Unrelated Symptoms Research Articles

Synovial chondromatosis of the temporomandibular joint: clinical, cytologic, histologic, radiologic, therapeutic aspects, and differential diagnosis of an uncommon lesion

Synovial chondromatosis (SC) of the temporomandibular joint (TMJ) is a rare disorder with an indolent clinical course that leads to nonspecific symptoms, dysfunction, and anatomic distortion of the TMJ. We describe a case of SC in an 82-year-old male that presented as an incidental 2 cm cystic tumor of the left TMJ, during diagnostic work-up for unrelated symptoms. A fine needle aspiration of the lesion yielded fragments of abnormal mature cartilage and myxoid fluid. The diagnosis of SC was suggested after correlating the clinical and pathologic findings. Open TMJ surgery was performed for definitive diagnosis and therapy. This manuscript describes the clinical, radiologic, cytologic, and pathologic features of this entity, and relates the differential diagnosis to other cartilaginous lesions and neoplasms of the TMJ. Awareness of this disorder is important to provide adequate care and avoid overtreatment.

PCS, Iatrogenic Symptoms, and Malingering Following Concussion

In postconcussive syndrome (PCS), subjective experience of symptoms seems to surpass objective evidence of those symptoms. For many years, clinicians and researchers have suspected both neurologic and psychologic forces in PCS. While the neurologic symptoms tend to resolve, psychological factors appear to have a more complex and difficult to characterize course. We argue in this paper that this complexity leads to diagnostic problems when considering PCS. We review several difficulties with current nosology regarding PCS and related conditions, as well as the inter-related and complicating roles of iatrogenic factors and malingering. We conclude that PCS is of insufficient diagnostic specificity and that it is prone to misdiagnosis, even causing new and possibly unrelated symptoms to develop in some cases. Further research on PCS and the factors that affect its course is needed.

Predicting parkinsonism: New opportunities from Gaucher disease

Predicting parkinsonism: New opportunities from Gaucher disease

Traumatic Stress Symptomatology After Child Maltreatment and Single Traumatic Events: Different Profiles

The sequelae of child maltreatment tend to extend current posttraumatic stress disorder (PTSD) symptoms. This study examined this assumption, hypothesizing that (a) PTSD and trauma-related symptoms are more severe after single trauma than after child maltreatment; (b) symptoms unrelated to trauma are more severe after child maltreatment than after single trauma; and (c) a comorbid association of clinical PTSD with trauma-related symptoms is more prevalent after single trauma, whereas a comorbid association of clinical PTSD with trauma unrelated symptoms is more prevalent after child maltreatment. The Trauma Symptom Checklist for Children (TSCC) assessed PTSD and trauma-related symptoms in 256 children (83 children exposed to single trauma, 173 to child maltreatment). The Strengths and Difficulties Questionnaire (SDQ) assessed trauma-unrelated symptoms. Single-trauma children reported significantly more severe PTSD and trauma-related symptoms. Significantly more severe trauma unrelated symptoms were reported after child maltreatment. A significant relation was found between clinical PTSD and more severe trauma-related symptoms in both samples. Likelihood of children meeting PTSD symptoms after trauma seems to decrease when traumatization becomes more complex. Findings support our assumption that symptomatology of maltreated children extends current PTSD symptoms.

Bilateral Duplex collecting system in Horse shoe kidney: An unusual association

A 17 years unmarried female presented to Gastroenterology Department of our hospital for nonspecific symptoms of epigastric pain. The Ultrasonographic examination of the patient re-vealed triple kidney with horseshoe anomaly. She was then referred to us for further evaluation. We further proceed with Intravenous Urography (IVU) which demonstrated a bilateral duplex system in a asymmetrical horseshoe kidney (L shaped fusion). Left side kidney was vertically placed while the right side kidney was horizontally placed. One of the moieties was on the right side of vertebral col-umn while the other moiety was overlying the ver-tebra and isthmus was on the left side of vertebra (Figure-1). A contrast enhanced computed tomog-raphy (CECT) scan confirmed the diagnosis of bilat-eral duplex system in horseshoe kidney (Figure-2). As the patient had non-specific, unrelated symp-toms, patient was give symptomatic treatment for the same and was advised regular follow-up. Du-plicated collecting systems (also known as duplex collecting systems) can be defined as renal units containing two pyelocaliceal systems that are as-sociated with a single ureter or with double ureters. The prevalence of Partial duplication is 0.6%, while complete duplication of ureters occurs in 0.2% of live births (1). When a single ureteral bud bifurcates before the ampulla bifurcates, a duplex kidney with a bifid renal pelvis or bifid ureter results (2). Con-genital anomalies of the kidneys include a group of so-called fusion anomalies, in which both kidneys are fused together in early embryonic life. Fusion anomalies of the kidneys can generally be placed into 2 categories: [1] horseshoe kidney and its vari-ants and [2] crossed fused ectopia. Horseshoe kid-ney is probably the most common fusion anomaly. The term horseshoe kidney refers to the appearance of the fused kidney, which results from fusion at one pole. Horseshoe kidney is the most common renal fusion anomaly, the incidence being about 1

Complications of Bezoar in Children: What Is New?

A bezoar is a mass found trapped in the gastrointestinal system. The condition may be associated with pica, especially in developmentally retarded children. Clinical manifestations are usually nonspecific. Endoscopic diagnosis and removal of the foreign materials is often indicated. Occasionally, severe complications may occur. We report two cases to illustrate the clinical features and complications in these children. In the first case, a reliable history was not obtained in the developmentally delayed girl which precluded prompt diagnosis, but the grossly dilated stomach on plain abdominal radiograph gave clues to an underlying insidious mechanical obstruction of upper gastrointestinal tract. In the second case of a normal child, the unrelenting symptoms and weight loss prompt further investigations which revealed the diagnosis. Literature on pediatric bezoar is reviewed. Oesophagoduodenoscopy is the investigation of choice for diagnostic confirmation, but surgical facilities must be available to deal with acute complications.

Is there a relationship between fibromyalgia and rhinitis?

Fibromyalgia (FM) is a common chronic pain disorder characterized by diffuse musculoskeletal pain and stiffness. It is recognized as a common syndrome affecting 2-4% of the population that may present with several ambiguous and seemingly unrelated symptoms. A broad variety of complaints and lack of tests to accurately identify the disease challenges physicians with confirming this elusive diagnosis. FM has significant overlap with several other systemic diseases including those of sensory hypersensitivity, autonomic deregulation, neurological dysfunction, migraine, and related chronic rhinitis. Current research suggests a relationship between allergic disease especially allergic and NAR and sinusitis. The pathogenesis of FM is related to aberrant pain processing and immunoregulatory abnormalities that may occur in autoimmune disorders with increases in immunologic signaling molecules such as ILs, cytokines, nerve growth factor, which is linked with rhinitis, TNF-alpha, and L-selectin suggesting that pathophysiology is a product of the inflammatory response system. Central nervous system cytokine activation through viral neurotropism and subsequent glial activation is speculated as a possible mechanism. Allergists-immunologists and other specialists such as rheumatologists and rehabilitation and psychiatric physicians may be able to more accurately diagnose and treat these debilitated and often stigmatized patients. The complexity of this disorder must be tackled by a multidisciplinary approach to ensure the successful management of this multifaceted syndrome.

Eating a Larger Number of High-Salt Foods is Not Associated with Short-Term Risk of Acute Decompensation in Patients with Chronic Heart Failure

BackgroundRisk factors for exacerbation of congestive heart failure have not been consistently validated. ObjectiveOur objective was to examine the role of short-term dietary sodium intake in acute decompensated heart failure. MethodsPatients with chronic congestive heart failure presenting to the Emergency Department for either acute decompensated heart failure (cases) or for other reasons (controls) were included in a case-control study. Cases and controls were compared with respect to age, smoking, recent sodium intake, medication nonadherence, coronary artery disease, and hypertension. A food frequency questionnaire was utilized to estimate recent sodium intake, defined as the number of food types consumed in the previous 3 days from the 12 highest-sodium food categories. ResultsThere were 182 patients enrolled. One patient was excluded due to uncertainty about the primary diagnosis. When adjusted for age, smoking, medication nonadherence, coronary artery disease, and hypertension, acute decompensated heart failure was not associated with short-term dietary sodium intake. The odds ratio for acute decompensated heart failure for each increase in the number of high-sodium food types consumed was 1.1 (95% confidence interval 0.9–1.3; p = 0.3). Acute decompensated heart failure was associated with medication nonadherence, with an odds ratio for decompensation of 2.5 (95% confidence interval 1.2–5.1; p = 0.01). ConclusionsPatients with chronic congestive heart failure who presented to the Emergency Department with acute decompensated heart failure were no more likely to report consuming a greater number of high-sodium foods in the 3 days before than were patients with chronic congestive heart failure who presented with unrelated symptoms. On the other hand, those who presented with acute decompensated heart failure were significantly more likely to report nonadherence with medications.

Spinal Dural Fistulas without Swelling and Edema of the Cord as Incidental Findings

SDAVFs cause hypertension and hence outflow obstruction in the perimedullary venous system resulting in swelling and edema of the cord followed by dysfunction. Clinical presentation is usually with gradual progressive paraparesis, numbness, and sphincter problems. MR imaging typically demonstrates the dilated perimedullary veins and the swelling and edema of the cord. During the past few years, we incidentally found an SDAVF on MR imaging with dilated perimedullary veins but without swelling and edema of the cord in 5 patients with unrelated presenting clinical symptoms. Spinal angiography confirmed the presence of an SDAVF in all 5 patients. Although the indication was considered questionable, eventually all 5 fistulas were endovascularly or surgically treated, resulting in normalization of the MR images.

Occam’s razor reveals a hidden Churg-Strauss syndrome

Abstract A 28 year-old caucasian lady, with nine years of uncontrolled bronchial asthma, rhinosinusitis and mild upper limb paresthesia, came to our attention to be followed for coeliac disease (CD). She had a biopsy performed elsewhere which proved the diagnosis five years before. Since there was no clinical improvement on a strict gluten-free diet, we re-evaluated the slides of her duodenal biopsies and we found an overestimation of the duodenal lesions due to the wrong orientation of the specimens. Moreover, she had never had positive CD-related antibodies and she was negative for DQ2/DQ8 MHC Class II heterodimers. Months later, she referred she was suffering from diffuse joint pain, epistaxis and a substantial weight loss. A few days later she was hospitalized because of a sudden onset of dyspnea, peripheral edema and pleural effusion. Her echocardiogram showed global left ventricular hypokenesia with an ejection fraction of 24%. The patient was discharged with a diagnosis of dilated cardiomyopathy and NYHA Class II. After a large spectrum of haematological exams, the diagnosis of Churg Strauss Syndrome (CSS), a rare multisystemic small-vessel necrotizing vasculitis, was confirmed by the presence of four/five out of six diagnostic American College of Rheumatology classification criteria (Asthma, Eosinophilia >10%, Neuropathy, Non-fixed pulmonary infiltrates, Paranasal sinus abnormality and Biopsy containing a blood vessel with extravascular eosinophils). Our patient had been under-diagnosed by pulmonologist and by gastroenterologists although she presented the criteria required for CSS diagnosis. Our case report emphasizes that often seemingly unrelated symptoms can be caused by a single rare clinical complex.

Incidental Detection of Pancreatic Neuroendocrine Tumors: An Analysis of Incidence and Outcomes

Pancreatic neuroendocrine tumors (NETs) are increasingly discovered incidentally during radiologic or endoscopic examinations. The frequency of incidental detection is unknown. It is also unclear whether patients with incidentally discovered, early-stage, asymptomatic tumors should be treated similarly to patients who present with tumor-related symptoms. Patients with nonmetastatic pancreatic NETs treated at the H. Lee Moffitt Cancer Center between 1999 and 2010 were assigned a stage (I-III) on the basis of the new American Joint Committee on Cancer classification. The frequency of incidentally diagnosed tumors was evaluated and stratified by stage. Progression-free survival was measured by log rank testing to compare patients with incidentally detected versus symptomatic tumors. Multivariate analysis was performed controlling for other prognostic factors including tumor stage, grade, and location, and patient age. Among 143 patients with nonmetastatic pancreatic NETs, 56 patients (40%) had tumors that were discovered incidentally. Most stage I tumors (55%) were incidental. The 5-year progression-free survival rate was 86% for incidentally diagnosed tumors, versus 59% for symptomatic tumors (P = 0.007). On multivariate analysis, incidental detection of tumors was the strongest prognostic factor for progression. A sizable fraction of patients with early-stage pancreatic NETs are diagnosed incidentally during evaluations for other conditions or unrelated symptoms. This study highlights the necessity of developing guidelines for management of patients with incidentally discovered early-stage tumors.

Imagerie des chémodectomes de la bifurcation carotidienne

Introduction : The carotid body tumor, which arises from its chief cells (glomus type 1), is the most common paraganglioma of the head and neck (up to 50%). Observation : The following case report is particularly useful for dailypractice; the patient has surgical history of tiroid neoplasm which requires a thorough diagnosis, in order to determinean accurate follow-up. Discussion : This tumor is in most cases clinically silent and is detected incidentally at imaging study during evaluation of patients with unrelated symptoms such as painless, slowly growing lateral neck mass, dysphagia, sleep apnea, and paresia or atrophy of the tongue. Conclusion : According to its appearance, precise non-invasive imaging techniques may allow the radiologist to reach the correctdiagnosis and treatment.

Histological characteristics of incidentally-found growing meningiomas

With the wider use of CT and MRI, many meningiomas are discovered as incidental findings during diagnostic work-up for unrelated symptoms. The majority shows no or minimal growth. The purpose of this study was to distinguish pathological features of incidentally-found growing meningiomas by comparing incidentally-found with symptomatic meningiomas. One hundred and thirty two consecutive non-recurrent surgically-treated meningiomas treated between 2005 and 2007 were divided into three categories: 19 incidentally-found growing meningiomas (IG), 50 incidentally-found meningiomas (I), and 63 symptomatic (S) meningiomas. The average follow-up period for the IG meningiomas was 3.7 years. Six out of 19 patients of the IG meningiomas became symptomatic during observation. There is a significant difference of the incidence of WHO grades I, II, and III between all three groups (p=0.035). The incidence of WHO grades II and III in groups IG, I, and S were 26%, 2%, and 10%, respectively. We compare MIB-1 staining index between three groups: an average was 3.8% in IG, 1.3% in I, and 2.4% in S meningiomas. Incidentally-found meningiomas need careful follow-up. One fourth of the meningiomas that showed signs of growing belonged to the atypical or malignant grade.

Incidental Rickets in the Emergency Department Setting

Vitamin D deficiency rickets is a childhood osteomalacia, with impaired skeletal development and potentially skeletal deformities. The radiographic findings of rickets are many but include widening, fraying, and cupping of the metaphysis. Developmental delay and related complications of seizure and tetany have also been reported. This medical entity is often thought of as a classic medical disease of the past. However, it persists, and the recognition of rickets is on the rise. The reemergence of rickets correlates with the increase in the number of children exclusively breastfed and with the frequent use of sun block in the pediatric population. We present two cases of rickets, diagnosed through a visit to the Emergency Department made for unrelated symptoms. These two cases illustrate the importance of diagnosing rickets as an “incidental” finding. With early detection, dietary supplementation can be initiated potentially sparing the patient symptomatic disease.

Exercise, Stand Up, Flip a Coin, or Just Say No

The 2011 challenge in considering a diagnosis of long-QT syndrome (LQTS) is best viewed as having 4 distinct clinical scenarios. The first and most straightforward is the family member with a genotyped kindred in whom, within a month, a relatively firm diagnosis can be obtained by family-specific testing, along with an ECG. The second, the genotype-negative index patient with otherwise unexplained, repeated, markedly prolonged QTc (>480), is similarly straightforward. The third scenario comprises family members of those same patients with unambiguous LQTS but no available gene. For those patients, their prior probability of having LQTS is estimated by careful pedigree analysis, with ECG findings combined with other clinical evaluation to help characterize the potential phenotype. The likelihood of making the diagnosis is relatively large (50%, 25%, 12.5%), depending on distance from an affected individual. The most challenging scenario is the young person with the “borderline” test obtained either for unrelated symptoms or during screening efforts before sports or medication without a clear family history. For that patient, the prior probability of having LQTS may as low or lower than the estimated gene prevalence of ≈1 in 2000 (0.05%).1 Indeed, in that setting, even genetics sometimes leaves the clinicians challenged when the result returns with a variant of unknown significance, requiring further pedigree analysis. In that context, the careful descriptive study of exercise QT dynamics by Berger and colleagues2 in this issue of Circulation: Arrhythmia and Electrophysiology adds useful information to this challenge. Article see p 448 The study itself is straightforward: 94 boys …

Pleomorphic hyalinizing angiectatic tumor of renal hilum

Pleomorphic hyalinizing angiectatic tumor (PHAT) is a recently described rare entity. The tumor histogenesis is proposed to be of primitive undifferentiated mesenchyme. The tumor has a predilection for the subcutaneous soft tissue especially of lower extremity, although other locations have been well documented. We report a case of PHAT arising in the hilum of the kidney, clinically mimicking an infiltrating malignant neoplasm of renal pelvis. The tumor was discovered during workup for unrelated gastrointestinal tract symptoms. Because of the location of the lesion, excision of mass and radical nephrectomy were performed. The tumor had strong immunohistochemical expression of vimentin, CD34, CD99, and vascular endothelial growth factor (VEGF). No additional lesions were documented during 3 years of follow-up. This is consistent with the current thinking that PHAT is a benign neoplasm with increased incidence of recurrence. We document the unique retroperitoneal location of this rare tumor and suggest that PHAT should be considered among the list of unusual lesions at this site.

Monoclonal Antibodies for the Treatment of Severe Asthma

Patients with severe asthma have a significant unmet need with persistent symptoms and/or frequent exacerbations despite treatment with high-dose steroid and other currently available therapies. These patients are also at risk of developing steroid-related side effects, and their severe, unrelenting symptoms have a huge impact on health care resources due to frequent hospital admissions and requirement for intensive medication use. Consequently, a compelling need exists for more effective and safer pharmacotherapies to help them achieve adequate disease control. Recent novel therapies for severe asthma are now emerging, some of the most promising of which are monoclonal antibodies. Monoclonal antibodies represent a form of immunotherapy used in a wide variety of therapeutic roles. The spectrum of disease states in which monoclonal antibodies have been approved for therapeutic use now includes respiratory and allergic diseases. At present, only one drug is licensed for allergic asthmatics with severe disease, omalizumab. We review some of the currently available biologics that are approved or under investigation for use in severe asthma. Some have shown to be useful in specifically targeted subpopulations of patients with severe asthma, whereas other have proven to be unsafe and/or unsuccessful. Despite these developments, more effort should be devoted to identifying new molecular targets, testing innovative approaches, and establishing the best use of what is available. Regarding this latter point, identifying individual characteristics that predict successful responses to these treatments is highly desirable.

P03-217 - Recovery Versus Remission in Schizophrenia and Related Persistent Psychotic Disorders: no Contrasting but Complementary Models

At present there is no consensus on defining “Recovery” in schizophrenia,while there is an accepted definition of “Remission”. Remission model considers “stability” the treatment primary goal and, once achieved, focus is on mainteining stability and preventing relapse. This model reflects a condition where are absent prominent symptoms but may be present some mild symptoms of schizophrenia, retaining not realistic absence of any symptoms. It would require treating an acute psychotic episode,then there still may be a range of no detectable or persistent and disabling symptoms:remission and level of functioning are related but not the same. Some patients could have good level of functioning despite persistent symptoms and others could meet remission criteria despite considerable impairments. Remission is an obteinable outcome for many psychotic outpatients:the point of departure between manteinance and recovery-oriented model happens only after “stability” is achieved;no one could recover in face of repeated crisis,hospitalisation or unrelenting psychotic symptoms. Unfortunately two causes have resulted in a relative neglect of the concept of recovery from psychotic illness:the divide between mainstream biologically oriented psychiatry and the psychiatric rehabilitation movement;the misunderstanding fact that term “recovery movement” is sometimes construed as anti-medication or anti-psychiatry orientation. Irrefuteble point is that recovery model not rejects the importance of remission:stability and relapse prevention. The recovery model besides asserts that achieving remission is the beginning and not the end of treatment plan:then there will be continued efforts to work with patient,family,caregiver,to continue to achieve further improvements in life goals. The “Recovery” patient-centred model have to be embraced as prymary goal by mainstream organizations and services in Mental Health.

Incidental diagnosis of pancreatic neuroendocrine tumors.

190 Background: Pancreatic neuroendocrine tumors are often discovered incidentally during radiologic or endoscopic examinations. The incidence of incidental detection is unknown. It is also unclear whether patients with incidentally discovered, asymptomatic tumors should be treated similarly to patients who present with tumor-related symptoms. Methods: A database of 425 patients with pancreatic neuroendocrine tumors treated at the H. Lee Moffitt Cancer Center was developed. Patient charts were reviewed to assess whether their diagnosis was incidental or prompted by tumor-related symptoms such as pain, jaundice, or neuroendocrine hormone secretion. The frequency of “incidentalomas” was categorized by TNM stage (AJCC, 7th edition). Overall survival was stratified by “incidental” versus “symptomatic” diagnosis. Results: Among 425 patients with histologically proven pancreatic neuroendocrine tumors, 112 patients (26%) had tumors that were discovered incidentally. The majority of stage I tumors (55%) were incidentally discovered. Among patients with stage IV tumors, 20% were detected incidentally (Table). Median survival of patients with incidentally discovered tumors was 103 months versus 84 months in patients who were symptomatic at diagnosis. Conclusions: A sizeable fraction of patients with pancreatic neuroendocrine tumors are diagnosed incidentally during evaluations for other conditions or unrelated symptoms. The majority of patients with stage I tumors are incidentally diagnosed. The increased incidence of pancreatic neuroendocrine “incidentaloms” may be contributing to improving survival rates in this disease. This study highlights the necessity of developing guidelines for management of patients with incidentally discovered, early-stage tumors. [Table: see text] No significant financial relationships to disclose.

Gastrointestinal Tract Langerhans Cell Histiocytosis

Gastrointestinal (GI) tract involvement by Langerhans cell histiocytosis (LCH) is a rare condition. It is typically noted in male patients with systemic disease and is associated with both poor prognosis and high morbidity. The incidence peaks in childhood. However, a limited number of cases have been reported in adults. To further characterize this disease process, we collected 24 cases of GI tract LCH from 12 patients. The patients included 2 children (4 mo and 2.3 y) and 10 adults (40 to 77 y; mean, 58.4 y), with a female predominance (9 of 12, 75%). Both children presented with failure to thrive, bloody diarrhea, and anemia. In contrast, 5 of 10 (50%) adults were asymptomatic and the rest had unrelated symptoms. Endoscopically, the pediatric patients showed the involvement of the duodenum and multiple colonic sites. However, 8 of 10 (80%) adults presented with a solitary polyp, primarily involving the colorectum (7 of 8, 88%). The lesions ranged in size from 0.1 to 0.8 cm (mean, 0.4 cm), and were predominantly intramucosal (18 of 24, 75%) with either a marginated (14 of 24, 58%) or infiltrative (10 of 24, 42%) growth pattern. Microscopic features were similar to those of LCH found elsewhere, although some cases differed by showing prominent lymphocytes (12 of 24, 50%) rather than eosinophils and large nucleoli (2 of 24, 8%). Reactive overlying mucosal and entrapped epithelial changes (10 of 24, 42%), mucosal ulceration (3 of 24, 13%), focal necrosis (1 of 24), and multinucleated giant cells (1 of 24) were also identified. Mitotic figures were absent. On immunohistochemistry, all lesions expressed the S-100 protein and CD1a. Follow-up information was available for 11 (92%) patients ranging from 2 months to 5.3 years (mean, 1.8 y). One pediatric patient was lost to follow-up. However, the other patient developed multisystem disease and died 1 year after the initial diagnosis. Two adult patients developed cutaneous disease, 2 months and 2 years after the initial diagnosis, 1 of whom had multifocal colonic disease. On the basis of this study, GI tract LCH lesions present in both children and adults with a female predominance. Consistent with earlier reports, pediatric cases are associated with systemic disease and poor prognosis. However, in adults, LCH is typically encountered as an incidental, solitary polyp. Rare cases of systemic disease may occur and, therefore, close follow-up may be warranted.