Gloria González-Saldivar

Cutaneous coccidioidomycosis: a great mimicker.

An 18-year-old immunocompetent woman with a history of coccidioidal meningitis (positive cerebrospinal fluid complement fixation test, titre 1:128) who was treated 2 years earlier with placement of a ventriculoperitoneal valve because of hydrocephaly along with fluconazole (300 mg two times per day) for 5 months, was referred to dermatology because of a 3-year history of a dermatosis. Physical examination revealed two erythematous plaques with central atrophy and telangiectasias on the right cheek and dorsal aspect of the nose (figure 1). Skin biopsy demonstrated …

Ovarian and Adrenal Androgens and Their Link to High Human Chorionic Gonadotropin Levels: A Prospective Controlled Study

Background. Although the association between human chorionic gonadotropin (hCG) and hyperandrogenism was identified more than 40 years ago, relevant questions remain unanswered. Design and Methods. We conducted a prospective, longitudinal, and controlled study in 23 women with a diagnosis of a complete hydatidiform mole (HM). Results. All participants completed the study. Before HM evacuation mean hCG was markedly higher in the cases than in the control group (P ≤ 0.001). Free testosterone (T) and dehydroepiandrosterone sulfate (DHEA-S) were found to be higher in the cases (2.78 ± 1.24 pg/mL and 231.50 ± 127.20 μ/dL) when compared to the control group (1.50 ± 0.75 pg/mL and 133.59 ± 60.69 μ/dL) (P = 0.0001 and 0.001), respectively. There was a strong correlation between hCG and free T/total T/DHEA-S concentrations (r = 0.78; P ≤ 0.001, r = 0.74;  P ≤ 0.001, and r = 0.71;  P ≤ 0.001), respectively. In the cases group 48 hours after HM evacuation, hCG levels were found to be significantly lower when compared to initial levels (P = 0.001) and free T and DHEA-S declined significantly (P = 0.0002 and 0.009). Conclusion. Before uterus evacuation, hCG, free T, and DHEA-S levels were significantly higher when compared with controls finding a strong correlation between hCG and free T/DHEA-S levels. Forty-eight hours after HM treatment hCG levels declined and the difference was lost. A novel finding of our study is that in cases, besides free T, DHEA-S was also found to be significantly higher and both the ovaries and adrenal glands appear to be the sites of this androgen overproduction.

Diagnosis of diabetes.

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Massive Barium Aspiration

A 77-year-old man presented to the hospital with a 2-month history of dysphagia and cough. Dysphagia gradually progressed to liquids and was referred to be primarily pharyngeal. Weakness, weight loss (10 kg) and progressive dyspnea were also referred. Cough started 5 days earlier and was exacerbated by meals. On physical examination, he was cachectic, had severe halitosis with a room air oxygen saturation of 96% and diminished respiratory movements along with rales and crackles in right upper lobe. Thoracic computed tomography revealed bilateral “tree-inbud” pattern and multiple cavitations in upper right and left lobes. Ziehl-Neelsen stain was positive for acid-fast bacillus. Dysphagia persisted and an esophagography (barium swallow) was performed, starting minutes after, with cough, white foamy sputum, and acute respiratory failure. The esophagography films revealed a tracheoesophageal fistula (Figure 1) with radiopaque material inside the respiratory tract (Figure 2). He underwent orotracheal intubation and urgent bronchoscopy, but despite prompt treatment efforts, the patient rapidly progressed to an acute respiratory distress syndrome and shortly developed cardiac arrest, with no response to advanced resuscitation maneuvers. Aspiration of barium into the lungs is a recognized complication, occurring accidentally during upper gastrointestinal studies. Predisposing factors for aspiration are anatomical irregularities of pharynx and esophagus, diseases compromising the swallow mechanism, extremes of age, and alcoholism. Barium sulfate was thought to be relatively harmless in the airways, but this was based on the use of low-density suspensions, suggesting that the degree of pulmonary reaction may be proportional to the heterogeneity of the barium particles. However, complications have been reported with highor low-density formulations. A rapid diagnosis in the acute phase is made with a simple chest radiograph that characteristically shows striking airway opacities without a specific pattern. Treatment options are based on clinical experience and are mainly based on supportive measures. When a considerable amount of barium is aspirated, immediate bronchoscopy is recommended with the purpose of eliminating as much barium as possible. Bronchoalveolar lavage is contraindicated because it can expand barium distribution into the airway. The overall mortality rate associated is approximately 30% and exceeds 50% in patients with initial shock or apnea, secondary pneumonia or adult respiratory distress syndrome.

Acanthosis nigricans in the knuckles: an early, accessible, straightforward, and sensitive clinical tool to predict insulin resistance

ABSTRACT Any clinical/biochemical marker revealing obesity or diabetes before their appearance is valuable. Insulin resistance (IR) is present in both disorders many years before occurrence. Accordingly, we determined whether acanthosis nigricans (AN) in the knuckles is associated to higher insulin and homeostasis model assessment for estimated insulin resistance (HOMA-IR) index values, and assessed the influence of body-mass index (BMI) and the diagnostic performance of AN in the knuckles to detect IR. In this cross-sectional controlled study, we included men or women, 18 to 23 years old, with or without AN in the knuckles. In 149 cases with AN in the knuckles and 145 controls, fasting insulin was higher in cases (13.45 µU/mL ± 7.8 vs. 8.59 µU/mL ± 3.63, P < .001, respectively). Mean HOMA-IR index was also higher (2.86 ± 1.68 vs. 1.78 ± 0.77, P < .001). A significant increase in fasting insulin and HOMA-IR values between and within BMI groups from normal through obese category was identified in controls and cases. By multivariate regression analysis, cases with normal BMI were significantly associated to a HOMA-IR ≥2.5 (OR = 3.09, CI95% = 1.75–5.48, P = .001). A model of AN in the knuckles, normal BMI, and increased waist circumference allowed identifying 2 out of 3 cases with HOMA-IR index ≥2.5. AN in the knuckles could be addressed with two aims: as an easy, accessible, and costless diagnostic tool suggesting hyperinsulinemia secondary to IR, and, an early marker of IR even in the absence of overweight or obesity.

Buschke-Lowenstein Tumor

n 18-year-old man with a history of Human Immunodefi-ciency Virus infection presented to our clinic with a perianalmass.HewasrecentlydiagnosedwithHumanImmunodeficiencyVirus and had never been on antiretroviral therapy. Physicalexamination revealed a foul-smelling 25 3 15 cm verrucouscauliflower-likeulcerated mass originating from the perianal skin(Figure 1). Wide surgical excision was performed. Histologicexamination revealed squamous epithelial verrucous prolifera-tion with marked papillomatosis and acanthosis. Tumor cellsexhibited vacuolized cytoplasm with irregular and large nucleiconsistent with koilocytes. No atypia or dysplasia was found atthe histologic examination. These findings were consistent withagiant condyloma acuminata also known as Buschke-Lowensteintumor. Adjuvant treatment with topical imiquimod was startedwith no evidence of recurrence at 6-month follow-up.First described in 1896, the Buschke-Lowenstein tumoris a very rare (less than 100 cases) giant condyloma acuminata,which usually appears at the anogenital region.

Ackerman’s Tumor

Rene Rodriguez-Gutierrez, MD,* Mario Rodarte-Shade, MD, Gloria Gonzalez-Saldivar, MD and Jose Gerardo Gonzalez-Gonzalez, MD, PhD *Endocrinology Division, Department of Internal Medicine, “Dr. Jose E. Gonzalez” University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico (E-mail: renerodriguez@investigacion-meduanl.com) The authors have no financial or other conflicts of interest to disclose.

Resistant Hypertension: Coarctation of the Aorta

CASE PRESENTATION A 22-year-old man presented to our clinic with a 4-year history of headache and hypertension. He had previously used 3 antihypertensive agents with different mechanisms of action with poor response to the treatment. He presented to our hospital with a hypertensive crisis that was accompanied by headache, nausea and palpitations. On physical examination, he had a heart rate of 110 beats per minute with a blood pressure of 260/110 on both arms. Carotid, radial and brachial pulses were normal, but femoral, posterior tibial and dorsalis pedis pulses were absent. A chest radiograph revealed a “3” sign (absence of the proximal descending aortic arch shadow) (Figure 1). After that, a contrast-enhanced computed tomography with 3D reconstruction demonstrated a coarctation of the thoracic aorta 2 cm after the origin of the left subclavian artery (Figure 2). The patient underwent a transcatheter intervention with stenting without having any complications. At 6-month follow-up, he had normal blood pressure without the use of antihypertensive medications. Coarctation of the aorta is typically a discrete narrowing of the aorta that accounts from 4% to 6% of the congenital heart defects that occurs up to 5 times more frequently in males than females. As in this case, the most usual location of the coarctation is just distal to the left subclavian artery. Many times, it is asymptomatic in newborns and children, and in adults, the classic clinical presentation is hypertension, which is usually refractory to treatment. A high index of suspicion is necessary as the diagnosis is easily done when a difference in blood pressure is found between the upper and lower extremities. The electrocardiogram might show left ventricular hypertrophy, and in the chest radiograph, an indentation of the aortic wall might be seen (3 sign) as well as a notching of the posterior third to eighth rib. The definitive diagnosis can be made without invasive procedures such as a magnetic resonance imaging or a computed tomography angiography. It is critical that it is diagnosed as soon as possible, as the mean survival in patients with coarctation is 35 years. Surgery is the preferred therapeutic option for infants younger than 5 years and angioplasty with balloon or stent for older ones. The prognosis is good, with a long-term survival of over 80% after 20 years.