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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue

Published: Thu, 16 Mar 2017 00:00:00 GMT

Last Build Date: Thu, 16 Mar 2017 10:48:25 GMT


Anaplastic large cell lymphoma of the spinal cord


A 28-year-old man with unremarkable past history presented with a 2-month history of low back pain and 3-day history of fever. Physical examination revealed limited range of motion while bending. His routine blood investigations showed a white blood cell count of 35 × 103/μl; platlet count of 653 × 103/μl; Hgb of 11.6 g/dl and ESR of 78 mm/1 h,CRP of 23.90 U/l, LDH of 260 U/l, ALP of 86 U/l. MRI of S-spine showed bony destruction over S1 surrounded by inflammatory process from S4 to S2 with epidural invasion. Figure 1a. The patient underwent empiric antibiotic treatment with vancomycin and ceftriaxone due to suspected underlying osteomeylitis. Given the known compression on MR image, urgent surgical decompression and fusion was elected to prevent progressive neurological decline. Histological specimen analysis was consistent with highly aggressive anaplastic large cell lymphoma composed of moderate to large sized lymphoid cells with hyperchromatic nuclei and moderate amount of eosinophilic cytoplasma. The tumor was CD2(+), CD4(+), CD30(+), CD45(+) and negative for other markers, suggestive of a T-cell phenotype. Immunochemistry was positive for Epithelial Membrane Antigen (EMA), ALK, CD45, CD30, CD2, CD4, and vimentin(+); and negative for CK, CD34, CD138 (Figure 1b)The patient underwent further chemotherapy with CHOP regime and led an uneventful hospital course. Figure 1(a) Median sagittal T1-weighted fat suppressed MRI showed a hyperintensity mass over S1 with epidural invasion. (b) CT-guided needle biopsy demonstrated highly aggressive anaplastic large cell lymphoma.

Eye swelling and lacrimal gland lymphoma


Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma (NHL) accounting for 25% of NHL cases with an incidence of 7 cases per 100 000 persons per year.1 We report a case of lacrimal gland DLBCL diagnosed by the imaging and histology. The lacrimal gland lymphomas are rare; however, 37% of all malignant tumors of the lacrimal gland are lymphomas.2

Tuberculosis mimicking metastases by malignancy in FDG PET/CT


Learning point for cliniciansPositron emission tomography-computed tomography (PET/CT) is valuable in differentiating malignant from benign lesions. However, PET/CT has its own pitfalls for inflammatory lesions such as tuberculosis (TB) can be highly fluorodeoxyglucose (FDG)-avid, mimicking malignant metastases. Our case highlights that TB and metastasis are very similar in FDG PET/CT. Pathology is the prerequisite of correct diagnosis and intervention.

Primary aldosteronism—not just about potassium and blood pressure


Learning point for cliniciansPrimary aldosteronism is one of the few potentially curable causes of hypertension and it requires a high index of suspicion in making an accurate diagnosis. This case illustrates the importance of looking at electrolytes other than just the potassium in a patient with severe primary aldosteronism.

Is ionizing radiation a risk factor to diffuse panbronchiolitis?


Learning point for clinicians
  • An interesting hypothesis that ionizing radiation from atomic bombs and nuclear power plants is a risk factor to diffuse panbronchiolitis, and the evidence of the possible risks are based on the analysis of the epidemiological studies and the studies of different types and absorbed doses of ionizing radiation.

Bilateral adrenal haemorrhage


Learning points for clinicians
  • AH should be considered in anticoagulated patients with new-onset back pain.
  • Acute AH should be managed as an acute adrenal crisis with intravenous hydrocortisone.1
  • Underlying neoplastic pathology of the adrenal gland must be considered in the context of acute AH, interval imaging may reveal the diagnosis.

Stridor secondary to a subglottic neuroendocrine tumour


Learning points for clinicians
  • Value of flow volume loops in diagnosing upper airway obstruction.
  • Stridor can be inspiratory, biphasic, or expiratory
  • Stridor can be confused with wheeze.
  • Stridor is a clinical symptom/sign and not a diagnosis.
  • Specialist referral is appropriate if patient’s symptoms do not resolve with initial management.

Historical TB treatment—Plombage


An 82-year-old man with a history of pulmonary tuberculosis (TB) treated with Plombage, hypertension and hyperlipidemia was admitted to hospital for severe community-acquired pneumonia. He was admitted to medical intensive care unit, treated with intravenous hydration, antibiotics and mechanical ventilator support. The patient’s subsequent course was uneventful and was discharged home. Patient’s anteroposterior x-ray of the chest and computed tomography of the chest showed the right upper lobe filled with Lucite balls (Figure 1A and B). Figure 1(A) Anteroposterior X-ray of the chest showing the right upper lobe filled with Lucite balls (black arrows). (B) Computed tomography of the chest showing the right upper lobe filled with Lucite balls (black arrows).

Cardiac MRI and acute myocarditis


A 37-year-old woman presented with several hours of intermittent chest pressure at rest associated with nausea. She had no significant past medical history but reported a recent flu-like illness about 1–2 weeks prior, associated with mild fever, headache and a runny-nose. Physical examination was unremarkable with no abnormal cardiovascular findings. Her ECG showed sinus-rhythm with significant inferior ST-segment elevations (Figure 1A), and serum troponin-T levels were elevated at 2.5 ng/ml. Urgent cardiac-catheterization revealed angiographically normal coronary arteries. Cardiac magnetic resonance (CMR) cine-imaging showed normal left-ventricular function without valvular or pericardial abnormalities. CMR late gadolinium enhancement (LGE) imaging demonstrated patchy mid-myocardial and epicardial hyperenhancement in the inferior wall (Figure 1B, arrows), indicative of injury from myocarditis. Figure 1(A) ECG showed sinus-rhythm with significant inferior ST-segment elevation and reciprocal depressions. (B) Cardiovascular magnetic resonance imaging with LGE in the 2-chamber view demonstrated patchy mid-myocardial and epicardial hyperenhancement in the inferior wall (arrows) of the left ventricle.

Flight Lieutenant Peach’s observations on Burning Feet Syndrome in Far Eastern Prisoners of War 1942–45


Introduction: ‘Burning Feet Syndrome’ affected up to one third of Far Eastern Prisoners of War in World War 2. Recently discovered medical records, produced by RAF Medical Officer Nowell Peach whilst in captivity, are the first to detail neurological examinations of patients with this condition.Methods: The 54 sets of case notes produced at the time were analysed using modern diagnostic criteria to determine if the syndrome can be retrospectively classed as neuropathic pain.Results: With a history of severe malnutrition raising the possibility of a peripheral polyneuropathy, and a neuroanatomically plausible pain distribution, this analysis showed that Burning Feet Syndrome can now be described as a ‘possible’ neuropathic pain syndrome.Conclusion: After 70 years, the data painstakingly gathered under the worst of circumstances have proved to be of interest and value in modern diagnostics of neuropathic pain.

Choriocarcinoma as a cause of hyperthyroidism


Our patient is a 31-year-old lady who delivered her third child 3 months prior to the current admission. The delivery was uneventful but she continued to have per vaginal spotting occasionally. She presented with cough and breathlessness for 2 months associated with significant weight and appetite loss. On examination she was pale and tachycardic. She had fine tremor but no goiter or Grave’s opthalmopathy. Breath sounds were reduced bilaterally. Endocrine team was consulted as her thyroid function test showed freeT4 of 50 pmol/l with suppressed thyroid stimulating hormone (TSH) of <0.01 mIU/L. There were multiple canon ball lesions bilaterally in her chest x-ray (Figure 1). Beta human chorionic gonadotrophin (HCG) was markedly elevated (>200 000 mIU/ml). Trans-abdominal ultrasound revealed uterine mass with snowstorm appearance. 250 cc vesicle-like tissue was removed during evacuation. Histopathology examination of endometrial tissue was consistent with choriocarcinoma. Hyperthyroidism was treated with Lugol’s iodine, Carbimazole and propanolol. Chemotherapy (Methotrexate, Actinomycin and Etoposide) was initiated post surgery. Her thyroid function test improved dramatically with reduction of Beta HCG. Figure 1Chest X-ray showing multiple canon ball lesions.

Leprosy and bone marrow involvement


A 29-year-old female had a history of hypopigmented skin lesions over the left cheek, back and thighs for over 3 years. These lesions were not associated with itching or any altered sensation but were progressively increasing in size and number. She took indigenous medications for 3 years with no response. Finally, she visited our hospital for her complaints and a skin biopsy confirmed a diagnosis of leprosy. She was started on multi drug therapy. No new lesions developed following therapy and her existing lesions also reduced in size. On follow-up, after about 6 months, she started developing progressive anemia. Nutritional causes were excluded and drugs were stopped; however, the anemia persisted. The patient started experiencing intermittent and high-grade fever as well. On examination, she had pallor, was febrile (103°F) and had multiple skin lesions (Figure 1A). Complete blood counts revealed anemia (Hemoglobin - 80 g/L, Total leukocyte count-8.6 × 109/L and platelet count –201 × 109/L). Her blood and urine cultures were sterile and other infective work-up was negative. Finally, a bone marrow examination was performed to evaluate the cause of anemia and persistent fever. Bone marrow aspirate smears showed adequate representation and maturation of all hematopoietic lineage elements, however, had many foamy macrophages (Figure 1B). Fite stain demonstrated single and occasional bunches of acid fast bacilli in some of these macrophages (Figure 1B, inset). Ziehl Neelson stain for mycobacterium tuberculosis was negative. Trephine biopsy revealed multiple interstitial well formed granulomas composed of foamy macrophages (Virchow cells) (Figure 1C). The bone marrow involvement by leprosy was confirmed explaining the cause of persistent fever and anemia. Figure 1(A) Thick and shiny skin of face with hyperpigmented macular and papular lesions typical of leprosy. (B) Bone marrow aspirate smear showing foamy macrophages (May Grunwald Giemsa, ×100). (Inset) Fite acid fast stain shows single and clumps of acid fast bacilli in the macrophages. (C) Trephine biopsy section shows granulomas (Haematoxylin and eosin, ×20).

Creating a culture of health: evolving healthcare systems and patient engagement


We all recognize that today’s healthcare megatrends are challenging to people, practitioners, scientists, healthcare systems, governments and life science companies. This is particularly true for the increasingly frequent chronic conditions in which these trends coalesce.1 How do we handle the complexity of delivering personalized medicine that reflects individual preferences while taking advantage of the evidence base?2 What is the answer for the rising cost of both the proliferation of treatments effective for chronic conditions3 and those of conducting clinical research?4 Finally, how do we address the new business challenge for healthcare providers to move away from paying for volumes of services in favor of paying for the value of health outcomes achieved by the patients they serve who have lifelong chronic health problems?5

Higher risk for thyroid diseases in physicians than in the general population: a Taiwan nationwide population-based secondary analysis study


Background: Physicians have high work stress, responsibility for night shifts and chances of exposure to medical radiation, which may increase the risk for thyroid diseases.Aim: We conducted this study to assess the risk for thyroid diseases in physicians, which remain unclear.Design: We used a secondary analysis of the Taiwan National Health Insurance Research Database for this study.Methods: After excluding thyroid diseases occurring before 2006 and residents, physicians and general population were identified by matching with age and sex in 2009 in a 1:2 ratio. The risk for thyroid diseases was compared between the physicians and general population and among physicians by tracing their medical histories between 2006 and 2012.Results: In total, 28,649 physicians and 57,298 general population were identified. Physicians had a higher risk for overall thyroid diseases than the general population [odds ratio (OR): 1.27; 95% confidence interval (CI): 1.10–1.47], including individual thyroid disease: thyroid cancer (OR: 1.89; 95% CI: 1.22–2.95), hypothyroidism (OR: 1.64; 95% CI: 1.23–2.18) and thyroiditis (OR: 1.48; 95% CI: 1.00–2.19).Conclusions: We showed that physicians had a significantly higher risk for thyroid diseases than the general population. This reminds us to pay more attention to thyroid diseases in physicians. Further studies about the underlying mechanisms are warranted.

Restrictive antibiotic stewardship associated with reduced hospital mortality in gram-negative infection


Introduction: Antimicrobial stewardship has an important role in the control of Clostridium difficile infection (CDI) and antibiotic resistance. An important component of UK stewardship interventions is the restriction of broad-spectrum beta-lactam antibiotics and promotion of agents associated with a lower risk of CDI such as gentamicin. While the introduction of restrictive antibiotic guidance has been associated with improvements in CDI and antimicrobial resistance, evidence of the effect on outcome following severe infection is lacking.Methods: In 2008, Glasgow hospitals introduced a restrictive antibiotic guideline. A retrospective before/after study assessed outcome following Gram-negative bacteraemia in the 2-year period around implementation.Results: Introduction of restrictive antibiotic guidelines was associated with a reduction in utilization of ceftriaxone and co-amoxiclav and an increase in amoxicillin and gentamicin. Approximately 1593 episodes of bacteremia were included in the study. The mortality over 1-year following Gram-negative bacteraemia was lower in the period following guideline implementation (RR 0.852, P = 0.045). There was no evidence of a difference in secondary outcomes including ITU admission, length of stay, readmission, recurrence of bacteraemia and need for renal replacement therapy. There was a fall in CDI (RR 0.571, P = 0.014) and a reduction in bacterial resistance to ceftriaxone and co-amoxiclav but no evidence of an increase in gentamicin resistance after guideline implementation.Conclusion: Restrictive antibiotic guidelines were associated with a reduction in CDI and bacterial resistance but no evidence of adverse outcomes following Gram-negative bacteraemia. There was a small reduction in one year mortality.

Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India


Purpose: To evaluate the spectrum of acute infectious encephalitis/encephalopathy syndrome (AIES) in intensive care unit (ICU) and the predictors of mechanical ventilation (MV) and outcome of these patients.Methods: AIES patients diagnosed on the basis of fever, altered sensorium, seizure and cerebrospinal fluid pleocytosis admitted to the neurology ICU were prospectively included. The demographic and clinical details, hematological, biochemical, MRI and etiological findings of the patients were noted. Need of MV, death in hospital and 3-month functional outcome were analyzed.Results: One hundred sixty-four out of 258 (64%) AIES patients needed ICU admission. Their median age was 35 (2–85) years and 71 (43%) were females. The etiology was viral in 44 (herpes and Japanese encephalitis in 12 each, dengue in 17, mumps, measles and varicella in 1 patient each), non-viral in 64 (scrub typhus in 48, falciparum malaria in 6, leptospira in 3 and bacterial in 7) and undetermined etiology in 56 (34%) patients. Sixty-nine (42%) patients needed MV. On multivariate analysis, Glasgow Coma Scale (GCS) score, Sequential Organ Failure Assessment (SOFA) score and raised intracranial pressure were independent predictors of MV. Forty-three (26%) patients died, and all were in the MV group. Higher SOFA score and untreatable etiology were independent predictors of mortality. At 3-month follow-up, 14% had poor and 86% had good outcome. Low GCS score, focal weakness and status epilepticus independently predicted poor outcome.Conclusion: Twenty-six percent patients with AIES died in ICU, and 86% had good recovery at 3 months. Admission SOFA scores and untreatable etiology predicted mortality.

Excess long-term mortality in outpatient deep venous thrombosis patients managed in an ambulatory care setting


Background: Deep venous thrombosis (DVT) is increasingly being managed in the outpatient setting, particularly patients deemed low-risk at presentation. The long-term outcomes of these patients remain unclear.Aim: To determine the long-term outcomes of patients with DVT and those with raised D-dimer without DVT managed exclusively by an ambulatory care pathway.Design: Retrospective cohort analysis.Methods: 828 consecutive patients assessed at the Ambulatory Care Clinic of a tertiary care university hospital between 1 January and 31 December 2008 for potential lower limb DVT were analysed. Primary and secondary outcome was all-cause mortality and new diagnosis of cancer, respectively. Median follow-up was 6.4 years.Results: The final cohort comprised 131 patients with DVT, 396 with raised D-dimer without DVT and 165 with normal D-dimer without DVT. Long-term survival was 72.5% for DVT, 75.3% for elevated D-dimer without thrombosis and 93.3% for those with normal D-dimer (P < 0.0001). The risk of death with DVT remained significant after adjusting for age, gender, previous cancer, recent surgery and previous thromboembolism (HR 2.17, 95% CI [1.07, 4.38]). Cancer accounted for 44.4 and 37.8% of deaths within the first and second groups, respectively. 50% of cancers in the former group were diagnosed during follow-up vs. 95.1% in the latter.Conclusion: The 5-year survival of patients with DVT managed via ambulatory care was worse than expected. An algorithm is urgently needed to identify predictors of adverse outcomes for both these patients as well as those with raised D-dimer without thrombosis.