Hussam Ammar

Family history in necrotising fasciitis

In the Case Report on necrotising fasciitis of the breast by Rachel Tillett and colleagues (July 8, p 174), there were features on admission that we believe would point to the possibility of necrotising fasciitis. These were tachycardia, hypotension, erythematous swollen breast without evidence of abscess formation, pain dispropor tionate to local fi ndings, and worsening pain despite antibiotic coverage. Additionally, Tillett and colleagues mention that a history of gastroenteritis and family history of strepto coccal illness was overlooked initially, and that this was one of the clues to the diagnosis of necrotising fasciitis. However, a lack of such history should not have prevented clinical diagnosis. Predisposing factors include history of blunt trauma, varicella (chickenpox), injection drug use, penetrating injury such as laceration, surgical procedures, child birth, burns, and perhaps nonsteroidal anti-infl ammatory drugs. Although the presence of a family history of streptococcal-type illness in this case was interesting, too much reliance on this aspect of clinical history could be dangerous. Lastly, there is no strong published evidence to support penicillin prophylaxis to all family contacts: the patient’s baby would be the only one at a very high risk. In conclusion, a high index of suspicion and low threshold for surgical consultation leads to early diagnosis and appropriate treatment of this treatable but potentially fatal condition.

Metastatic retroperitoneal epithelioid angiomyolipoma

Angiomyolipoma (AML) is a rare benign neoplasm that usually arises in the kidneys, but may rarely originate in sites such as the retroperitoneum, liver and bone. It is characterised by an intimate admixture of blood vessels, smooth muscle and fat. This multiphasic composition allows for its recognition on ultrasound and CT scan examination. Metastases are exceedingly uncommon, and only one other case of metastatic extrarenal AML exists in the literature. Histological variants of AML such as epithelioid angiomyolipoma (EAML) are considered to be locally aggressive. A unique case of an EAML of the retroperitoneum that metastasised to the liver and bone in an 80-year-old woman is described.

Yield of diagnostic tests and its impact on cost in adult patients with syncope presenting to a community hospital.

Objectives Total annual costs for syncope-related hospitalizations were

Potential effect of Sildenafil beyond pulmonary hypertension in a patient with diffuse systemic sclerosis and cryoglobulinemic vasculitis

2.4 billion in 2000. The aim of this study was to examine the type and number of tests ordered for patients admitted with syncope and whether these tests helped establish the cause. Methods We studied the records of 1038 patients coded as “syncope” in billing records, and 167 fulfilled the eligibility criteria. The main outcome measures were the diagnostic yield of the ordered tests, the incremental cost/incremental benefit, and the number of admissions that can be averted if risk stratification were used in the evaluation. Results The etiology of the syncope was identified in 48.3% of the patients. Postural blood pressure measurement has the highest diagnostic yield at 58.7%, whereas history taking diagnosed 19.7% of cases. The diagnostic yields of telemetry, electrocardiogram, radionuclide stress test, echocardiography, and troponin measurement were 4.76%, 4.24%, 3.44%, 0.94%, and 0.62%, respectively. Chest x-ray, carotid ultrasonography, 24-hour Holter monitoring, brain computed tomography, and brain magnetic resonance imaging did not yield the diagnosis in any of the patients. Only 1.9% of the money spent in the evaluation of syncope was effective in leading to a definitive diagnosis. The orthostatic blood pressure measurement was ranked first in the incremental cost/incremental benefit ratio and the radionuclide stress test was ranked last (17.03 vs 42,369.0, respectively). Approximately 6% of the patients did not meet the admission criteria. Conclusions Physicians ordered unnecessary tests that have a low yield and are not cost-effective. A standardized algorithmic approach should be the cornerstone in the evaluation of syncope.

Impetigo herpetiformis during the puerperium triggered by secondary hypoparathyroidism: a case report

IntroductionPulmonary arterial hypertension (PAH) is a serious complication of systemic sclerosis (SSc), has a dramatic impact on prognosis and survival and is a leading cause of death.Case descriptionA 40 years old female patient with difuse cutaneous SSc (dcSSc) presented with progressive dyspnea, choking sensation, cough, abdominal distension, constipation and dysphagia to solids. The muscle power was mildly reduced and multiple purpuric eruptions were present on the legs of variable sizes. The patient was ANCA negative and had positive cryoglobulinemia. The hepatitis C virus test was positive and the skin biopsy histopathology proved small vessel (leucocytoclastic) vasculitis. The modified Rodnan total skin score (MRSS) was 37. There was deterioration of the pulmonary function tests and transesophageal echocardiography revealed PAH (RVSP 60 mmHg). Sildenafil 50 mg/day resulted in a remarkable improvement of the dyspnea and Raynauds’ with a significant improvement of the skin tightness as the MRSS became 22. The small vessel vasculitic rash remarkably improved and the RVSP became 34 mmHg with a dramatic improvement of the PAH.Discussion and evaluationSildenafil enhances vasodilatation, has antiproliferative effects and is effective in the treatment of PAH. The remarkable improvement in the vasculitic skin lesions in this case after sildenafil is the second report after the described dramatic improvement of small vessel vasculitis in a case with Takayasu arteritis. The emerging trends make it necessary to exploit the full therapeutic potential of Sildenafil in scleroderma and PAH with other extrapulmonary manifestations.ConclusionWe report a very rare association of dcSSc with small vessel cryoglobulinemic vasculitis with a remarkable improvement after sildenafil.

A case of paraneoplastic cerebellar ataxia secondary to renal cell carcinoma

A 38-year-old multiparous woman with post thyroidectomy hypoparathyroidism developed pruritic erythematous patches with multiple pustules on its margins on her thighs and groin accompanied by fever few days after delivery by caesarean section. Impetigo herpetiformis was diagnosed based on the typical clinicopathological findings. The patient was treated with intravenous fluids, calcium, Calcitrol and corticosteroids. The correction of hypocalcaemia was accompanied with rapid improvement of her skin disease and general condition. Our case is the fourth case of impetigo herpetiformis initially presented during puerperium and the first case of puerperal impetigo herpetiformis that is precipitated by secondary hypoparathyroidism. The awareness of the possible occurrence of impetigo herpetiformis during the puerperium allows early diagnosis, treatment and prevention of maternal complications.

Nocardia brasiliensis vertebral osteomyelitis and epidural abscess

A 64-year-old female patient presented with acute cerebellar ataxia. After ruling out vascular, infectious, metastatic, demyelinating, and medication etiologies, a paraneoplastic origin for her illness was determined. A renal mass was discovered and found to be renal cell carcinoma. Her symptoms resolved after a radical nephrectomy. Physicians should consider the diagnosis of paraneoplastic neurologic syndromes whenever a thorough evaluation fails to explain neurologic abnormalities.

Guillain-Barré syndrome after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: a case report

Nocardia species exist in the environment as a saprophyte; it is found worldwide in soil and decaying plant matter. They often infect patients with underlying immune compromise, pulmonary disease or history of trauma or surgery. The diagnosis of nocardiosis can be easily missed as it mimics many other granulomatous and neoplastic disease. We report a 69-year-old man who presented with chronic back pain and paraparesis. He was found to have Nocardial brasiliensis vertebral osteomyelitis and epidural abscess. Laminectomy and epidural wash out was performed but with no neurological recovery. This is the second reported case of N brasiliensis vertebral osteomyelitis in the literature.

Concomitant presentation of acute myeloid leukemia with T-cell large granular lymphocytic leukemia

IntroductionThe association of Guillain-Barré syndrome with vaccination has been described in the literature; it is infrequent and controversial. An association with swine influenza, influenza, hepatitis and tetanus vaccination has been documented in few case reports.Case presentationA 40-year-old Caucasian man sustained a small right temporal epidural hematoma and nondisplaced right skull fractures after a fall from a roof. He was managed conservatively; a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine was administered and a week later he was discharged home. A few days after his discharge, he experienced weakness and numbness in his legs, which progressed to involve his arms. Three weeks after his initial fall, he was readmitted with quadriparesis. A lumbar puncture revealed a cerebrospinal fluid protein of 790 mg/dL and one white blood cell. We diagnosed Guillain-Barré syndrome. Our patient was treated with intravenous immunoglobulin. Three months later his muscle strength had improved, but he continued to have tingling in his hands and feet and used a walker intermittently.ConclusionTo the best of our knowledge, this is the first case of Guillain-Barré syndrome to be reported in the English literature after administration of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine.

Dizziness in a community hospital: central neurological causes, clinical predictors, and diagnostic yield and cost of neuroimaging studies

T-cell large granular lymphocyte leukemia (T-LGL) also known as T-cell chronic lymphocytic leukemia is rare and comprises a small minority of all small lymphocytic leukemias. The concomitant presentation of T-LGL with acute myeloid leukemia (AML) has not been previously reported. We present an elderly gentleman with concomitant T-LGL and AML (non-M3) diagnosed by a combination of morphologic evaluation, immunophenotyping by flow cytometry, and T-cell gene rearrangement studies. The patient was managed with combination AML chemotherapy. He remains alive and well seven months after initial diagnosis. A brief review of literature is also presented.