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Fever in a patient with liver metastasis of bowel carcinoma

Wed, 31 Oct 2007 15:00:00 +0000

{mosimage}A 62-year-old patient presented with fever and abdominal pain in the right upper quadrant. He had an 18-month history of adenocarcinoma of the colon (T3N1M1) with liver metastases, for which he underwent a right hemicolectomy and received chemotherapy with irinotecan and cetuximab; in addition he underwent chemoembolization of the liver lesion. His past medical history was significant for diverticulosis, atrial fibrillation, hypertension (amlodipine 5 mg every 12 hours per os and atenolol 25 mg once a day) and appendectomy.

On examination he was cachectic and febrile with a temperature of 380C. He had hepatomegaly and his liver was hard and irregular on palpation. A scar of his previous operation was evident. Otherwise the physical examination was normal.

Investigations showed a leukocytosis and increased erythrocyte sedimentation rate and serum C-reactive protein levels. Blood cultures and urine cultures were sterile. His chest X-ray and his electrocardiogram were normal. Computed tomography scan of the abdomen showed lesions in the liver (Figure).

Lesions on blue skin base

Sun, 30 Sep 2007 14:00:00 +0000

{mosimage}A 32-year-old male presented with a 24-hour history of rash. He reported tingling and mild pain radiating to his right arm that started 2 days earlier. On physical examination, he had normal vital signs. There was a vesicular rash on deep blue base on his right shoulder (Figure 1). No other abnormal findings were noted. A complete blood count and biochemistry were within normal limits. The patient denied any previous or current use of medications, traveling abroad, or history of any disease.

What is the diagnosis?

Severe shortness of breath after PTCA

Fri, 31 Aug 2007 14:00:00 +0000

{mosimage}A 71-year-old woman was admitted to the hospital due to acute myocardial infarction. Prior medical history included arterial hypertension, insulin-dependent diabetes mellitus, and hyperthyroidism. The patient had no history of tobacco or alcohol use. On admission, she was afebrile. Oxygen saturation was 97 % on room air. Chest x-ray (CXR) was normal. Blood glucose was 288 mg/dl.

She stayed in the Coronary Care Unit (CCU) for 48 h and was treated with aspirin (100 mg per day), clopidrogel (75 mg per day), heparin (1.000 iu/h), and a monoclonal antibody against platelet receptor Gp IIb/IIIa. Percutaneous transluminal coronary angioplasty (PTCA) was performed. Two days following CCU discharge, the patient became febrile (38.5 oC) with non-productive cough and progressive dyspnoea. Three days later, she was readmitted to the medical Intensive Care Unit (ICU) due to severe dyspnea and type I respiratory failure. On admission, she was tachycardic (113 beats / min) and tachypneic (30 breaths/min). The temperature was 38.6 oC and ABG analysis disclosed a PaO2 of 58.0 mm Hg, a PaCO2 of 25.8 mm Hg, pH=7.39, and a HCO3 of 15.6 mmol/L. Chest auscultation revealed end-inspiratory crackles, bilaterally diminished breath sounds, and a grade I apical systolic heart murmur. The patient was intubated and admission-CXR revealed diffuse infiltrates in both lungs and pleural effusions. A white blood cell count of 17.600/ìL (89% polymorphonuclear leukocytes) was noted, as well as a hematocrit of 32 %, a platelet count of 344,000/ìL, and an erythrocyte sedimentation rate of 110 mm. Liver enzymes, and serum urea and creatinine were within normal limits.

The patient was treated with intravenous piperacillin-tazobactam, ofloxacin and teicoplanin. She remained febrile (39 oC) with no improvement in respiratory function and chest X-ray. Blood, urine and bronchial cultures were negative for common bacterial and fungal pathogens. A chest computerized tomographic (CT)-scan demonstrated confluent opacities in the right upper and middle lobes and in the left lower lobe as well as air-bronchograms, an extensive right pleural effusion and a pathological swelling of pretracheal lymph nodes (Figure 1).

What are possible causes of the pulmonary infiltrates?

Orofacial pain and fever

Tue, 31 Jul 2007 14:00:00 +0000

{mosimage}A 61-year-old male patient was referred to our hospital because of gradual painful enlargement of the left parotid, buccal and parapharyngeal region, of three days duration. The patient complained of difficulty and pain while attempting to open his mouth or swallow. Low-grade fever of up to 37.6oC was reported. Treatment with oral antibiotics was introduced 2 days prior to presentation at the hospital, without signs of response to therapy.
The patient had a 3-year history of colorectal cancer with liver, bone and soft tissue metastases. Seven days prior to presentation, a course of radiation therapy to the cervical spine, administered for a paravertebral soft tissue metastasis, was completed. The patient was also receiving second line chemotherapy with cetuximab (an EGFR inhibitor) plus irinotecan, the last cycle being administered 20 days earlier. His treatment regimen also included chronic zoledronic acid monthly infusions, and dexamethasone, at a current total daily dose of 6 mg, as well as opiod analgesics.
Five months earlier, the patient had developed a pulp infection of the lower left second molar tooth, which required tooth extraction and antibiotic treatment. Although symptoms of local inflammation had completely resolved, the patient reported a persistent foreign body sensation in that area ever since. The rest of the patient's medical history was unremarkable, except for arterial hypertension.
Physical examination revealed a tender, crepitant, erythematous mass of the left parotid, buccal, infratemporal and parapharyngeal region (Figure 1). Trismus and dysphagia were also observed. Intraorally, a portion of exposed bone was identified at the molar area of the left mandible. The exposed bone had a yellow-white, smooth surface, and it was hard and painless. It was surrounded by erythematous, ulcerated and tender oral mucosa. The rest of the oral examination was normal. Despite the striking local findings, the general condition of the patient was not severely compromised, and body temperature was normal.
Baseline routine laboratory investigations showed a normal white blood cell count of 8,860/mm3 with predominance of neutrophils (95.4%), a 35-fold elevated C-reactive protein value of 17.7 mg/dl, along with an erythrocyte sedimentation rate of 83 mm/h, all consistent with acute inflammation. Hypoalbuminemia (2 g/dl) was also noted, as well as elevated blood urea nitrogen (47 mg/dl).
What is your diagnosis?

Steep elevation of creatinine in a patient with acute flank pain

Sat, 30 Jun 2007 14:00:00 +0000

{mosimage}A 46-year-old, Caucasian, male patient presented to the emergency department suffering, for 12 hours, from acute, severe, left flank pain radiating to the left lower quadrant, with associated emesis. The patient reported minimal urine output after symptoms had started. Past medical history was unremarkable, and previous routine laboratory examinations had shown only chronic mild hyperuricemia.

The physical examination revealed mild tachypnea and left costovertebral angle tenderness, but was otherwise normal. On admission, abnormal laboratory findings included leukocytosis (17.220 white blood cells per mm3), a urinalysis showing hematuria (>100 red blood cells/high power field) and pyuria (20-22 white blood cells/high power field), and elevated values of serum creatinine (sCr) and blood urea nitrogen (BUN) (2,4 and 34 mg/dl, respectively).

What is the cause of the renal dysfunction?

Fever, confusion, and headache

Thu, 31 May 2007 14:00:00 +0000

A 45-year-old female patient presented with fever, confusion, nuchal rigidity, and vomiting to the emergency department of our hospital. She had a runny nose for the three days prior to admission and frontal headache. Her past medical history was significant for hypertension and allergy to penicillin. The patient was on nifedipine, monoxidine, and irbesartan per os. On examination, she was febrile with a temperature of 38.3 0 C. Her blood pressure was 140/90 mmHg, pulse 100 per minute regular and 14 respirations per minute. She was confused and stuporose.

A computed tomography of the brain was normal. Subsequently, she underwent a lumbar puncture. Examination of the cerebrospinal fluid revealed 550 cells/mm3, 78% lymphocytes, 56 mg/dl glucose levels (serum glucose levels: 111 mg/dl), protein 111,8 mg/dl. Gram stain of the cerebrospinal fluid (CSF) was negative, as was culture of the CSF.

Multifocal myositis in an apparently healthy adult

Mon, 30 Apr 2007 14:00:00 +0000

A 64-year old female presented with fever, diffuse muscle pains and extensive areas of erythema and edema over her thighs and arms. She reported that these skin lesions developed over a few days. In addition the patient noticed generalized edema.

{mosimage}On examination, she looked acutely ill. She could barely walk with the support of two of her family members. Generalized edema was evident. The patient weighed 100 kg (her usual weight was 75 kg). Her blood pressure was normal but she was tachycardic (104 beats per minute) and tachypneic (20 respirations per minute) with oxygen saturation level on air of 95%. Her temperature was 390C. Areas of erythema were noted over her right and left thigh (Figure) and her arms extending to the anterior chest wall and breasts. These painful skin lesions were accompanied by warmth and tenderness. An area of fluctuance could be felt in her right thigh. On auscultation of the chest there were decreased breath sounds bilaterally. The rest of the physical examination was normal.

A hematocrit of 23.7% (hemoglobin 7.6gr/dl) accompanied by leukocytosis (19650/mm3 with 87.4% neutrophils with a shift to left) and mild thrombocytosis (501000/mm3) were present. C-reactive protein levels were increased at 26.71 mg/dl (normal up to 0.5) and erythrocyte sedimentation rate was 130 mm/1st hour (normal 0-20). There was a striking increase in creatine phosphokinase with serum levels of 6763 IU/l [upper limit of normal (ULN)=215 IU/l] accompanied by an increase in lactic dehydrogenase serum levels (LDH: 302 IU/l, ULN=190) and serum transaminases levels [AST: 230 IU/l (ULN=37) and ALT: 129 IU/l (ULN=65)]. Urine dipstick was positive for hemoglobin (++). A significant hypoalbuminemia was present [1.7 gr/dl (normal >3.5]. On urine microscopy there were 4-5 leukocytes per high power optical field, while there were no erythrocytes. Her electrocardiogram was normal. Chest X-rays revealed moderate bilateral pleural effusions.

What is the diagnosis?

Pericardial and pleural effusion

Sat, 31 Mar 2007 14:00:00 +0000

{mosimage}A female patient from Greece, born in 1955, visited our office in January 1998 for evaluation of recurrent right pleural effusion (Figure). The patient was treated for Hodgkin's disease (supra-clavicular and mediastinal lymph node enlargement) with radiation and chemotherapy in February 1974. The treatment consisted of a series of MOPP (nitrogen mustard, vincristine, procarbazine and, prednisone) and Co60 radiation over the mediastinum and lymph nodes above the diaphragm. Details about the radiation, including dosage, were not available. She also had a splenectomy at that time. The treatment of Hodgkin's disease was successful and led to disappearance of the enlarged lymph nodes. The patient felt well and was able to receive a degree from a graduate school and subsequently to work full-time without any problem.

The patient initially felt progressively short of breath during November 1997. She did not have any fever. A chest x-ray at that time showed bilateral pleural effusion and enlargement of the shadow of the heart. An echocardiogram revealed a significant amount of pericardial fluid. The patient was subsequently admitted to a hospital for treatment.

Recurrent abdominal wall inflammation

Thu, 01 Mar 2007 00:00:00 +0000

{mosimage}A 59-year-old female presented with superficial hypogastric pain and low grade fever of one week duration. The patient had a history of ovarian cancer for which she underwent two abdominal operations as well as chemotherapy two years earlier. Six months prior to her visit she had been operated for hypogastric abdominal hernia with abdominal wall reconstruction using mesh support. Physical examination on admission showed erythema in the hypogastric area extending around the middle line (Figure). Routine laboratory testing, including erythrocyte sedimentation rate (ESR) did not show abnormal findings.

Fever and left lower abdominal quadrant pain

Thu, 01 Feb 2007 00:00:00 +0000

A 68-year-old male was admitted to our hospital due to fever and abdominal pain in the left lower quadrant that started 2 days prior to admission.

His past medical history was significant for coronary artery by-pass surgery 15 years earlier, perforation of the stomach 20 years earlier, and atrial fibrillation. His medication included acenocoumarol, isosorbide mononitrate, ramipril, furosemide, and carvedilol. The patient had dental work done 7 days prior to admission. He reported that he had stopped taking some of his medications, including acenocoumarol, prior to the visit to the dentist. However, two days prior to his admission he re-started taking acenocoumarol.{mosimage}

His temperature was 37.8 degrees Celsius. His blood pressure was 130/80 mmHg and his pulse rate was 120/min. Physical examination showed left lower quadrant abdominal tenderness and decreased bowel sounds. Routine laboratory testing showed: ALP 223 U/L, SGOT 41 U/L, ã-GT 239 U/L, total bilirubin 2.3 mg/dL, INR 2.33, prothrombin time 28.4 sec, partial thromboplastin time 49.2 sec, white blood cell count 15.70 K/ìl, neutrophills 83.5%, red blood cell count 3.77 M/ìl, hematocrit 39.3%, C- reactive protein 26.57 mg/dL (normal values up to 0.5 mg/dL), urea 34 mg/dL, creatinine 1.2 mg/dL.

A CT scan of the abdomen showed an area of hypodensity of the spleen with a size of 9.5x3 cm (Figure). Ascites was also noted.

Streaky lesions after insect bites

Mon, 01 Jan 2007 00:00:00 +0000

A 24-year-old man presented to our office{mosimage} because of fever and redness of his left lower extremity. The patient had been bitten at his left foot by an insect two days prior to his presentation. He could not recognize the kind of the insect. The patient used a local anti-allergic ointment at the site of the insect bite. He developed fever accompanied by rigors two days after the insect bite. Concomitantly, the patient started feeling a burning sensation on his left lower limb. Physical examination at presentation showed temperature of 38,7° C. The rest of the vital signs and of the physical examination were normal except for findings from the left lower extremity. He had an extensive area with redness, increased local temperature, and tenderness extending from the foot to the upper part of the thigh (Figure 1). On the lateral surface of the left ankle there was a small area of necrosis, at the site of the insect bite (Figure 2). In addition, there were palpable and tender lymph nodes of maximum 2 cm of diameter in the left inguinal area. Routine laboratory tests on admission were normal except for the white blood cells count [12,750 cells/ìl (neutrophils 81,5%, lymphocytes 11,9%)]. The rest of hematological and biochemical tests were normal.

What is the most likely diagnosis?
Thrombophlebitis of the major saphenous vein
B. Cellulitis
C. Erysipelas
D. Allergic reaction
E. Lymphangitis

Impetigo-like vegetating nasal lesion

Fri, 01 Dec 2006 20:59:52 +0000

{mosimage}A 56-year-old female patient seeked medical advice because of mild fever and a face lesion of two-week duration. Her past medical history was significant for diabetes mellitus (managed with insulin), mild chronic renal insufficiency and breast cancer for which she underwent total right mastectomy 10 years ago. The patient also received radiation and chemotherapy at that time. She recently received again chemotherapy due to hepatic and bone metastases (the last chemotherapy regimen was one month ago). Physical examination showed a temperature of 37 degrees Celsius and a large, vegetating lesion on the nose with areas of honey-coloured and black areas (Figure 1). Routine laboratory testing showed: hematocrit 39.6%, hemoglobin 13 g/dL, white blood cell count 6.91 K per cubic mm, neutrophills 93.6%, glucose 622 mg/dL, creatinine 1.9 mg/dL, blood urea 96 mg/dL, and total bilirubin 1.36 mg/dL. What is the diagnosis?

Rash, abdominal pain, hematochezia, and dysuria

Wed, 01 Nov 2006 00:34:03 +0000

A 47-year-old female patient presented with haematochezia and fatigue. She reported that she had 4 bowel motions, which were dark red in colour without mucus. 3 weeks prior to presentation she noticed a rash that begun on the lower limbs (including the soles) and was ascending in nature and eventually involved the trunk, buttocks and upper limbs as well as the palms. Arthralgias, dysuria and frequency accompanied the skin manifestations. A skin biopsy performed elsewhere, showed leukocytoclastic vasculitis but immunofluorescence was not performed. The patient was not taking any medication prior to the development of the rash. She was on a tapering dose of methylprednisolone since and was generally well, except for continuing dysuria and frequency.{mosimage}

On examination, her blood pressure was normal but she was tachycardic (114 bpm) and tachypneic (20 respirations per minute) with oxygen saturation levels on air of 95%. Her temperature was 37,3 0C. A generalized purple skin rash was evident in the aforementioned areas (Figures 1 and 2). Her abdomen was exquisitely tender in all quadrants with a degree of rebound tenderness. On rectal examination dark red blood was present. The rest of the physical examination was normal.

Significant leukocytosis (34000/mm3) was present, as were mildly elevated urea levels (56 mg/dl). Urine dipstick was positive for blood (++) and leukocytes (++) and albumin (+). On urine microscopy there were 70 leukocytes and 5 erythrocytes per high power optical field, but there were no casts. Her electrocardiogram was normal but her chest X-ray revealed moderate bilateral pleural effusions. What is the diagnosis?

Periorbital and facial swelling and fever

Sat, 30 Sep 2006 23:00:00 +0000

A 55-year-old female patient presented to us with a 10-day history of malaise, lethargy, and fever up to 39.50 C accompanied by rigors. She also complained of diffuse myalgias, arthralgias, and bilateral facial edema. Her past medical history was significant for a modified mastectomy for invasive breast cancer in 2000 but she is free of disease 6 years later. There was no history of trauma. She admitted that she had botulinum toxin injections in the forehead 4 years ago but there was no prosthesis in the periorbital area (neither silicone nor fat).{mosimage}

On examination, her blood pressure was 130/70 mm Hg and she was feverish (390 C). Pulse rate was 90 bpm regular and respirations were 18/ minute. There was marked edema of the face, especially in the periorbital and malar areas (Figure 1), and this was accompanied by erythema and sensitivity. There was no associated feeling of pruritus of the aforementioned area. A scar from the previous surgical operation in the breast area was evident.

Laboratory examinations showed leucocytosis (12480 /mm3 with a left shift), normal eosinophil count, increased C-reactive protein [11.4 mg/dl (normal values 0-0.5)], and increased erythrocyte sedimentation rate [70 mm/1st hour (normal 0-20)]. Creatinophosphokinase levels were increased [1453 IU/lt (normal 21-215)]. Immunoglobulin levels were increased for IgA [550 (normal 55-377) mg/dl] and IgE [(696 IU/lt (normal 0-200)], Serum protein electrophoresis was normal. C1 esterase inhibitor levels were normal [339 mg/lt (normal 210-390)]. Antinuclear autoantibodies, anti-dsDNA and anti-Sm were all negative. Serology testing was negative for Trichinella spirallis and C. trachomatis. Magnetic resonance angiography of the brain vessels was normal. MRI imaging confirmed the presence of edema in the periorbital area. Electromyography of the muscles of the upper and lower limbs was normal. What is the diagnosis?

Fever, knee pain and calf swelling

Thu, 31 Aug 2006 23:00:00 +0000

A 53-year old woman presented to us because of pain and swelling of the right knee joint for the previous 2 days before admission. She took non-steroidal anti-inflammatory medication but experienced only minimal and temporary relief for a few hours. The pain and swelling got gradually worse. She checked her temperature and it was 400 C. The day before admission while the symptoms of the knee joint persisted, edema and pain appeared in the upper half of the calf musculature. The past medical history was significant for partial resection of the larynx due to idiopathic paralysis and a thyroidectomy for goitre.{mosimage}

Physical examination on admission showed a temperature of 38,50 C, blood pressure was 140/80 mmHg, respirations 14 per minute and pulse: 90 per minute regular. A tracheostomy was evident. The right knee had signs of inflammation: pain, redness, and edema. There was accompanying edema and pain of the calf musculature. The rest of the physical examination was normal.

Laboratory tests showed a leukocytosis with a shift to the left (15.250 leukocytes/mm3 with 80,9% neutrophils) and a markedly increased C-reactive protein (28,84mg/dl (normal: 0-0.5 mg/dl) and erythrocyte sedimentation rate (120 mm/1st hour (normal:0-20 mm/1st hour). Magnetic resonance imaging (MRI) of the right knee and the right calf (figure 1) disclosed extensive synovitis of the right knee with the concomitant presence of increased arthritic fluid. There was accompanying inflammation of the muscle groups of the calf and especially the gastrocnemius muscle and compression of the popliteal vein in the popliteal fossa.

What was the cause of fever, knee pain, and calf swelling? What is the diagnosis?

Leg edema and fever

Mon, 31 Jul 2006 23:00:00 +0000

A 46-year-old female patient complained {mosimage}of mild fever, weakness, left extremity swelling, and fullness of the left inguinal area that became progressively worse over a period of 1 month. She was seen by her primary care physician who did not find any abnormal findings in the physical examination except lymph node enlargement in the inguinal area. He recommended biopsy of the enlarged lymph nodes that was unrevealing. She developed lymphorrhea for about 2 weeks after the procedure.

She acutely complained of higher fevers and more weakness about 2 months after the start of her initial symptoms. She was admitted to the hospital for further management. Physical examination showed left lower extremity swelling and lymph node enlargement in the left inguinal area (Figure 1). Routine laboratory investigation revealed increased white blood cell count (WBC: 20070/mm3, 81,9% neutrophils), C-reactive protein [CRP: 9,1 mg/dl (normal:0-0,5)], and erythrocyte sedimentation rate (ESR:87 mm 1st hour). She was found to have MRSA bacteremia. Imaging of her body with computed tomography (CT) scans revealed abscesses in the left iliopsoas and obturator muscle (pyomyositis) (Figure 2). No other source of active infection was identified, except the findings from the retroperitoneal space. A magnetic resonance imaging (MRI) of the spine and a colonoscopy that included visualization of the terminal ileum were negative. She received intravenous antimicrobial treatment with linezolid (600 mg every 12 hours), clindamycin (600 mg every 8 hours) and rifampicin (600 mg every morning and 300 mg every night) for 4 weeks that improved her condition. Specifically the fever decreased and she felt better. In addition, the laboratory indices of inflammation also improved.

What was the cause of the leg edema?

Shortness of breath in an HIV-infected patient

Fri, 30 Jun 2006 23:00:00 +0000

A 36-year-old man was diagnosed to be infected with HIV in November 2000 and was started on azidothymidine/lamivudine /nevirapine in January 2001. He tolerated this treatment well for 20 months, achieving suppression of the viral load to undetectable levels and increase of his CD4 count to 1,506 cells/ml. Then, he began to complain of nausea, fatigue, dyspnea, and pain in the epigastrium. He did not take any other prescription or over the counter medications.

On admission, he was slightly tachypneic (20 breaths/min); physical examination was notable only for mild epigastric tenderness. Laboratory work-up showed mildly elevated transaminases (AST: 44 U/L, normal: 7-40, and ALT: 64 U/L, normal: 7-40), elevated triglycerides (268 mg/dL, normal: 50-150), cholesterol (317 mg/dL, normal: <190) and a lactate level of 13.1 mmol/L (normal: 0.6-2.4), with mild metabolic acidosis (pH: 7.34, HCO3: 18.3 mmol/L). Hepatitis serologies for hepatitis B and C viruses were negative. Antero-posterior and lateral chest X-rays were normal.

What was the cause of his hyperlactaemia?

Recurrent vomiting and dyspepsia

Thu, 01 Jun 2006 13:15:05 +0000

A 43-year-old male presented to the {mosimage}Emergency Department complaining for vomiting and dyspepsia. He refused persistently to give any more details. He asked for an intramuscular injection of metoclopramide, refusing further investigation, since "he already knew his problem ("recurrent gastritis")". However, he was convinced to undergo an electrocardiogram in our attempt to rule out vomiting of cardiac origin, which showed ST changes and minimal U wave, suggestive of hypokalemia (Figure 1). The physical examination on presentation was unremarkable except for epigastric tenderness. Routine laboratory testing on admission was unremarkable except for low serum potassium (K=2,1 mmol/liter). The arterial blood gas testing showed metabolic alkalosis (pH=7,66, bicarbonate = 55,2 mmol/liter, pC02 49mmHg, pO2 63mmHg, saturation O2 96%). Since his symptoms insisted, the patient accepted to be admitted.

During his hospitalization, he revealed that he had history of upper gastrointestinal bleeding four years earlier without undergoing further investigation. Since then he has been complaining for occasional vomiting that was empirically managed with metoclopramide. He didn't report chest pain, headache, fever, weight loss, or other symptoms. He was afraid of hospitals and doctors and he avoided visiting his family physician. The last two weeks prior to admission, his condition deteriorated. His other past medical history was unremarkable and he received no medications, except the occasional use of metoclopramide. He did not smoke and he did not drink alcohol.
Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?
A. Functional or non-ulcer dyspepsia
B. Peptic ulcer disease complicated by pyloric stenosis
C. Esophagitis or reflux without esophagitis
D. Gastric or esophageal cancer
E. Biliary track disease

Back pain and skin lesions

Sun, 30 Apr 2006 23:00:00 +0000

A 55-year-old farmer was {mosimage}admitted to the hospital with low back pain without neurological compromise and nodulopustular skin lesions in the thighs and forearms. The patient reported recurrent episodes of right elbow bursitis as well as right heel pain during the last 8 months.

Past medical history revealed renal transplantation for end stage glomerulonephritis 15 years prior to the admission to the hospital and therapy with immunosuppressive agents since then. During the last 3 years, the patient received methylprednisolone, 4mg per day, and azathioprine, 75mg per day. Moreover, the patient had liver cirrhosis due to chronic hepatitis C viral infection diagnosed at the time of transplantation.

Physical examination and plain radiographs of the lumbar spine showed no abnormalities. The patient was discharged from the hospital with the advice to receive a 2-week treatment with non-steroid anti-inflammatory medications and bed rest for the low back pain and amoxicillin/clavulanic acid for the skin lesions.

Four weeks later, he presented with intense low lumbar pain, numbness of the lower extremities and gait disturbance. Furthermore, there was cervical spine pain, loss of dexterity, and numbness of the hands. The patient had malaise, vertigo, and tinnitus but no fever.

Physical examination revealed a palpable gibbus at the cervical region. Neck motion was decreased. The muscle strength of both lower and upper extremities muscles was mildly decreased (4/5). Deep tendon reflexes of the upper extremities were decreased. Deep tendon reflexes of the lower extremities were normal. There was no clonus.

Imaging evaluation with plain radiographs, computed tomography and magnetic resonance imaging of the spine showed spondylodiscitis at C4-C5, C5-C6, C7-T1, and T1-T2 intervertebral discs (Fig. 1) and spondylodiscitis at L4-L5 associated an epidural mass. Cervical kyphosis was present because of osteolysis with anterior wedged deformity of the C5 vertebra. Posterior C5-C6 spondylolisthesis resulted in compression of the spinal cord at this level. Osteolytic lesions were also shown radiographically at the left elbow (olecranon and radius), the right carpal bones, the distal right fibula, the right calcaneus (Fig. 2), and the right middle and forefoot (the head of the fifth metatarsal and the proximal phalanxes of the fifth, fourth, third and second toes).

What is your diagnosis?

Gangrenous, hemorrhagic, bullous cellulitis

Sat, 01 Apr 2006 13:32:26 +0000

A 57-year-old man was admitted {mosimage}to the intensive care unit (ICU) after initial resuscitation and hemodynamical stabilization in the emergency ward (EW), where he presented in a comatose state with shock (blood pressure 60/40 mmHg, heart rate 140 pulses/min, body temperature 36.5oC, respiratory rate 28 breaths/min, O2 saturation 90% on room air). Family members reported that the patient had developed a rash (not further specified) and fever seven days prior to his admission to the hospital.

The rash gradually extended on large areas of both lower extremities. The patient had a 30-year history of multiple sclerosis and a 2-year history of Waldenström's macroglobulinemia for which he was receiving corticosteroids. He also had a history of fracture of the right hip. He was confined to bed for the last 10 years prior to his admission. The rest of the physical examination on admission showed icteric conjunctivae and decreased respiratory sounds as well as fine crackles in the pulmonary bases. There were extensive, hemorrhagic, necrotic areas of the skin of the lower extremities and the abdomen as well as ulcers and bullae (Figures 1 and 2).

Routine laboratory testing on admission revealed normochromic, normocytic anemia (hematocrit 32.1%), decreased white blood cell count (WBC = 3.38 x 103/ìl of peripheral blood) with 89.9% neutrophils, and thrombocytopenia (20 x 103/ìl of peripheral blood). The prothrombin time (PT) and INR were increased (16.2 sec and 1.35, respectively). Also, blood urea and direct bilirubin were elevated (66 mg/dl and 2.15 mg/dl, respectively). The serum protein electrophoresis revealed increased gamma globulins (25.4%) and detection of monoclonal IgM ê chains. The concentration of IgM was increased (990 mg/dL) while IgG and IgA were decreased (124 mg/dL and < 25 mg/dL, respectively). Chest X-ray films revealed lower lobe atelectasis bilaterally.

Oral lesion in an HIV-infected patient

Wed, 01 Mar 2006 00:00:00 +0000

A 30-year-old female with a body {mosimage}weight of 47 kg was confirmed to be HIV seropositive shortly after her husband was diagnosed with HIV infection by the blood bank service. On clinical examination, the woman was pale, emaciated, with bad oral cavity hygiene, while a purple coloured mass (resembling Kaposi sarcoma) was identified in the oral cavity (on the right upper jaw extending to the inside of occupying the gingiva and part of the hard palate) (Figure 1). Small (< 0.4 cm) cervical and submandibular lymph nodes were found. Examination of the abdomen revealed a - just palpable below the respective hypochondrium- enlargement of the liver and spleen.

Laboratory examinations revealed pancytopenia (white blood cell count 1.60 x 103/ìL, neutrophils 59.4%, lymphocytes 29.1%, monocytes 11.5%, red blood cell count 2.9 x 106/ìL, hemoglobin 8.4 g/dL, hematocrit 26.2%, and platelet 63 x 103/ìL), elevated lactic dehydrogenase 593 IU/L (normal range 225-450) and elevated gamma globulins 32.7% (normal range 11-22%). Electrolytes, liver function tests, creatinine, and urea were within normal limits. Her CD4 were 102 cells/ìl and HIV viral load 30,764 copies/ml. The patient was further investigated with CT scans of the chest, abdomen, and pelvis that did not show any abnormal findings. Highly active antiretroviral therapy (HAART) with zidovudine, lamivudine, and effavirenz as well as primary prophylaxis for opportunistic infections with atovaquone (she was allergic to cotrimoxazole) and azithromycin was initiated.

Malodorous vaginal discharge after pelvic surgery

Wed, 01 Feb 2006 15:03:01 +0000

A 29-year-old female patient presented {mosimage}initially with symptoms of stress urinary incontinence occurring several times every day, for 4 years. She also reported symptoms of urgency and urge urinary incontinence and pelvic dragging. In the past she had 2 uncomplicated spontaneous vaginal deliveries and she suffered from asthma that was well controlled by medical treatment (bronchodilators by inhalation).

Physical examination revealed a moderate cystocele with paravaginal defects, a small rectocele, and a first-degree uterine prolapse. Urodynamic investigation showed urodynamic stress incontinence. As previous conservative treatment with pelvic floor exercises and physiotherapy had failed, she underwent a Burch colposuspension. The procedure and the recovery were uneventful and the stress urinary incontinence was cured.

Ten months after surgery the patient reported increasing pelvic dragging sensation. Clinical examination revealed a moderate rectoenterocele and 1st-2nd degree of uterine prolapse with an elongated cervix and a small high cystocele. The patient underwent a Manchester procedure with repair of cystocele using a polypropylene mesh (Prolene). The uterus was also suspended by the posterior IVS (intravaginal slingplasty) technique. Pelvic organ prolapse symptoms were subsided.

However, the patient noted an offensive vaginal discharge 3 months after the second operation and she reported an episode of light vaginal bleeding. Examination revealed a large mesh erosion of the anterior vaginal wall (2x3cm) (Figure 1) and 2 small erosions of the IVS tape on the posterior vaginal wall. The uterus and the vaginal walls were well supported.

Calcific constrictive pericarditis

Sun, 01 Jan 2006 00:00:00 +0000

A 40-year-old man {mosimage}suffered from gradually worsening dyspnea and swollen ankles for six months prior to his evaluation. He underwent a chest X-ray, lung function tests, a 24-hour Holter heart rhythm monitoring, and a polysomnography study. A working diagnosis of sleep apnea syndrome was made in another institution and the patient was advised to use a continuous positive airway pressure (CPAP) mask. With the use of the mask, his symptomatology got worse: he had severe dyspnea at rest and leg edema, which was extending up to the knees. He also noticed an increased abdominal girth. The patient was assessed by a cardiologist in his hometown who perfomed a Doppler echocardiography and diagnosed a thrombus of the right ventricle and an abnormally moving intraventricular septum. These findings prompted an emergency referral to the hospital.

On physical examination the patient was hemodynamically unstable with a blood pressure of 90/65 mmHg, pulse rate 105 per minute, respiratory rate 25 per minute, and temperature 38,2 0 C. He was severely dyspneic at rest and was mildly obese (Body Mass Index of 27,75). The first and second heart sounds were normal but there was a pericardial knock. Pulsus paradoxus was present as well. There were few crackles of the lung fields up to the midzone. Abdominal examination revealed splenomegaly and signs of free peritoneal fluid. He had edema of the legs up to the level of the knees.

An initial workup revealed the presence of mild anemia (Ht: 37.6%), an increased erythrocyte sedimentation rate (ESR = 50 mm at the first hour), an elevated C-reactive protein (CRP = 16.36 mg/dl with upper normal limits: 0.5 mg/dl) and decreased serum albumin levels (2.7 gr/dl). Measurement of other routine biochemical parameters was normal. Tuberculin skin testing was negative. An electrocardiogram showed decreased voltage. Imaging included a chest X-ray which showed calcification of the pericardium and a small left pleural effusion, and an echocardiogram which showed a localized pericardial effusion causing tamponade of the right ventricle and calcification of a thickened pericardium. A CT scan of the chest is shown in Figure 1.

Scalp necrosis in an elderly woman

Thu, 01 Dec 2005 00:00:00 +0000

A 90-year-old woman presented to{mosimage} the emergency department complaining of a 3-month history of headache, and recent blindness of her right eye. She also reported weakness and weight loss (5 kg during the last 3 months prior to her presentation) but no fever. She had been treated symptomatically with non-steroidal anti-inflammatory drugs without noting any significant relief. There was no history of trauma or burn. Her past medical history included diabetes mellitus type II and arterial hypertension.

The physical examination on presentation was unremarkable except for a large area of scalp necrosis in the temporo-parietal region bilaterally (photos 1 and 2).

Routine laboratory testing on admission showed anemia (hematocrit = 31,1%) and elevated erythrocyte sedimentation rate (ESR = 120mm/first hour). Serological tests for varicella-zoster virus (VZV) and herpes simplex virus 1 and 2 (HSV1 and HSV2) were negative. A CT scan of the head was unremarkable.

Extensive skin papular lesions

Tue, 01 Nov 2005 15:52:39 +0000

A 44-year-old white man{mosimage} presented with a 12-month history of slightly pruritic, papular lesions on his face, upper and lower extremities. No other complains were mentioned. No similar skin dermatosis was reported from his family history including first-degree relatives. The patient had no history of kidney disease, diabetes mellitus or liver disease.

Physical examination was unremarkable except for the skin findings. Specifically, skin lesions were 8 in number located on the middle of the chin, on the right angle of the mouth and on the extensor surfaces of the forearms, elbows, thighs and knees. There was no mucous membrane involvement. Skin lesions were characterized by areas with diameter of 1 cm up to 8 cm consisting of multiple hyperkeratotic plaques and burrows. The large and old lesions of the extremities did not have signs of inflammation (Figure 1). In contrast, the small and new lesions on the face had clear signs of ongoing inflammation with an erythematous halo surrounding them (Figure 2). Mild tenderness and increased temperature was also evident on the face skin lesions.

Testing for anti-nuclear and anti-mitochondrial antibodies was negative, but it was weakly positive for anti-smooth muscle antibodies. There was also a slight elevation of the level of the haemolytic complement [CH50 = 556 U/ml (normal 300-510 U/l)]. The levels of the third and fourth component of complement (C3 and C4) were normal. Finally, a serologic test for syphilis [Venereal Disease Research laboratory (VDRL) slide test] was negative.

Persistent Klebsiella septicemia

Fri, 30 Sep 2005 23:00:00 +0000

A 15-year-old girl was admitted to the hospital because of mild abdominal pain and fever up to 37.8°C of 2-day duration. Specifically, she developed peri-umbilical abdominal pain that gradually moved to the right lower abdominal quadrant. In addition, she vomited twice on the day of admission. Her past medical history was unremarkable. She was not receiving any medications.

Physical examination on admission showed temperature 38°C, respiratory rate 14 breathes/min, arterial blood pressure 120/70 mm/Hg, and heart rate 84 beats/min. There was mild tenderness during the palpation of the right lower abdominal quadrant. There was no rebound tenderness or abdominal wall rigidity. The rest of the examination was normal.

Routine laboratory testing on admission revealed increased leucocytes (12,360 white blood cells per mm3 of peripheral blood, 86.3% neutrophils). Liver function tests and serum creatinine, urea, electrolytes, and glucose were normal. An abdominal ultrasound showed small amount of fluid in the Douglas pouch.

The patient received intravenous metronidazole 500 mg every 8 hours and tazobactam/piperacillin 4/0.25 gr every 8 hours after her admission to the hospital. Appendicitis was considered as the most likely diagnosis. The patient underwent laparoscopic appendectomy 40 hours after her admission. No transfusion of blood products was needed. The intra-operative findings were consistent with inflammation of the appendix (erythema and edema). In addition, a small amount of cloudy fluid was seen in the Douglas pouch.

Despite the operation, the patient continued to have fever and rigors. In fact, a gradual increase of the body temperature was noted during the post-operative period. There was no evidence from the physical examination and the laboratory and imaging testing for any of the likely causes of post-operative fever such as respiratory or urinary tract infection, post-operative wound infection, atelectasis, deep venous thrombosis, and drug fever.

Klebsiella pneumoniae was isolated from cultures of blood specimens, which were taken for first time during the second post-operative day. The pathogen was resistant to 1st, 2nd, and 3rd generation cephalosporins, quinolones, piperacillin/tazobactam, and aztreonam, intermediately susceptible to meropenem (mean inhibitory concentration, MIC = 8 mg/l), and susceptible to gentamicin and colistin. Cultures of urine specimens did not grow any micro-organisms. Chest and abdominal x-rays, abdominal ultrasound, as well as computed tomography (CT) scan of the chest and upper and lower abdomen, a transthorasic echocardiogram, ultrasound triplex testing of the intra-abdominal arteries and veins as well the lower extremities veins, and a gallium nuclear medicine scan did not reveal any abnormal findings.

The patient continued to have high fever (up to 39.8 °C), sweating, malaise, and persistent isolation of Klebsiella pneumoniae from blood specimens, despite the administration of various antimicrobial regimens, including the use of intermittent intravenous gentamicin (60 mg every 8 hours), meropenem (1g every 8 hours), and colistin (1.000.000 units every 8 hours).

What are the therapeutic options?

Cellulitis of the axillary area

Thu, 01 Sep 2005 16:07:34 +0000

A 28-year-old white man was admitted to our {mosimage}hospital because of chronic swelling and redness of the left sub-axillary area. No fever, pruritus, or sweating was reported. His past medical history was unremarkable. The patient reported that, after switching deodorant, he noticed a painful swelling in his left axilla 3 months prior to his admission to our hospital. He was treated by his family physician for postulated hidradenitis suppurativa with antibiotics and anti-inflammatory medications, which did not lead to any improvement. Because of the persistence of the lesion in the axilla, a fine needle aspiration was performed then, which showed "atypical degenerating cells suspicious for malignancy". This finding prompted referral to a major tertiary medical center. At that time there was a flare-up of symptoms in the left axilla in addition to the appearance of a new palpable, tender mass in his left supraclavicular area. This mass was chosen by the attending surgeon to be removed for testing. Culture of a part of the removed specimen grew Propionibacterium acnes. Microscopic examination showed fibrous adipose tissue with acute and chronic inflammation findings consistent with organizing abscess. No lymph node tissue was identifiable. Based on these findings the patient received treatment with levofloxacine 500 mg once a day and metronidazole 500 mg three times a day p.o., which, again, did not lead to any improvement.

Physical examination on admission showed temperature 37,5 degrees C and pulse rate 80/min. His body mass index (BMI) was 35,46 kg/m2 (weight: 128 kg, height: 190 cm). He had gynecomastia and inversion of the nipples. Examination of the chest and neck revealed inflammation of the skin surrounding the left nipple, extending up to the left axilla, and a scar in the left supraclavicular area related to previous biopsy (Figures 1-2). Small, palpable, and tender lymph nodes in the left axilla, left and right cervical areas and left and right inguinal areas were also found. All other systems were examined and found normal.

C-reactive protein level was increased at 2.99 mg/dl (normal less than 0.5 mg/dl). Erythrocyte sedimentation was increased as well at 39 mm/first hr. Complete blood count, blood glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), glutamyl transpeptidase, bilirubin, lactate dehydrogenase (LDH), creatine phosphokinase (CPK), serum sodium, potassium, urea, and uric acid were all normal. Tests for cytomegalovirus (CMV), Epstein-Barr (EBV) and human immunodeficiency virus (HIV) were negative. Mantoux test was also negative.

Recurrent omphalitis

Sun, 31 Jul 2005 23:00:00 +0000

A 23-year-old man presented with{mosimage} one year history of recurrent pyorrhoea from the umbilical area. Specifically, the patient had 5 episodes of omphalitis during the last year prior to his admission to the hospital. All episodes were successfully treated with courses of antimicrobial agents (second generation cephalosporins or amoxicillin/clavulanic acid) by mouth. No fever, abdominal pain or other complaints were reported. His past medical history was significant for dysfunction of the left kidney (79% loss of function in a recent nuclear medicine renal scan), which was attributed to recurrent urinary tract infections during his childhood.

Physical examination on admission showed temperature of 37,4 degrees C, signs of inflammation (redness, tenderness, swelling, and increased temperature) in the umbilical area (Figure 1) as well as purulent umbilical discharge (Figure 2).

Routine laboratory tests including a complete blood count, blood urea, serum creatinine, blood glucose, liver function tests, C-reactive protein, erythrocyte sedimentation rate, and a urinalysis were normal. No growth of microorganisms was found from the culture of the umbilical discharge.

What are the likely underlying causes for the recurrent omphalitis of this young adult?

Not just a usual community-acquired infection

Thu, 30 Jun 2005 23:00:00 +0000

A 64-year-old male presented to the Emergency Room of the local hospital in a rural area of Greece complaining of fever, shortness of breath, productive cough, and mild low back pain. He had no previous hospitalizations.{mosimage}The patient's symptoms suggest a lower respiratory tract (LRT) infection as the most likely diagnosis. Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis are common etiologic agents in patients with community acquired LRT infections. In addition, atypical bacteria including Mycoplasma, Chlamydia, Legionella, and Rikketsiae species are the cause of a considerable proportion of lower respiratory tract infections that varies in different age groups. Also, several viruses including influenza, parainfluenza, and adenoviruses may cause LRT infection, especially during the winter session.The patient was a farmer. His past medical history was significant for a work-related injury in the lower back 10 years ago. He consumed alcohol, about half a liter of wine per day, for 20 years. He did not smoke. He never traveled outside Greece. The details of the medical history and the habits of the patient suggest additional possible pathogens for his LRT infection, mainly Klebsiella pneumoniae, given the history of alcoholism. Because of his occupation, leptospirosis should be considered in thedifferential diagnosis. In addition, brucellosis should be also considered given that the patient lives in a rural area in Greece where the infection is endemic. It should be noted that brucellosis may cause manifestations from the respiratory system.The patient's condition deteriorated despite the administration of antimicrobial treatment (ceftriaxone 1 g every 12 hours i.v. and clarithromycin 500 mg every 12 hours p.o.) at the local hospital. He was transferred to a tertiary hospital in Athens, two days after his admission at the local hospital. He presented with temperature 38.5 oC, heart rate 108/min, and tachypnea (45 breaths/min). Physical examination on admission revealed crackles in the base of the left lung and the upper right lung. Routine laboratory testing showed white blood cell count 8,800/mm 3, neutrophils 88%, erythrocyte sedimentation rate 104 mm/1st hour, serum urea 57 mg/dl and creatinine 1.4mg/dl. Gram stain of a sputum specimen showed about 20 neutrophils per optic field. Chest x-rays on admission showed infiltrates in the left lower and the right upper lobe (figure 1). Arterial gas testing showed PaO2/FiO2=240, arterial pH = 7.48, and PCO2=28 mmHg.The patient's worsening condition despite the use of appropriate antimicrobial treatment for community-acquired pneumonia suggests several possibilities. First, that the pathogen responsible for his pneumonia was indeed one of the most commonly implicated micro-organisms in LRT infections, namely Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, or an atypical pathogen that was however resistant to the administered agents. There is an increasing proportion of pneumococcal isolates with full resistance to penicillin in several countries during the last years. Although still a controversial issue, it seems that the majority of evidence supports that the outcome of patients who receive treatment with ceftriaxone for pneumonia due to Streptococcus pneumon[...]

Painful facial swelling

Tue, 31 May 2005 23:00:00 +0000

A 58-year-old man was {mosimage}admitted to the hospital complaining of a 3-day history of fever, malaise and a painful swelling of the right parotid gland. For 2 days before his admission, he had been taking amoxicillin and metronidazole, as the swelling was thought to be related to dental infection, by his general practitioner. His medical history was unremarkable. The patient did not suffer from any immune or endocrine disease and has not taken any other medication in the past. He did not mention any history of diarrhea, vomiting, abdominal pain, joint pain or joint swelling. He was living in Athens suburbs, working as a civil servant.

As the symptoms seemed to persist, the patient was referred to our Hospital's ENT department for evaluation. At physical examination, a firm mass was palpable at the right parotid, and the patient was admitted for further investigation. No evidence of palpable regional lymph nodes was noted and no other clinical findings could be revealed. The chest X-ray showed no abnormalities. His white blood count was 9,250/mm3 (69.7% neutrophils, 17.2% lymphocytes, and 6.8% monocytes), haematocrit 48.5%, haemoglobin level 16.1 g/dl, platelet count 267,000/mm3, C - reactive protein 8.3 mg/dl (normal values up to 0.5 mg/dl) and erythrocyte sedimentation rate 70 mmHg/1st hour. A CT scan of the face was performed (Figure).

What is your diagnosis?

Fever and shortness of breath

Sat, 30 Apr 2005 23:00:00 +0000

A 67-year-old female patient was admitted to our unit due to fever and shortness of breath.{mosimage}

Her past medical history was significant for breast cancer, which was treated with mastectomy in November 2003. She received chemotherapy from December 2003 until April 2004 (every 21 days). Then she underwent 30 cycles of radiation treatment.

The patient finished the last radiation treatment in June 2004. In September 2004 she developed difficulty in breathing and mild fever (up to 37.50C), which was felt to be due to radiation pneumonitis. She was given steroid treatment (methylprednisolone 16 mg every 12 hours for 1 week, with gradual decrease of the dose and discontinuation within one month). She felt improved with this treatment. However, 3 months later she developed similar symptoms for which she received methylprednisolone again (16 mg every 8 hours, with gradual decrease of the dose and discontinuation within 3 months), which led again to improvement of her symptoms.

However, in February 2005 the patient complained again of shortness of breath and mild fever. Physical examination on admission showed a temperature of 37.70C. There were bilateral rales in the middle and lower lung fields (more in the right lung). C-reactive protein and erythrocyte sedimentation rate were elevated.White blood cell count was also elevated. A chest X-ray showed an infiltrate mainly in the right middle and lower lobes (Figure 1).

Severe panniculitis

Thu, 31 Mar 2005 23:00:00 +0000

A 36-year-old woman was admitted to the hospital because of fever and abdominal pain of one-week duration. Fever was up to 39 degrees Celsius and was accompanied by chills. The pain was located in the right lower quadrant of the abdomen. She did not complain for other symptoms.

The patient was married to a shipman and had five healthy children, three of whom were delivered by cesarean section. Her past medical history included recurrent cellulitis-like episodes after a glass related injury, which was located in her left forearm.

Physical examination showed elevated temperature (38,8 degrees Celsius). The pulse rate was 90/min and the blood pressure 120/70 mmHg. There were three areas (2X2 cm), on her left forearm, with atrophy and hyperpigmentation. Inflammation was obvious on the right lower quadrant of the abdominal wall, where swelling, tenderness, heat and redness were found in an area of 25X15 cm. Liver, spleen and peripheral lymph nodes were not palpable. The rest of the physical examination did not show any abnormal findings.

Laboratory work-up revealed: Ht=36%, Hb=12,9 g/dl, WBC=9980/mm3 (neutrophils=75%, lymphocytes=18%, monocytes=6%, eosinophils=1%), platelets=210,000/mm3, erythrocyte sedimentation rate (ESR) = 57mm/first hour. The level of C-reactive protein was normal. The biochemical (glucose, renal and liver function, electrolytes, lipid profile, uric acid, amylase, lactate dehydrogenase, creatine kinase, and proteins) and immunological tests of the serum (rheumatoid factor test, antinuclear antibodies, antimitochondrial antibodies, anti-smooth muscle antibodies, cytoplasmic and perinuclear anti-neutrophil cytoplasmic antibodies, serum angioconverting enzyme and complement), were normal, except of the slight elevation of IgM, slight reduction of IgA and low value of C4. Urinalysis did not show abnormal findings. Chest X-rays, ECG, U/S of the abdomen and C/T of the thorax, upper and lower abdomen were normal.

Limitations in the management of aortic graft infection

Tue, 01 Mar 2005 00:00:00 +0000

A 56-year-old female from Greece with a history of {mosimage}Takayasu's disease (diagnosed in 1992) was admitted in late November 2002 to our unit because of fever, which started in April 2002. She was diagnosed at another hospital to have aortofemoral graft infection in June 2002. Only one of several blood cultures, performed at the previous hospital, grew a strain of Staphylococcus epidermidis. She received prolonged courses of antibiotics including vancomycin, linezolid, and rifampin. In addition, a-lactam antibiotics with coverage against Gram negative organisms had been given, because of the possibility that the isolated microorganism (Staphylococcus epidermidis) was a contaminant. Her fever relapsed and she was admitted to our unit for management.

Her past medical and surgical history was rich: rheumatic fever (1959), premature labour and eclampsia (1970), extrauterine pregnancy (1972), caesarean section (1982), small intestine ileus due to adhesions (1982), bilateral aortocarotid bypass and aortofemoral bypass (1992), which were both attributed to Takayasu's arteritis . Also, erythema nodosum (1992), appendectomy (1992), jaundice due to hepatitis B virus infection (seronegative at time of presentation), operations for femoral artery aneurysms (1994, 1995, 1997, 2001), cholecystectomy (1995), and coronary main stem bypass using the internal mammary artery (1999).

Physical examination on admission showed temperature 37.5 degrees Celsius. There were scars from previous operations. A bruit was audible over the left carotid and her femoral arteries. Right radial artery was not palpable. Laboratory testing on admission showed erythrocyte sedimentation rate (ESR) 60 mm/ 1st hour (normal<10) and C-reactive protein (CRP) 3mg/dl (normal<0.5). An electrocardiogram showed T wave inversion in leads V1 and V2. A magnetic resonance imaging (MRI) of the area of the aortofemoral graft was suggestive of active inflammation of the graft and of the surrounding area as well as adhesions of the third (retroperitoneal) part of the duodenum with the abdominal aorta.

She was treated with iv trimethoprim/sulphomethoxazole (80/400 mg) every 12h, iv chloramphenicol 1gr every 6h, iv quinupristin/dalfopristin 500 mg every 8h, sc enoxaparin 60 mg every day, ranitidine 150 mg every 12h, acetylsalicylic acid 100 mg once daily, atorvastatin 20 mg once daily, isosorbide mononitrate 60 mg once daily, and metoprolol 50 mg every 12h. Laboratory indices of inflammation initially improved and fever stopped. However, her aortofemoral graft infection seemed to be resistant to medical treatment.

What is the appropriate management?

Fever and left tibia erythema and pain

Tue, 01 Feb 2005 00:00:00 +0000

A 73-year-old male patient was admitted{mosimage} to our hospital because of fever and pain of the left tibia.

His past medical history was significant for diabetes mellitus (managed with oral antidiabetic agents) and lung cancer for which he underwent resection of the left upper lobe one year ago. The patient also received chemotherapy that was completed 1 month ago.

Physical examination showed a red area of the left tibia (Figure). His temperature was 37.40C. Routine laboratory testing showed: C-reactice protein 30.50 mg/dL (normal value (0-0.50 mg/dL), creatinine 1.7 mg/dL (0.8-1.3 mg/dL), urea 61 mg/dL (15-50 mg/dL), hematocrit 28.1% (41.0-53.0%), white blood cell count 9.19 K/ìl (4.50-11.00 K/ìl).

An ultrasound of the lower extremities arteries and veins was performed which showed a generalized atherosclerotic disease, including a total obstruction of the left superficial femoral artery.

What is your diagnosis? What should be done?

Back pain and fever after facet joint injection

Sat, 01 Jan 2005 00:00:00 +0000

A 78-year-old male was presented to his local orthopedic surgeon for low back pain. The patient had no neurologic deficits, and with the presumptive diagnosis of degenerative spondylosis, he has been treated with non-steroidal anti-inflammatory medications and physiotherapy for 3 months.{mosimage}

The past medical history included hypertension, chronic obstructive pulmonary disease, atrial fibrillation and congestive heart failure. He was receiving b-blockers, loop diuretics, and digoxin for his cardiovascular problems and inhaled corticosteroids and ipratropium for his chronic obstructive pulmonary disease.

Three months later, the patient had worsening of his back pain. Plain radiographs, computed tomography and magnetic resonance imaging of the lumbar spine were obtained, which showed osteoarthritis of the lower lumbar facet joints. Facet joints injection was done using methyl-prednisolone acetate and bupivacaine hydrochloride 0.5%. The patient had temporary relief of his symptoms for 2 days followed by deterioration of his low back pain and acute onset of low-grade fever. Laboratory investigation revealed increased white blood cell count (16.010/ìl), erythrocyte sedimentation rate (83 mm/1st hour), and C-reactive protein (185 mg/l). Spine infection was suspected and ciprofloxacin was administered (500 mg per os, twice a day) for four weeks. However, this treatment led to minimal improvement of the clinical symptoms.

The patient was referred to us for further evaluation and treatment. At the time of his admission, his main signs and symptoms included low back pain and tenderness, and increased body temperature (37.8o). Magnetic resonance imaging of the lumbar spine showed end plate erosions of L3, L4, L5 vertebral bodies (Figure 1) and signal abnormalities at the L2-L3 and L3-L4 intervertebral discs (Figure 2).

What is the appropriate management?

Recurrent post-sternotomy mediastinitis

Wed, 01 Dec 2004 00:00:00 +0000

Representative case report
A 55-year-old man presented to us with pyorrhea from the sternotomy site of 11 months duration. His past medical history was significant for a coronary artery bypass grafting (CABG) operation that was performed 2 years earlier [using the left internal mammary artery {mosimage}(IMA) and a saphenous vein graft]. A superficial sternal wound infection developed a few days postoperatively. The patient received anti-bacterial treatment (amoxicillin-clavulanic acid per os) for 3 months and wound care that did not lead to any clinical improvement. Subsequently, he underwent a second operation with extended sternal wound debridemend, which included partial sternectomy. Seven months after the second operation he developed signs of inflammation in the sternotomy site as well as purulent discharge. He received several combinations of antimicrobial agents including rifampin and ciprofloxacin per os for 4 months, which did not lead to control of the infection. The patient was admitted to our hospital for the management of recurrent mediastinitis.

His past medical history was also significant for a spinal column operation due to protrusion of a lumbar intervertebral disk 3 years earlier. In addition, ulcerative colitis was diagnosed 15 years earlier for which the patient had not received any medications for five years prior to his admission to our hospital.

Physical examination on admission showed a fistula of the median sternotomy site with purulent discharge (Figure 1) and local signs of inflammation (redness, tenderness, swelling and increased temperature). Palpation of the upper chest revealed swelling in the area of the suprasternal notch (Figure 2). The patient was afebrile and had normal blood pressure, pulse rate, and respiratory rate.

Routine laboratory tests including a complete blood count, hematocrit, hemoglobulin, blood urea, serum creatinine, blood glucose, liver function tests, and urinalysis did not show abnormal findings except for an increased platelet count (617,000/mm3). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated (CRP = 1.43 mg/dl with normal values < 0.50 mg/dl, and ESR = 34 mm/first hour with normal values 0-20 mm). A computed tomography scan of the thorax showed a big cavity in the mediastinum that was in direct contact with the aorta and the trachea (Figure 3). Pseudomonas aeruginosa, Enterococcus faecalis and Staphylococcus aureus were isolated from cultures of 3 different samples of the discharge.

What is the best therapeutic approach?

Multiple skin lesions

Mon, 01 Nov 2004 00:00:00 +0000

A 56-year-old white male was admitted to the hospital due to multiple skin lesions. {mosimage}In addition, he complained for dysuria and hematuria within the last month prior to his admission, with clinical characteristics compatible with urethritis or prostatitis. One month prior to his admission, pruritic skin lesions appeared, first on his back, and then spread to upper extremities trunk and finally to the lower extremities. His primary physician treated him with steroids per os but no improvement was achieved. During the last days prior to his admission the patient noticed an increase in the number of skin lesions, as well as seropurulent discharge from several of them. The patient did not report arthralgias, anorexia, or loss of weight. His past medical history included an idiopathic thrombocytopenic purpura episode 8 years ago, a cytomegalovirus "mononucleosis like" infection 1 year ago, and a urinary truck infection (not otherwise specified) six months ago.

Physical examination revealed multiple skin lesions with diameter ranging from 0,5 cm to 5 cm (Figures 1 and 2). Some lesions had a central crust, while others an erythematous halo. The lesions were in different shapes vesicles and pustules, coalescing in some areas. In some of the lesions, seropurulent discharge was present. No lymphadenopathy was found. The rest of the physical examination was normal.

Pulmonary cavitary lesion

Thu, 30 Sep 2004 23:00:00 +0000

A 35-year-old man with no significant past medical history suffered from relapsing infections of the upper respiratory tract and episodes of nasal bleeding for five months. Chest radiography, which was perfomed in a local hospital, showed a big infiltrate in the right upper pulmonary field. Fiberoptic bronchoscopy was performed twice and a Staphylococcus aureus strain and a Klebsiella pneumoniae strain grew from bronchial samples. The patient had no clinical improvement despite the anti-bacterial and anti-tuberculous treatment that he received for a month.{mosimage}

The patient refused to be operated on for the postulated diagnosis of a pulmonary abscess. He was admitted in an infectious diseases department of another hospital for the management of a persisting pulmonary abscess despite the antimicrobial treatment that he received. Physical examination on admission in our hospital showed fever up to 38.80 C. There were small blood clots in the nose. The examination of the chest showed ronchi in the upper right lung field.

Laboratory tests on admission revealed white blood cell count (WBC) of 13,230/cubic mm (neutrophils = 77.9%, lymphocytes = 12.9%), hematocrit (Ht) =36.3%, platelets =588,000/cubic mm, C-reactive protein = 21.74 mg/dl (normal values < 0.50 mg/dl), and erythrocyte sedimentation rate (ESR) = 105 mm/first hour (normal values 0-20 mm). Laboratory tests for cancer indices and renal function, including urinalysis, did not show abnormal findings. Chest radiography and computed tomography of the thorax showed a big infiltrate with a central cavitation in the right upper pulmonary field (figure 1 and 2). Craniofacial computed tomography revealed ethmoid sinusitis.

Asymptomatic hepatic lesion

Tue, 31 Aug 2004 23:00:00 +0000

A 37-year-old Greek woman presented for a routine "check up" physical examination. Her past medical history included mitral valve prolapse, an episode of herpes zoster of the first branch of the left trigeminal nerve, and a cyst in the left ovary, which did not need surgical removal. She did not complain of any symptoms.{mosimage}

Physical examination revealed a systolic murmur over the mitral area with intensity 2 out of 6, which was attributed to the known mitral valve prolapse. Deep palpation of the right upper abdominal quadrant caused mild discomfort and pain to the patient. The rest of the physical examination was normal.

Routine laboratory testing, including complete blood cell count, serum glucose, creatinine, total lipids, cholesterol, triglycerides, alanine animotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), iron, ferritin and thyroid hormones (T3, T4, TSH) did not reveal any abnormal findings. There was a slightly elevated erythrocyte sedimentation rate (ESR) [26 mm/first hour (normal values less than 20)]. The finding of the right upper abdominal quadrant tenderness was further investigated with an ultrasound (U/S) examination, which revealed a well-circumscribed mass, with mixed echographic pattern, in the right hepatic lobe. A contrast enhanced CT of the abdomen was subsequently performed (Figures 1 and 2). What is the diagnosis?

Chronic thoracic spine pain

Sat, 31 Jul 2004 23:00:00 +0000

A 49-year-old woman complaining of thoracic spine pain for 18 months was admitted to the hospital for evaluation. The pain was accompanied by profuse sweating but she did not report any fever.{mosimage}

Physical examination revealed tenderness of the affected area on percussion, as well as pain and limitation of motion.

Erythrocyte sedimentation rate (ESR) was 86 mm (first hour). Chest x-ray showed destruction of the lower part of the body of the eighth thoracic vertebra. Magnetic resonance imaging of the thoracic spine showed pathology of the T8-T9 intervertebral disk and destruction of the T8 vertebral body (Figure 1). Computed tomography scan-guided fine needle aspiration of the affected disc was performed. Gram stain and culture of the obtained specimens for common microorganisms and Brucella species were negative. Serology tests for brucellosis were also negative. In addition, Ziehl-Neelsen stain, polymerase chain reaction (PCR), and culture for Mycobacteria were negative. Because of continuing symptoms and lack of diagnosis the patient underwent a vertebrectomy and substitution of the eighth thoracic vertebra with Moss titanium cylinder filled-up with auto-bone grafts. The stabilization was completed using the Kaneda system (Figure 2).

Skin lesions after corticosteroid use

Wed, 30 Jun 2004 23:00:00 +0000

A 53-year-old female visited our office for dermatopathy of 'the right side of the trunk'. For one week prior to the appearance of the lesions she was feeling pain and 'a strange, creeping sensation' over the affected area. The patient had a known history of rheumatoid arthritis for which she was receiving medications, namely, methotrexate 10 mg p.o. once weekly and prednisolone 5 mg p.o. once daily. Five months prior to her visit she had a hospitalisation due to exacerbation of rheumatoid arthritis manifested by arthritis and pulmonary involvement. Throughout her childhood she suffered from uncomplicated mumps, chickenpox and pertussis.{mosimage}

The cutaneous eruption at the time of presentation had a dermatomal distribution extending from her right upper abdominal quadrant to her back and consisted of small vesicles coalescing to form plump-reddish plaques (Figures 1 and 2). Lesions were extremely tender on palpation. Lung auscultation revealed bilateral crackles at the lower fields, which, according to previous medical reports, were first noticed at her previous hospitalisation.