Joshua E. Lane

Successful Treatment of an Infant with Chromobacterium violaceum Sepsis

Chromobacterium violaceum sepsis, a rarely reported phenomenon, has a high mortality rate. We report a unique case of C. violaceum sepsis in an infant. A 4-month-old girl presented to our institution with fever, pustular skin lesions, and distended abdomen, as well as diminished activity and mental status. Radiological investigation revealed brain, lung, and hepatic abscesses. The infant was successfully treated with trimethoprim-sulfamethoxazole and ciprofloxacin.

CHRONIC ACETAMINOPHEN TOXICITY: A CASE REPORT AND REVIEW OF THE LITERATURE

Acetaminophen is one of the most frequently used medications in the United States. While usual dosing of acetaminophen is considered harmless, both acute and chronic overdoses can be fatal. The majority of reported cases of chronic acetaminophen toxicity in adults occur in chronic alcohol abusers, patients taking P450-inducing medications, or following massive dosing. We describe a case of toxic hepatitis free of the aforementioned risk factors associated with chronic ingestion of moderately excessive doses of acetaminophen. Our patient ingested approximately 5.0 to 6.5 g of acetaminophen daily for 6 to 8 weeks via multiple medications. The inclusion of acetaminophen in numerous medications combined with the frequency of use of acetaminophen necessitates an increased concern for not only acute but also chronic acetaminophen toxicity.

An unusual case of malignant hyperthermia during desflurane anesthesia in an African-American patient.

Implications Malignant hyperthermia is an uncommon, heritable condition triggered by anesthesia and is followed by an increase in temperature that may be fatal without prompt treatment. It is rare with desflurane and in black individuals of African descent. We present a case of malignant hyperthermia in an African-American patient during desflurane anesthesia.

Small-cell undifferentiated carcinoma of neuroendocrine type originating in the gallbladder

PURPOSE We report a case of small-cell undifferentiated carcinoma with neuroendocrine (SCUCN) of the gallbladder in a 67-year-old man who presented with suspected cholelithiasis. Treatment included a cholecystectomy and a 4-cycle course of etoposide and carboplatin. CONCLUSIONS Small-cell undifferentiated carcinoma with neuroendocrine features of the gallbladder is a rare disease with approximately 30 cases reported in the literature. Clinical characteristics include an association with cholelithiasis, an elderly age distribution, a female preponderance, and a correlation with cigarette smoking. It is known to behave aggressively and carry a grave prognosis, with extensive local invasion and early metastasis being characteristic. Medical and surgical therapies exist and have demonstrated best results when used in combination.

GI bleeding from duodenal diverticula

iting (one), nausea and headache (one), and chills and diarrhea (one). Stool frequency among responders decreased from 8.3 to 1.3 per day. Two responders received 6-mercaptopurine (50 mg/day) and one received azathioprine (75 mg/day). For responders, average time to discontinuing steroids was 3.5 months. Responders have been asymptomatic on azathioprine/6-mercaptopurine alone for 3–51 months (average 29.3). One patient has twice attempted to discontinue 6-mercaptopurine and on both occasions has had recurrence of diarrhea. Although the number of patients in the study is small, azathioprine/6-mercaptopurine seems to be effective for LC/CC patients who are steroid dependent. In fact, all of our patients who were able to tolerate azathioprine/6-mercaptopurine benefited. The exact mechanism by which these drugs improve symptoms in LC/CC is unclear, but as with Crohn’s disease and ulcerative colitis, it may involve blocking lymphocyte proliferation and activation. The rate of intolerance among our cohort was higher than would have been expected from a series reporting their use for Crohn’s disease or ulcerative colitis. Although azathioprine/6-mercaptopurine sometimes cause serious side effects such as nausea or bone marrow suppression, they are clearly preferable to steroids when a long term maintenance agent is required. Despite the LC/CC’s differences from Crohn’s disease and ulcerative colitis endoscopically and pathologically, this series of patients responding to immunosuppressive therapy with azathioprine/6-mercaptopurine demonstrates yet another similarity in the response to medical therapy among these diseases.

Successful surgical treatment of spontaneous coronary artery dissection

To present a case of spontaneous coronary artery dissection (SCAD). Spontaneous coronary artery dissection is rare and often difficult to surgically repair. Additionally, diagnosis by coronary angiography is uncommon. We present a case of SCAD in a postpartum woman who underwent successful surgical correction of the left anterior descending artery. Such surgical intervention in cases similar to ours is critical for survival.

Repair of Large Surgical Defects with a Donor Skin-Sparing Full-Thickness Skin Graft

Multiple reconstructive options exist, including second-intent wound healing, primary closure, flaps, and grafts. In appropriate locations (temple, medial canthus), second-intent healing can result in excellent wound healing. This may also be a reconstructive decision because of patient age and surgical tolerance. Allografts are a useful adjunctive technique, especially in this type of situation. They allow a protective layer and expedite wound healing. Splitthickness skin grafts (meshed and unmeshed) are particularly useful when the surgical defect approaches donor site size limits or the defect area approaches the limits of viability for a full-thickness graft. Split-thickness skin grafts offer the benefits of reliability and coverage at the expense of a painful donor site and poor cosmesis. Full-thickness skin grafts offer better cosmesis than split-thickness skin grafts but are often limited based on the size of the required donor site. We describe a reconstructive technique of full-thickness skin grafting that offers the benefit of a smaller donor site. The surgical defects documented herein were repaired using full-thickness skin grafts harvested using this technique. Most surgeons harvest a donor site as a fusiform excision with the width of the graft (and respective fusiform excision) approximating the diameter of the surgical defect. Alternatively, the donor site is harvested in a manner that approximates the outline of the surgical defect, because many defects are not symmetrical. We suggest an alternative technique that allows the surgeon to use a donor excision width as small as the radius of the surgical defect,

Metastatic Hepatocellular Carcinoma of the Gallbladder

Accessible online at: www.karger.com/journals/dsu A 78-year-old man with a history of cholelithiasis and cirrhosis presented with jaundice and severe right upper quadrant pain. Hepatic ultrasonography demonstrated findings consistent with cirrhosis, including three nodular lesions in the right lobe presumed to be regenerating nodules. Cholecystectomy yielded an inflamed, congested gallbladder; microscopic examination revealed mucosal ulceration and inflammation. Venous spaces contained aggregates of neoplastic cells that occluded the vascular lumina (fig. 1), but did not invade gallbladder wall or mucosa. These cells possessed moderate amounts of eosinophilic cytoplasm and vesicular nuclei with prominent

Cutaneous cholesterol embolization

melanoma excision at 65, and the breast biopsy at 71. Upon further questioning, she reported that her appendicitis was complicated by perforation. She noted that the telangiectasesonherappendectomyscar andonher extremities developed gradually together over several years during her forties and have since remained stable. Generalized essential telangiectasia (GET) is a rare, primary cutaneous condition characterized by widespread telangiectases that often start at the lower extremities and spread to the rest of the body over years to decades. The mechanism causing blood vessel dilatation in GET remains to be elucidated. Histologic examinations typically reveal dilated thin-walled postcapillary venules in the upper epidermis without any other epidermal or dermal abnormalities. Ultrastructural analyses of the vessels have suggested that the telangiectases arise from alterations of the existing microvasculature, because there is no evidence of neovascularization or vascular malformations in the lesions. Interestingly, although our patient had five surgical scars, only the appendectomy scar was prominently affected with telangiectases. This scar was the only one formed before the onset of the patient’s GET. We hypothesize two possible explanations for this unusual finding. One explanation is that scars are only preferentially targeted as the disease progresses, and the patient’s later scars are spared because they arose in a time when her GET had already stabilized. An alternative explanation hinges on the link between inflammation and wound healing. Our patient’s emergent appendectomy, performed in the setting of a perforated appendix, had a higher risk of microbial contaminationand inflammation than theother elective surgeries. Excessive inflammation often impairs and prolongs wound healing. The delayed healing response may have produced structurally weaker blood vessels in the appendectomy scar that predisposed this microvasculature to dilatation with the onset of GET. Telangiectases in GET are not typically associated with any preexisting skin lesion, and their appearance in surgical scars has not been commented upon in previous reports. In our case, the involvement is sporadic and targets a singular old scar. Nevertheless, clinicians should be aware of the possibility of telangiectases developing prominently in the scars of patients with GET, and therefore, inform patients appropriately before performing surgery.

A report of Epstein-Barr virus–positive primary cutaneous natural killer–/T-cell lymphoma

We describe a patient who presented with Epstein-Barr virus-positive tumor-stage primary cutaneous lymphoma. Our patient had previously been treated with oral methotrexate for long-standing rheumatoid arthritis. Tissue analysis revealed large tumor cells that were surface CD2- and CD3-positive; T-cell-restricted intracellular antigen-positive; CD56-, CD20-, and CD30-negative; and stained positively for Epstein-Barr virus. Our case is noteworthy for several reasons. Although the presence of rheumatoid arthritis and therapy with methotrexate are putative risk factors for the development of immune suppression-related and Epstein-Barr virus-related lymphomas, the vast majority of lymphomas in this setting are of B-cell origin, and rarely are these primary cutaneous in nature. In addition, our patients tumor displayed an unusual phenotype, with immunophenotypic features suggestive of an atypical natural killer-/T-cell lymphoma. Methotrexate was withdrawn, and our patient was successfully treated with local radiotherapy. She has remained in complete remission 28 months since diagnosis.