Fadi Hammoudeh

An Obscure Case of Hepatic Subcapsular Hematoma

Spontaneous liver bleeding is often reported in preeclampsia. It is otherwise rare and has been linked to gross anatomical lesions and coagulopathy. We report a case of subcapsular hematoma of the liver without any apparent lesion and in the absence of coagulopathy. A 41-year-old male, paraplegic for 16 years, presented to the emergency department 3 days after sudden onset of right upper quadrant and shoulder pain. He had been on vitamins and 5,000 units subcutaneous heparin 12-hourly at the nursing home for the last month. He was in no distress, afebrile, with stable vitals. Physical examination showed a diverting colostomy, tender hepatomegaly and sacral decubiti. A fecal occult blood test was negative. There was spastic paraplegia below the level of T12. Two days after admission, the patient was afebrile and hemodynamically stable. PTT, PT, liver profile, BUN and creatinine were all normal, however his hemoglobin had dropped from 11.3 to 7.6 g/dl. An abdominal CT scan revealed an isolated 9.0 × 1.8 cm subcapsular hematoma. The patient received blood transfusion in the intensive care unit and was discharged 7 days later. In conclusion, spontaneous liver hemorrhage occurs in the nonobstetrical population in the setting of gross anatomical lesions or coagulopathy. This is the first report of an isolated subcapsular liver hematoma.

Disseminated Mycobacterium avium intracellulare infection in an "immunocompetent" host.

We are reporting the case of a 37-year-old immunocompetent patient who presented with anterior chest wall swelling, jaw swelling and pain, back pain, night sweats, and unintentional weight loss. He underwent mediastinoscopy with lymph node biopsy, which revealed caseating and noncaseating granuloma and special stains positive for acid-fast bacteria. Cultures from two different sites surprisingly grew Mycobacterium avium intercellulare (MAI), and a diagnosis of disseminated MAI was made. He was switched from antituberculous treatment to MAI treatment.

Devic Syndrome: A Diagnostic Dilemma

Neuromyelitis optica (NMO, also known as Devic syndrome or Devic disease) is a rare clinical entity. Early recognition and prompt treatment can save patients from long-term disability, especially in themonophasic variant of disease. A 24-year-old African American female presented with high-grade fever for 1 day associated with frontal headache, photophobia, and 2 episodes of nonbloody vomiting. She had a history of nonitchy vesicular rash with sudden diminution of vision in the left eye 2 weeks ago. Over the next 24 hours, she developed progressively worsening weakness and numbness in her left arm and left leg, which later involved all limbs. Left eye vision was reduced to light perception with light and accommodation reflexes intact. Lumbar puncture showed lymphocytic pleocytosis with elevated protein. On day 2, neurological examination exhibited quadriparises with hypereflexia and clonus. Magnetic resonance imaging showed diffuse hyperintense signals in the spinal cord in cervical and lumbar regions. An assessment of neuromyelitis optica was made. Anti-NMO antibodies were negative. On day 3, she was intubated because of progressive dyspnea. Plasmapheresis resulted in rapid improvement in respiratory and neurological status. She was extubated on the second day and transferred to floor on day 4. Later, the patient was discharged.

Pain in right thigh: a benign presentation of a life-threatening disease.

To the Editor A 25-year-old African–American gentleman with no known medical history presented with vomiting and pain in his right thigh for 1 day. According to the patient, he had attended a party the previous night when he participated in a group dance for about 15 min. About 2 h later, he was engaged in sexual activity, but had to stop because of the sudden onset of severe pain and tightness in his right thigh. The pain was 8/10 in intensity and aching in nature. He tried Tylenol to relieve pain, but to no effect. Next morning he had three episodes of nonbloody projectile vomiting. He also noticed that his urine was red in color. He did not complain of shortness of breath, chest pain, cough, headache or trauma, and reported no smoking or drug abuse. He works in Home Depot as clerk and only drinks alcohol socially. Family history: his father had myocardial infarction at 62 and his mother had diabetes mellitus. On physical examination, the patient was alert, awake and oriented, lying in bed in moderate distress because of the pain in his right thigh. Vitals showed blood pressure of 131/85 mmHg, pulse of 65/min and temperature of 99.28F (37.38C). His chest was clear to auscultation with bilateral vesicular breathing. Both heart sounds were regular with no added sound. The right thigh was tender on the medial side. No discoloration or bruising was noticed. Pulses were equal in both limbs. Laboratory data showed severe rhabdomyolysis [creatine phosphokinase (CPK) 332674] and hemoconcentration. ECG showed normal sinus rhythm. Chest radiograph was normal, with no infiltrates, effusions or mediastinal widening.