Adelman Hm

Cholesterol embolism: A pseudovasculitic syndrome

T HE ORIGINAL description of atheromatous embolism was credited by Panum in 1862, although it has been justly noted that he only described the necropsy of the famous Danish sculptor Thorwaldsen performed two decades earlier by Dahlerup and Fenger.’ Cholesterol embolism remained a pathologic curiosity until the 1960s when its clinical similarity to a multisystern disorder was recognized. One factor that increased the awareness of the entity was Flory’s* demonstration of cholesterol crystals in small arteries of experimental animals after injection of human atheromatous material into their circulation. Despite the various descriptions in the literature, both the failure to recognize this clinical phenomena and the subsequent institution of improper therapy continue to occur and contribute to patient morbidity. Cholesterol microembolism may produce a variety of signs and symptoms resembling a multisystem disorder such as a systemic vasculitis. Laboratory abnormalities contributing to the diagnostic confusion include leukocytosis, eosinophilia, hypocomplementemia, and erythrocyte sedimentation rate (ESR) elevation. Our current series demonstrated the additional finding of antinuclear antibody (ANA) and rheumatoid factor positivity, whose presence should not automatically implicate a systemic vasculitis or connective tissue disease.

Recurrent Pneumothorax in a Patient With Rheumatoid Arthritis

ABSTRACT Rheumatoid arthritis is a multisystem disease. Pulmonary manifestations and complications include pleural disease, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis. Pulmonary rheumatoid nodules, including rheumatoid pneumoconiosis (Caplan’s Syndrome), can result in spontaneous pneumothorax. In this article, the authors present a patient with rheumatoid arthritis and recurrent spontaneous pneumothorax. Through investigation, a bronchopleural fistula caused by a rheumatoid nodule was revealed. The authors also discuss the potential pitfalls caused by a lung nodule in a patient with rheumatoid arthritis, including the overlap with bronchogenic carcinoma and confusion with tuberculosis.

Arthralgias following dilation and curettage

A 36-year-old woman presented to the emergency department with right hip pain of one weeks duration. An x-ray of the hip was unremarkable. She was diagnosed with trochanteric bursitis, given ibuprofen (800 mg tid) and crutches, and sent home. The next day, continual pain and progressive functional impairment prompted her to see an orthopedist. He concurred with the initial diagnosis and administered a corticosteroid injection into the right trochanteric bursa. Propoxyphene (65 mg q4h prn) was added to her medical regimen, and she was again sent home. Pain developed in the right sacroiliac area the next day. Within 24 hours, the right shoulder and right sternoclavicular joint were also involved, and the patient began having subjective fever and chilliness. She returned to the orthopedist and was immediately referred to a rheumatologist who ordered blood cultures and admitted her to the hospital.

D-penicillamine-induced myasthenia gravis: Diagnosis obscured by coexisting chronic obstructive pulmonary disease

D-penicillamine, a drug used to treat rheumatoid arthritis, Wilsons disease, and cystinuria, can cause myasthenia gravis. Fortunately, the myasthenia typically resolves after discontinuation of the drug. The diagnosis may be missed if weakness is blamed on a patients underlying disease(s), in particular, rheumatoid arthritis. Reported here are the cases of two patients with chronic obstructive lung disease who were taking D-penicillamine for rheumatoid arthritis, then experienced increasing respiratory failure. At first, their problem seemed to stem from chronic lung disease, but further evaluation revealed the cause of the hypoventilation to be D-penicillamine-induced myasthenia gravis.

Abdominal pain and diarrhea after minor trauma.

General Hospital. This case was presented by I Dr. Reichmuth, Allergy and Immunology Fellow, and , moderated by Dr. Lezama, Chief Medical Resident, I Veterans Hospital. A 16-year-old girl presented to the emergency department with diffuse crampy abdominal pain, nausea, vomiting, and watery diarrhea. Her symptoms had begun two hours earlier after she hit her abdomen on the corner of a kitchen table.

A man with inflamed ears.

A 23-year-old man presented with fever, dyspnea, nonproductive cough, left eye redness, reduced vision, and bilateral ear pain and tenderness. The symptoms had begun two days earlier, eight days after he was discharged from the hospital with a presumptive diagnosis of Stills disease. He was first seen a month before the current admission for complaints of fever (as high as 39.4 degrees C), nonproductive cough, and asymmetric arthritis. The workup at that time included arthrocentesis of the right knee. Analysis of the joint fluid showed 7,500 white blood cells/mm3 and no crystals. A gram stain and culture of the fluid were negative. HIV and hepatitis tests, bone marrow biopsy and culture, transesophageal echocardiography, abdominal computed tomography, radionuclide bone scanning, and rheumatologic tests failed to identify the problem. The development of an evanescent macular pink rash on day 15 suggested the possibility of Stills disease. Treatment with prednisone (40 mg po qd) was initiated, and the patient was discharged on day 19.A 23-year-old man presented with fever, dyspnea, nonproductive cough, left eye redness, reduced vision, and bilateral ear pain and tenderness. The symptoms had begun two days earlier, eight days after he was discharged from the hospital with a presumptive diagnosis of Stills disease. He was first seen a month before the current admission for complaints of fever (as high as 39.4°C), nonproductive cough, and asymmetric arthritis. The workup at that time included arthro- centesis of the right knee. Analysis of the joint fluid showed 7,500 white blood cells/mm3 and no crystals. A gram stain and culture of the fluid were negative. HIV and hepatitis tests, bone marrow biopsy and culture, transesophageal echocardiography, abdominal computed tomography, radionuclide bone scanning, and rheumatologic tests failed to identify the problem. The development of an evanescent macular pink rash on day 15 suggested the possibility of Stills disease. Treatment with prednisone (40 mg po qd) was initiated, and the patient w...

Syncope two years after hysterectomy.

A 61-year-old woman presented to the emergency department after experiencing palpitations, shortness of breath, and syncope while taking a shower. Her husband revived her with mouth-to-mouth resuscitation. She had had a similar episode three days earlier while making her bed and had lost consciousness for about 10 sec. She did not appear to have had a seizure. Five months earlier, while taking a walk, she had experienced dizziness, dyspnea, and chest pressure lasting about an hour. A workup at that time included cardiac catheterization, lung scanning, and esophagogastroduodenoscopy, but no abnormality was found. Lower extremity edema was noted.

A CONFUSED MAN WITH RAPID RESPIRATION

A 71-year-old man presented with incoherent, slurred speech, auditory hallucinations, and tachypnea. According to the neighbor who called for emergency medical service, the man had appeared to be in good health the day before. On admission, his blood pressure was normal.

An inflamed elbow after an insect sting.

A 63-year-old man presented with fever and a painfully swollen right elbow and forearm. He had been stung by a yellow jacket two weeks earlier and had since found it increasingly difficult to bend his arm.

A veteran with acute mental changes years after combat.

A 49-year-old man presented with a five-week history of worsening confusion, agitation, and bizarre behavior. According to his mother and sister, who live with him, he had inexplicably jumped out of bed one day and complained of injuring his back. The pain apparently resolved within several days. Two weeks later, again just after awakening, he had experienced a period of confusion, lasting about 15 min. The latest episode occurred three days previously and included vivid hallucinations--at various times, he seemed to believe that he was talking to his brother on the telephone, drinking a glass of water, emptying the refrigerator, jumping into a foxhole, and stomping on rattlesnakes. He was disoriented to time as well as environment.