually presents with symptoms/signs of hyper-calcaemia. Brown tumours are rare focal giant-cell lesions that arise as a direct result of the effect of parathyroid hormone on bone tissue in some patients with hyperparathyroidism. Brown tumours can affect the mandible, maxilla, clavicle, ribs, and pelvic bones. Therefore, diagnosis requires a systemic investigation for lesion differentiation. In this case there was a 28 yr old woman who presented with solitary symptom of pain and swelling over left knee joint which was diagnosed as primary hyperparathyroidism with Browns tumour. Primary hyperparathyroidism is caused by a solitary adenoma in most of the cases and comparatively very less by glandular hyperplasia.

Telephone Calls by Individuals With Cancer

To describe symptom type and reporting patterns found in spontaneously initiated telephone calls placed to an ambulatory cancer center practice. Retrospective, descriptive. Adult hematology oncology cancer center. 563 individuals with a wide range of oncology diagnoses who initiated 1,229 telephone calls to report symptoms. Raw data were extracted from telephone forms using a data collection sheet with 23 variables obtained for each phone call, using pre-established coding criteria. A literature-based, investigator-developed instrument was used for the coding criteria and selection of which variables to extract. Symptom reporting, telephone calls, pain, and symptoms. A total of 2,378 symptoms were reported by telephone during the four months. At least 10% of the sample reported pain (38%), fatigue (16%), nausea (16%), swelling (12%), diarrhea (12%), dyspnea (10%), and anorexia (10%). The modal response was to call only one time and to report only one symptom (55%). Pain emerged as the symptom that most often prompted an individual to pick up the telephone and call. Although variation was seen in symptom reporting, an interesting pattern emerged with an individual reporting on a solitary symptom in a single telephone call. The emergence of pain as the primary symptom reported by telephone prompted educational efforts for both in-person clinic visit management of pain and prioritizing nursing education and protocol management of pain reported by telephone. Report of symptoms by telephone can provide nurses unique insight into patient-centered needs. Although pain has been an important focus of education and research for decades, it remains a priority for individuals with cancer. A wide range in symptom reporting by telephone was evident.

Painless transient paraparesis as the solitary manifestation of aortic dissection

We present a 62-year-old man with acute and temporary paraparesis of the lower extremities as the solitary symptom of an anterior spinal artery syndrome caused by a type B aortic dissection. Ischemia of the spinal cord was confirmed by magnetic resonance imaging. Neurologic symptoms resolved completely within 6 hours and conservative treatment was successful up to 8 months follow-up. Our report illustrates that painless, transient neurologic deficit can be the only presenting symptom of acute aortic dissection and that aortic dissection should be part of the differential diagnosis of acute paraparesis.

Supernumerary impacted teeth in a patient with SOX2 anophthalmia syndrome

SOX2 anophthalmia syndrome characteristically presents as anophthalmia or microphthalmia, with various extraocular symptoms, such as hypogonadotropic hypogonadism, brain anomaly, and esophageal abnormalities. In this report, we describe a patient with SOX2 anophthalmia syndrome complicated with a dental anomaly, multiple supernumerary impacted teeth, and persistence of deciduous teeth. Multiple supernumerary teeth are usually not solitary symptoms, but indicate systemic syndrome such as cleidocranial dysplasia. In odontogenesis, many transcriptional factors, such as BMPs, FGFs, and Wnts, play significant roles and SOX2 is known to interact with some of them. The role of SOX2 in dental development remains unknown, however, multiple supernumerary teeth can be considered as extraocular symptoms of SOX2 anophthalmia syndrome, rather than the coincidence of two rare diseases.

Risk factors for fatigue severity in primary brain tumor patients

In addition to neurologic symptoms, fatigue is commonly reported in patients with primary brain tumors during radiation therapy and in long-term survivors of low-grade brain tumors. Other factors have not been explored. The aim of this study was to identify demographic and clinical factors that predict fatigue severity and to evaluate the association of fatigue with other symptoms throughout the disease trajectory. Two hundred one patients with primary brain tumors completed the M. D. Anderson Symptom Inventory-Brain Tumor Module and a demographic checklist. Clinical data, including treatment, tumor grade, and performance status, were also collected. Correlations among fatigue and other recorded symptoms were evaluated. Logistic regression modeling was performed to evaluate factors associated with fatigue severity. Fatigue severity was associated with symptoms including pain, drowsiness, distress, difficulty sleeping, and weakness as well as overall symptom severity and interference. Poor performance status (Karnofsky scale) (odds ratio [OR], 5.73; P = .001), female sex (OR, 2.48; P = .005), and disease status (OR, 2.20; P = .013) were the strongest predictors of fatigue. Severity of fatigue for women was primarily predicted by disease status (OR, 3.33; P = .01) For men, antidepressant use (OR, 4.43; P = .013) in addition to opioids (OR, 3.46; P = .017) and performance status (OR, 12.47; P = .0001) predicted fatigue severity. Fatigue should not be considered a solitary symptom with 1 root cause, but a complex symptom related to the severity of other symptoms and potentially having various etiologies. Future studies should consider these factors in planning interventions and assessing response.

Slow-transit constipation: solitary symptom of a systemic gastrointestinal disease.

Autonomic neuropathy is thought to play a role in the pathogenesis of slow-transit constipation, but other gastrointestinal organs may also be involved, even if they are symptom-free. We investigated whether motility in gastrointestinal organs other than the colon was impaired in patients with slow-transit constipation and whether the autonomic nervous system was involved. Twenty-one consecutive patients (18 females; median age, 46 years) with severe chronic constipation (< or = 2 defecations/week and delayed colonic transit time) were studied. Autonomic neuropathy function was tested with esophageal manometry, gastric and gallbladder emptying (fasting and postprandial motility) by ultrasonography, orocecal transit time (H2-breath test), colonic transit time (radiopaque markers), and anorectal volumetric manometry. The integrity of the autonomic nervous system was assessed by a quantitative sweat-spot test for preganglionic and postganglionic fibers, tilt-table test, and Valsalva electrocardiogram R-R ratio. Esophageal manometry showed gastroesophageal reflux or absence of peristalsis in five of the seven patients examined. Gallbladder dysmotility (i.e., increased fasting, postprandial residual volume, or both) was observed in 6 of 14 (43 percent) patients. Gastric emptying was decreased in 13 of 17 (76 percent) patients. Orocecal transit time was delayed in 18 of 20 (90 percent) patients; median transit time was 160 (range, 90-200) minutes. Median colonic transit time was 97 (range, 64-140) hours. Anorectal function showed abnormal rectoanal inhibitory reflex and decreased rectal sensitivity in 11 of 19 (58 percent) patients. Signs of autonomic neuropathy of the sympathetic cholinergic system were found in 14 of 18 (78 percent) patients. Only one of nine patients had vagal abnormalities detected with the Valsalva test and four of five patients with a history of orthostatic hypotension had a positive tilt-table test. Slow-transit constipation may be associated with impaired function of other gastrointestinal organs. More than 70 percent of patients with slow-transit constipation present some degree of autonomic neuropathy. Severe constipation may be the main complaint in patients with a systemic disease involving several organs and possibly involving the autonomic nervous system. This should be considered in the management of such cases.

A survey of dyspepsia in Great Britain.

To determine the prevalence of dyspepsia in the adult population of Great Britain and to describe the clinical features, treatment, effect of dyspepsia on daily lives and perceptions of peptic ulcer disease. Cross-sectional survey of the adult population using structured questionnaires. Subjects interviewed at more than 150 sampling points in England, Scotland and Wales in November 1994. A representative sample of the adult population comprising 2112 subjects, aged 16 years or more. The prevalence of dyspepsia in the adult population and the frequency of various characteristics in dyspeptic subjects. The prevalence of dyspepsia was 40%. Upper abdominal pain and heartburn were the most frequently reported symptoms. Solitary symptoms were uncommon and there was frequent overlap between 'ulcer-like' and 'reflux-like' dyspepsia. Forty-six per cent of dyspeptic subjects reported moderate or severe symptoms. More than half of symptomatic subjects took medication and 22% had visited their GP during the previous year. Overall, 2% of the survey sample had been absent from work due to dyspepsia. Awareness of the factors precipitating or aggravating peptic ulcer disease was poor, particularly in relation to anti-inflammatory drugs. The present study emphasizes the magnitude of the problem of dyspepsia in the adult population of Great Britain. The survey also shows that the public in general, and patients in particular, require more information if they are to avoid factors known to damage the upper alimentary tract.

Headache and painful lymphadenopathy in extracranial or systemic infection: etiology of new daily persistent headaches.

From 108 cases of new daily persistent headaches, clinical or laboratory evidence was found suggesting extracranial or systemic infections in: 28 cases (25.9%) of gastrointestinal mainly Salmonella, 28 (25.9%) urinary Coli, 16 (14.8%) Streptococcal, 4 (3.7%) each of Epstein Barr virus or Toxoplasma, and 1 (0.9%) each of Herpes Zoster or pneumonia. A group of 26 (24.1%) showed high Proteus OX titer or clinical adenoviral involvement. All had normal neurological examinations plus selective negative neuroimaging or spinal taps. The mean headache duration was 13.8 days, and mean age 28.8 years. Prominent symptoms were fever in 37 (34.2%) cases, nausea/vomiting in 30 (27%) and vertigo in 17 (15.7%). Diarrhea, dysuria, and abdominal discomfort were rare. Headache was a solitary symptom in 36 (33.3%). The predominant sign was painful cervical lymphadenopathy in 61 (56.5%). These cases represent 1.2% of our 9060 neurology patients.

Vertebro-basilar insufficiency as a cause of vertigo-myth or reality?

An analysis of 1455 patients suffering from vertigo indicated vartebro-basilar insufficiency as the underlying cause in 147 patients. Vertigo was the sole symptom in 79%, without any accompanying neurological dysfunction. In general, these patients were elderly, suffered from transient vertiginous episodes precipitated by neck movements or change of posture; their audiograms were normal for their age and their ENG showed bilateral hyperactive caloric responses, often exhibiting a petite ecriture pattern. Cervical spondylosis was present in 76% and cardiovascular disorders in 17%. Treatment with aspirin and dipyridamole gave encouraging results. It is felt that vertebro-basilar insufficiency, in its early stages, can manifest with vertigo as a solitary symptom, without neurological features.

Crohn's Disease in Children

Once considered rare in children, Crohn's disease (CD) is being recognized with increasing frequency.1-3 This is due not only to physical awareness but to an alarming increase in the incidence of the disease in young people. Although early descriptions of CD localized the site of involvement to the terminal ileum, it is now recognized that all organs of the alimentary tract may be affected, and in some unfortunate patients involvement extends proximally as far as the stomach, esophagus, or oropharynx and distally, to involve even perianal tissue. Unlike ulcerative colitis which is rather clear-cut in its presentation, CD is often insidious with solitary symptoms of anorexia, weight loss, short stature, or fever of unknown origin being its only manifestation. The presenting symptoms and longterm course vary with the site of disease, and although each patient must be evaluated and treated individually, some overall predictions may be offered as to the victim's future quality of life.4-6 Significant advances have been made during the last decade in understanding the pathophysiology of the disease and in methods of its treatment, although as yet the etiology remains to be defined. Although CD has many features in common with ulcerative colitis and the two are often combined in the terminology, "inflammatory bowel disease," the pathologic findings, course, and complications are distinctive enough that they should be considered as two distinct diseases.

Crohn's Disease in Children

Once considered rare in children, Crohn9s disease (CD) is being recognized with increasing frequency.1-3 This is due not only to physical awareness but to an alarming increase in the incidence of the disease in young people. Although early descriptions of CD localized the site of involvement to the terminal ileum, it is now recognized that all organs of the alimentary tract may be affected, and in some unfortunate patients involvement extends proximally as far as the stomach, esophagus, or oropharynx and distally, to involve even perianal tissue. Unlike ulcerative colitis which is rather clear-cut in its presentation, CD is often insidious with solitary symptoms of anorexia, weight loss, short stature, or fever of unknown origin being its only manifestation. The presenting symptoms and longterm course vary with the site of and although each patient must be evaluated and treated individually, some overall predictions may be offered as to the victim9s future quality of life.4-6 Significant advances have been made during the last decade in understanding the pathophysiology of the disease and in methods of its treatment, although as yet the etiology remains to be defined. Although CD has many features in common with ulcerative colitis and the two are often combined in the terminology, inflammatory bowel disease, the pathologic findings, course, and complications are distinctive enough that they should be considered as two distinct diseases.

Dysarthria Resulting From Lithium Carbonate

SEVERAL authors have noted slurred speech as one sign of lithium carbonate intoxication. Levels of lithium ion reported with this symptom exceed 2.0 mEq/liter, and other toxic reactions are associated with it. We report a case of dysarthria that occurred as a solitary symptom of lithium carbonate administration at maintenance dosage. Report of a Case A 70-year-old, retired, widowed railroad clerk had a thyroidectomy in 1964 for a toxic goiter. He was always energetic and talkative; but after the death of his wife the previous year, he had become obsequious and pestered everyone he met. His sisters, who tried to cope with this behavior, attempted to control him and obtained court orders to restrain his harassment. Later he was hospitalized for entertaining paranoid ideas and sending threatening letters. At that time, he was grandiose and messianic. In the hospital, he became calm, with or without drugs, but his symptoms recurred

Cold Urticaria With Cryoglobulinemia

Cold urticaria was found to be the solitary symptom in a patient with chronic lymphocytic leukemia and an associated cryoglobulinemia. Following therapy there was a concurrent remission in both the cold urticaria and cryoglobulinemia. It was then possible to produce local sensitization to cold in the patient's skin by injecting serum collected during the pretreatment phase. The injection of posttreatment serum was without effect. Cold urticaria could be induced not only by injection of the cryoprecipitate, an IgG immunoglobulin, in concentrations as low as 25 mg/100 ml but also by the supernate after removal of the cryoglobulin. Addition of streptomycin to the serum prevented both cryoprecipitation in vitro and cold sensitization in vivo. Attempts to demonstrate an immunological mechanism for the production of cold urticaria were unsuccessful.