Kiyoshi Shikino

Positron emission tomography findings in a patient with multiple myeloma of polymyalgia rheumatica-like symptoms caused by paraneoplastic syndrome

A 50-year-old Japanese man was referred to our department with pain in his limb joints persisting for 3 months. Although his joints showed no redness, swelling or tenderness, he had a limited range of motion of his hip and shoulder joints, suggesting a diagnosis of polymyalgia rheumatica (PMR). However, his relatively young age and subacute course along with the absence of morning stiffness made the diagnosis uncertain. We performed positron emission tomography/CT, which revealed 18F-fluorodeoxyglucose uptake in bilateral upper and lower joints, consistent with PMR. There was also uptake by a sacral tumour, suggesting a diagnosis of paraneoplastic syndrome. Immunoglobulin A-κ type M protein was detected in serum and bone marrow aspiration/biopsy identified diffuse proliferation of atypical plasma cells, confirming a diagnosis of multiple myeloma. The patient received chemotherapy, which alleviated his limb pain, and achieved stringent complete remission after autologous peripheral blood stem cell transplantation.

Problem-based learning using patient-simulated videos showing daily life for a comprehensive clinical approach.

Objectives We examined whether problem-based learning tutorials using patient-simulated videos showing daily life are more practical for clinical learning, compared with traditional paper-based problem-based learning, for the consideration rate of psychosocial issues and the recall rate for experienced learning. Methods Twenty-two groups with 120 fifth-year students were each assigned paper-based problem-based learning and video-based problem-based learning using patient-simulated videos. We compared target achievement rates in questionnaires using the Wilcoxon signed-rank test and discussion contents diversity using the Mann-Whitney U test. A follow-up survey used a chi-square test to measure students’ recall of cases in three categories: video, paper, and non-experienced. Results Video-based problem-based learning displayed significantly higher achievement rates for imagining authentic patients (p=0.001), incorporating a comprehensive approach including psychosocial aspects (p<0.001), and satisfaction with sessions (p=0.001). No significant differences existed in the discussion contents diversity regarding the International Classification of Primary Care Second Edition codes and chapter types or in the rate of psychological codes. In a follow-up survey comparing video and paper groups to non-experienced groups, the rates were higher for video (χ2=24.319, p<0.001) and paper (χ2=11.134, p=0.001). Although the video rate tended to be higher than the paper rate, no significant difference was found between the two. Conclusions Patient-simulated videos showing daily life facilitate imagining true patients and support a comprehensive approach that fosters better memory. The clinical patient-simulated video method is more practical and clinical problem-based tutorials can be implemented if we create patient-simulated videos for each symptom as teaching materials.

Finger stiffness or edema as presenting symptoms of eosinophilic fasciitis

Abstract To investigate the clinical features and finger symptoms of eosinophilic fasciitis (EF), we reviewed five patients with EF. The chief complaint was pain, edema and/or stiffness of the extremities. The distal extremities were affected in all patients, and there was also proximal involvement in one patient. One patient had asymmetrical symptoms. All four patients with upper limb involvement had limited range of motion of the wrist joints, and three of them complained of finger symptoms. Two of these three patients showed slight non-pitting edema of the hands, and the other one had subcutaneous induration of the forearm. All four patients with lower limb symptoms had limited range of motion of the ankle joints, and two showed edema or induration of the legs. Inflammatory changes in the joints were not detected in any of the patients. Two patients displayed neither objective induration nor edema, and two patients had muscle tenderness. In conclusion, finger symptoms of patients with EF might be caused by fasciitis of the forearms, which leads to dysfunction of the long finger flexors and extensors as well as slight edema of hands. Limited range of motion of wrist and/or ankle joints indicates sensitively distal muscle dysfunction caused by fasciitis.

Scrub Typhus (Tsutsugamushi Disease) Presenting as Fever with an Eschar

A 76-year-old Japanese male farmer presented with a 2-day history of high fever, rash, intense headache, and diffuse myalgias. Physical examination revealed a non-pruritic maculopapular rash on his trunk and extremities (Fig. 1). An eschar was located on his right chest, which indicated the site of an infected chigger bite (Fig. 2). Serological tests revealed 1:160 titers of anti-Orientia tsutsugamushi IgM and a fourfold increase in titers between paired samples. Scrub typhus was diagnosed. After

Influence of predicting the diagnosis from history on the accuracy of physical examination

Background This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. Methods The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. Results For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). Conclusion Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Giant Cell Arteritis with Carotidynia

A 74-year-old woman presented with 6 weeks of fevers and right neck pain. At the time of symptom onset, she also experienced bilateral temporal headache with scalp allodynia, which resolved within 3 weeks. Physical examination revealed a pulseless, enlarged right temporal artery (Fig. 1) and a tender right carotid artery. The erythrocyte sedimentation rate was 78 mm/h. Contrast-enhanced computed tomography (CT) revealed wall thickening of the thoracic aorta and its carotid and subclavian branches, with a double-ring appearance (Fig. 2). The patient was diagnosed with giant cell arteritis (GCA) and treated with oral prednisolone. Within 10 days, the patient’s symptoms had improved. GCA is a vasculitis of medium and large vessels. It rarely occurs before the age of 50 years. In one study, headache was present in 86% of cases. However, the headache may be progressive, spontaneously subside, or wax and wane in intensity. Carotid artery tenderness has been reported in 7% of GCA cases. Temporal artery biopsy remains the gold standard for the diagnosis of GCA. CT and magnetic resonance angiography can be used to demonstrate large vessel involvement. 6 Ultrasonography and PET-CT are also being evaluated as possible diagnostic tools, but are not yet reliable testing modalities.

An Abscess of Urachal Remnant

A 43-year-old man presented with one week of abdominal pain and umbilical discharge (Fig. 1). On exam, there was a painful mass in the infraumbilical region and a positive Carnett’s sign (increased pain with tensing of the abdominal muscles suggestive of abdominal wall pathology). Urine test results were negative. Abdominal enhanced computed tomographyshoweda rim-enhancingmassanda linear lesionbetween the mass and bladder dome (Fig. 2). Culture of the umbilical dischargewas positive forPeptoniphilus species. Urachal remnant abscess was diagnosed. After abscess drainage and intravenous antibiotics administration, the symptoms alleviated. The urachus, a vestigial structure connecting the bladder dome to umbilicus, occludes and normally becomes a fibrous cord after birth. If occlusion is insufficient, an urachal remnant forms and may eventually become infected. Tenderness between the umbilicus and lower abdomen in conjunction with pus discharge from the umbilicus are indicative of a urachal remnant abscess. Urine test results are negative in more than 80% of cases. The differential diagnoses include BUmbilicus cellulitis^ and a BSister Mary Joseph’s nodule. ^ After resolution of the infection, there are recommendations that the urachal remnant should be excised to prevent recurrent infection and avoid the risk of neoplastic transformation.

Oblique Flashlight Test: Lighting Up Acute Angle-Closure Glaucoma

A n 89-year-old woman presented with severe right-sided headache, nausea, and blurry vision at night. Physical examination revealed right eye conjunctival injection and corneal edema. The right eyeball was much harder than the left, and the pupil was mid-dilated (6 mm) and poorly responsive to light. An oblique flashlight test revealed a shadow on the nasal iris (Figs. 1, 2). Slit-lamp examination of the eye revealed corneal edema, a shallow anterior chamber, and intraocular pressure of 58 mmHg. She was diagnosed with acute angle-closure glaucoma. Her symptoms improved after administration of eye drops containing a non-selective muscarinic receptor agonist, IV carbonic anhydrase inhibitor, and IV mannitol. This was followed by laser peripheral iridotomy. The oblique flashlight test allows rapid estimation of the depth of the anterior chamber of the eye without gonioscopy. A penlight is held next to the temporal side of the eye, with the light beam parallel to the iris, shining across the anterior chamber. If a shadow projects onto the nasal iris, the angle is narrow, because the iris bows forward and blocks the path of the light. The oblique flashlight test has relatively high sensitivity (76.3 %) and specificity (80.7 %) for angle-closure glaucoma. Corresponding Author: Kiyoshi Shikino, MD, PhD; Department of General MedicineChiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba Prefecture, Japan (e-mail: kshikino@gmail.com).

Unilateral lower abdominal wall protrusion and umbilical deviation

Postherpetic pseudohernia must be suspected when a patient develops motor dysfunction coincident with or following a herpes zoster eruption.

Non-episodic angioedema associated with eosinophilia

A 26-year-old woman presented with a 1-week history of peripheral oedema, fever and polyarthralgia. Physical examination revealed symmetrical non-pitting oedema of her hands and legs (figure 1). Her medical history was unremarkable. Laboratory findings showed blood eosinophilia (3800/μL). The serum IgM level was within normal. Skin histopathology revealed slight interstitial oedema, dilated venous vessels with endothelial swelling and inflammatory cells extending into the subcutaneous tissue (figure 2 …