Renal Salmonella enteritidis abscess in a patient with severe aplastic anemia after allogeneic stem cell transplantation

We describe an unusual case of a renal abscess by Salmonella enteritidis in a 32-year-old man with severe aplastic anemia undergoing allogeneic stem cell transplantation. He was receiving immunosuppressive therapy with CsA and corticosteroids for chronic GVHD. He was not neutropenic and had no history of enterocolitis or cholelithiasis before the onset. Four months after the transplantation, he developed an abscess in the upper pole of his right kidney from which Salmonella enteritidis was isolated in culture. He was successfully treated with a combination of percutaneous drainage and washing the cyst through the catheter using piperacillin sodium-containing solution. The possibility of salmonellosis should be considered in the differential diagnosis of such patients.     

Birth in triplet pregnancies. Vaginal delivery--how often is it possible?

The patient was born by emergency cesarean section for fetal distress at 35 weeks gestation with a weight of 2740 g. The early neonatal course was complicated by transient tachypnea and renal failure. He was receiving oxygen and diureticus in incubator for 5 days and his condition was very improved on day 5. On day 7 he became lethargy and there was inability to tolerate feeding. Investigation of the cerebrospinal fluid revealed 8,000 leukocytes/microliter. S. marcescens was grown from cultures of both blood and cerebrospinal fluid. Treatment was started with cefotaxime and ampicillin every 6 hour. On day 14 the CT showed a brain abscess located parietooccipitally on the left side and diffuse infarction on the right side. On day 14 and 23 recurrence of increased leukocytes in the cerebrospinal fluid, high values of serum CRP and deterioration of clinical symptoms were observed. It is thought that the episodes show rupture of the abscess into the lateral ventricle. On day 55 surgical drainage was performed for the hydrocephalus. On day 110 the abscess was not found in the brain CT scan. His psychomotor development 3 years later was equivalent to two years old and he had secondary epilepsy.     

Iliopsoas abscess accompanied by epidural abscess--a case report]

A 55-year-old man was admitted to a hospital with pain of the low back as well as the left leg, and fever. He was suspected of suffering from the lumbar disc herniation because of the presence of Lasegue's sign on the first physical examination. Abdominal computed tomography, however, revealed the swelling of the left iliopsoas muscle. Iliopsoas abscess accompanied epidural abscess was confirmed by subsequent magnetic resonance imaging (MRI). Antibiotic therapy was started for the successive 8 days. The fever resolved, but the pain persisted. The abscess extending from the iliopsoas muscle to the epidural space was still seen on the MRI 20 days after the completion of the antibiotic therapy, and he still complained of the pain of his low back and left leg. Therefore, we conducted epidural puncture under fluoroscopic guidance. Approximately 3 ml of pus was aspirated from the epidural space. Then, his complains decreased remarkably. Iliopsoas abscess should be taken into account in case of a patient with pain on the low back and leg and also inflammatory signs such as fever and leucocytosis.     

A case of brain abscess accompanied with sudden-onset hemiplegia as initial manifestation

A 58-year-old male experienced a sudden stroke-like onset of right hemiplegia and numbness of his right upper limb while engaged in his desk-work on April 7, 1997. He had a past history of diabetes mellitus and hyperlipidemia. On admission, he had no fever and the blood pressure was 140/70 mmHg. General physical examination was unremarkable. Neurological examination showed 4/5 strength of his right unilateral extremities and numbness of his right upper limb. Clinical features and computed tomography (CT) without contrast medium at the onset of hemiplegia suggested a stroke. Seven days after admission, his consciousness worsened and body temperature fluctuated between 37 and 38 degrees C. Subsequent Gd-enhanced magnetic resonance (MR) which demonstrated an irregular shaped ring-enhancement lesion and lumbar puncture 9 days after admission was compatible with the diagnosis of brain abscess. Surgical drainage confirmed the presence of brain abscess due to alpha-streptococcus. It improved following surgical drainage and antibiotic therapy with PAPM.BP 2 g/day and PIPC 4 g/day. An afebrile patient of sudden stroke-like onset may be a rarity to be added to the differential diagnosis of brain abscess.     

Case of the Color-Blind Boy.

"But how do we know what the color-blind person really sees, or whether we see things differently?" is a question frequently raised by students. Readers may be interested in a unique case which is a part answer, or at least a help on this old problem. This boy had normal color vision until the age of 16, when he suffered carbon disulphide poisoning and became totally color-blind. Now 2 1/2 years later, he reports that his dreams are sometimes in color, whereas his perceptions and usual dreams are in black-gray-white. Moreover, on rare occasions when his eyes are well rested, he reports capacity for normal color vision for a short time. He shows no symptoms of psychosis or hysteria. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.     

Craniofacial resection. An alternative incision and skull base repair

Neoplasia of the superior group of paranasal sinuses (frontal, ethmoidal and sphenoidal) has an extremely poor prognosis. Resection, preceded or followed by radiotherapy offers a 5 year survival of less than 30% (1). Satisfactory surgical excision has been undermined by difficulties of access to the cribriform plate area, a common site for residual disease. Furthermore the practice of piecemeal removal invariably resulted in inadequate clearance. The craniofacial approach allows not only excellent access to the anterior skull base but also in bloc excision. The results of treating 7 patients with craniofacial resection for tumours in this area are presented. Particular reference is made to a horizontal forehead skin crease incision for intracranial access. A new technique using a combination of surgical, pericranium, partial thickness skin and fibrin glue to repair the skull base defect is described.     

Lipoma of the mitral valve in a child

We report a case of pyodermia chronica glutealis complicated by acromegalic gigantism associated with hyperprolactinemia. The serum prolactin, growth hormone, adrenocorticotropic hormone, and 11-deoxycortisol levels were elevated, but the estradiol and dehydroepiandrosterone-sulphate levels were within normal limits. However, the testosterone level was very low. Histopathologically, we found sinus tracts and scarring in a specimen from the buttocks. We could not immunohistochemically detect clear androgen, growth hormone, or prolactin receptors at any site. The patient was a man with a height of 197 cm and weight of 140 kg, he had clinical features of active acromegaly such as excessive sweating and increased thickness of soft tissue. He was also diagnosed with diabetes mellitus. Under such conditions, bacteria could easily grow and lesions might have been aggravated by the heavy pressure from his weight, a possible causes of his pyodermia chronica glutealis.     

Isolation and absolute structures of enantiomeric 1,2-bis(4-hydroxy-3-methoxyphenyl)-1,3-propanediol 1-O-glucosides from the bark of Hovenia trichocarpa

The common diagnoses in low back pain are lumbar strain, lumbosacral radiculopathy, osteoarthritis, degenerative disc disease, spinal stenosis, and sacroiliac joint dysfunction. Unusual causes of low back pain that have been previously identified include abdominal aortic aneurysms, pelvic neoplasms, and retroperitoneal hemorrhages. This report describes a case of back pain that was apparently caused by a duodenal ulcer. A 54-year-old man with no significant medical history presented with a complaint of mid to low back pain (T10-L2), which was diagnosed as joint dysfunction. A comprehensive treatment program was prescribed and the patient was instructed to return to clinic in 4 weeks. Three weeks later, he experienced a syncopal episode followed by coffee ground emesis. He immediately sought medical attention at an emergency room, where he was admitted to the hospital with a diagnosis of upper gastrointestinal bleed. Esophagogastroduodenoscopy showed a large duodenal ulcer, and the patient underwent vagotomy and pyloroplasty. He returned to his physiatrist's office 3 weeks after hospital discharge with minimal back pain. The cause of the back pain proved to be referred visceral pain from his duodenal ulcer. This case is presented to reemphasize the need to include the uncommon phenomena in the differential diagnosis of low back pain.     

The effect of 12 months'' treatment with eicosapentaenoic acid in five children with cystic fibrosis

BACKGROUND: The use and indications for laparoscopy have been increasing. As part of this trend, a new algorithm may emerge for pediatric trauma in which laparoscopic techniques are used in hemodynamically stable patients with suspected hollow viscus perforation. CASE REPORT: We present a case in which laparoscopy was successfully used in a pediatric trauma patient as a diagnostic and therapeutic modality. A 4-year-old boy was a back-seat passenger in a head-on collision motor vehicle accident. He was restrained by a lap seat belt. He sustained a concussion, a large forehead laceration and a seat belt abdominal injury. On admission, he complained of abdominal pain. Physical examination revealed a soft, non-distended abdomen with moderate diffuse tenderness. He was hemodynamically stable. Computerized tomography of the abdomen revealed free fluid in the pelvis. No abnormalities were detected in the liver or spleen. Because of clinical deterioration and suspected intestinal perforation, diagnostic laparoscopy was utilized instead of proceeding directly to celiotomy. At laparoscopy a jejunal perforation was found and successfully repaired laparoscopically. Large hematomas were seen in the mesentery, as well as an unsuspected splenic laceration. No active bleeding was found. The patient recovered uneventfully and was discharged 5 days following the surgical procedure. CONCLUSION: This case illustrates the efficacy of using early laparoscopy in children with abdominal trauma when diagnosis is difficult and hollow viscus injury is suspected.     

Successful meropenem therapy of recurrent multiple brain abscess

Authors describe the history of a 37-year-old man suffering from multiple purulent brain abscess. The multiple brain abscess evolved primarily from a gluteal abscess to the lung, and secondarily from the lung to the brain by hematogenous spreading of the bacteria. The identification of the pathogene/s was unsuccessful despite numerous bacteriological examination. Despite many regimens of empiric antibacterial therapy the brain abscesses progressed, neurologic state of the patient deteriorated. At long last, the patient was given chloramphenicol. After that, he had no more fever, his consciousness cleared, no more epileptic convulsion occurred and the cell number of the cerebrospinal fluid became normal. The patient was thought to be cured and was sent home. Two months later fever occurred again and it was accompanied by excrutiating headache, increasing disorientation, so the patient was admitted to the hospital. The occurrence of a new brain abscess and purulent meningitis indicated the relapse of the disease. It was again unsuccessful to identify the pathogene/s therefore the authors treated the patient with many empiric antibiotic regimen, all of which-including chloramphenicol too--proved to be uneffective. As all the therapeutic regimens usually used in the treatment of purulent brain abscess were uneffective--including the combinations which have the widest antibacterial spectrum, authors gave meropenem as ultimum refugium. Some days later the fever came to an end, his consciousness cleared, the brain pressure and the cerebrospinal fluid became normal. The patient had no serious complaints in the course of the four years follow up, his residual neurologic symptoms regressed. On the base of this case history, authors suppose that meropenem--which has already proved to have a very wide antibacterial spectrum and to be very effective in the therapy of many kinds of serious bacterial infections--could also become a promising new therapeutic alternative in the treatment of purulent brain abscess.     

Benjamin Kleinmuntz (1930-2006).

In the 1960s, the idea that clinical judgments should be aided, or even replaced, by computerized algorithms was quite radical. Computerized interpretation of standardized tests is accepted now, although its role remains controversial. Benjamin Kleinmuntz was a pioneer in the study of computers in clinical reasoning and a founder of the field of judgment and decision research. He passed away at his home inWilmette, Illinois, on June 28, 2006, at the age of 76. Although he lived with a transplanted heart for almost 11 years, he died of complications of unrelated abdominal surgery. Ben's early research concerned statistical methods for identifying psychopathologies and interpreting personality profiles. Ben then focused on investigating the use of computers in clinical diagnosis. Ben also wrote or cowrote textbooks on general psychology, abnormal psychology, and personality assessment. He was also a great teacher and advisor, with a unique personal style and an emphasis on both rigor and relevance. He received multiple awards for teaching excellence, and his two all-University teaching awards were as important to him as his many books, publications, and professional recognitions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of a preparation from the horns of the saiga antelope on the goal-directed drinking behavior of rats

We analyzed 79 consecutive patients with aneurysms and found a patient who lacked type III collagen. Collagen was extracted from the skin, and the lack of type III collagen was determined by means of sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). Only 1 of the 79 patients was found to lack type III collagen. This patient was a 55-year-old man who had sustained an abdominal aortic aneurysm and aortic dissection. He did not show any of the typical clinical symptoms of Ehlers-Danlos syndrome type IV, such as hyperextensible skin and joints. He had none of the usual risk factors nor any clear family history of the syndrome. Furthermore, his collagen fibrils demonstrated a homogeneous appearance. This case may represent a new form of type III collagen deficiency.     

Gymnastic world championship in Lausanne: medical staffing

A 64-year-old man who presented with sudden, unilateral loss of vision was found to have endophthalmitis associated with a pyogenic liver abscess. The patient was successfully managed with subtotal vitrectomy and percutaneous drainage of the liver abscess. Eikenella corrodens was cultured from the blood and the pus drained from the liver abscess. This is the first reported case of Eikenella corrodens liver abscess complicated by endophthalmitis.     

Heterotopic ossification as a complication of toxic epidermal necrolysis

The development of heterotopic ossification (HO) as a complication of toxic epidermal necrolysis (TEN) has not been previously reported. TEN, also known as Lyell's syndrome, is a rare but serious skin disorder that typically occurs after the administration of drugs, especially sulfonamides, barbiturates, phenytoin, and nonsteroidal anti-inflammatory agents. TEN is characterized by the development of large fluid-filled bullae with separation of large sheets of skin. Complications of TEN can include extensive denudation of skin with dehydration and electrolyte abnormalities, gastrointestinal hemorrhage, acute tubular necrosis, secondary infection of denuded skin, pneumonia, bacterial conjunctivitis, keratitis, and septic infarcts of internal organs. We report a case of HO in a patient with TEN after treatment with trimethoprim-sulfamethoxazole. A 49-year-old man developed an erythematous rash, bullae, fever, and extensive skin loss consistent with a diagnosis of TEN. He was intubated for complications of TEN (pneumonia) and maintained on bed rest for several weeks. In addition, he developed HO that resulted in multiple joint contractures. He was treated with aggressive range of motion by physical therapy, surgical resection of the HO followed by radiation to both elbows, right hip, and right knee. Postoperative outpatient rehabilitation enabled improved function in his mobility and activities of daily living. HO is known to occur after spinal cord and brain injuries and burns. It has not been reported to occur after TEN. Our experience with this case suggests that HO may merit inclusion into the list of complications of TEN.     

Anterior capsulotomy created by radiofrequency endodiathermy and continuous curvilinear posterior capsulorhexis in a patient with intumescent cataract and primary capsular fibrosis

PURPOSE: To report a clinicopathologic correlation of angiosarcoma affecting the eyelid skin. METHODS: An 82-year-old man developed multiple bruise-like maculopapular lesions, subcutaneous nodules, and diffuse edema over his scalp, face, and eyelids. Biopsy disclosed angiosarcoma, and the patient was treated with wide-field external beam radiotherapy (5,000 cGy). RESULTS: He responded to radiotherapy with partial regression of the tumor. Twelve months later, he developed extensive lymphedema secondary to the residual tumor. He was also found to have parotid gland and bone metastases, treated with radiotherapy. The patient died of widespread bone metastases 3 months later. CONCLUSIONS: Angiosarcoma is a rare skin tumor that has a poor prognosis despite treatment. It should be considered in the differential diagnosis of eyelid tumors and edema because it may affect only the central portion of the face.     

A case of bacteremia and disseminated intravascular coagulation after the conduit procedure for tetralogy of Fallot with pulmonary atresia

A case undergoing conduit procedure for tetralogy of Fallot with pulmonary atresia was complicated postoperatively by bacteremia due to non-fermentative Gram-negative rods and by disseminated intravascular coagulation. He was able to be cured without any sequela. The patient was a 16-year-old male, who had undergone Blalock-Taussig anastomosis in his infancy. The present operation was carried out as follows: ventricular septal defect was closed with a Teflon-patch and discontinuity between the right ventricle and the pulmonary artery was corrected using a Hancock's valved conduit. Two weeks after the operation, pleural effusion in the right chest cavity was shown by a chest X-ray film. On the 32nd postoperative day, high fever with chills occurred, and subsequently developed pulmonary edema, shock and hemorrhagic tendencies with petechia. Pseudomonas aeruginosa, Flavobacterium and Alcaligenes faecalis were detected by the culture of pleural effusion. The platelet count decreased to about 10,000/microliters. Carbenicillin, tobramycin and minocycline were administered for the infection, and heparin and aprotinin were used for disseminated intravascular coagulation. By these treatments for about 6 months, the patient became well and was discharged without any sequela.     

Lessons learned from a complicated case of cephalic obstructive chronic pancreatitis

The authors report the complex case of a 51 year-old man admitted to his local hospital for gallbladder and common bile duct lithiasis, 1 year before admission to our hospital. There, he was treated by cholecystectomy and transduodenal biliary sphincteroplasty. He was readmitted after 3 months because of a painful episode and was discharged with the diagnosis of "relapsing acute pancreatitis in chronic pancreatitis." At our hospital, he underwent laparotomy and revision of the previous transduodenal biliary sphincteroplasty. Pancreatic sphincteroplasty and septectomy were also performed. The night after surgery, the patient suffered from acute post-operative pancreatitis complicated by severe hemorrhage due to erosion of the superior pancreaticoduodenal arteries, treated with gastroduodenal artery embolization by tungsten coils. Three months later, the patient suffered from another acute episode. An endoscopic retrograde colangio pancreatography (ERCP) showed the complete patency of the sphincteroplasties but clearly identified the persistence of a severe cephalic stricture. Therefore, the patient was readmitted to our hospital and underwent another laparotomy. A pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. The post-operative course was uneventful and at 14 months follow-up the patient was in good health. The discussion focuses on the surgical treatment of chronic pancreatitis with cephalic Wirsung duct stenosis, stressing the increasing role of PPPD as a first-choice option.     

Prenatal ultrasound diagnosis of massive subchorionic thrombohematoma

We present a case report of a variation of a Bosworth fracture, which is a posterior dislocation of the proximal fragment of a distal fibula fracture. Our patient had a distal fibula dislocation without fracture. He was treated with an open reduction and internal fixation using syndesmotic screws. At his most recent follow-up, he was ambulating without pain.     

Disagreement with others, their credibility, and experienced stress.

"In a setting where the subject was confronted with disagreement from three other subjects, we varied both the degree to which he was in disagreement with them and his relative ability to make the visual judgments in question. He was confronted with… judgments… and found himself in disagreement with the others… . We determined, after each series, the internal consistency of his selfevaluation, his evaluation of the others, and the evaluation he guessed they had made of him. We also measured the stress the subjects experienced as reflected by changes in his skin conductance. Where there was a clear differential in ability, the subject evidenced both a relative diminution of stress and greater relative consistency of self-other evaluation." From Psyc Abstracts 36:04:4GE59G. (PsycINFO Database Record (c) 2010 APA, all rights reserved)