Lawrence M. Tierney

Necrotizing lymphadenitis associated with systemic lupus erythematosus

OBJECTIVE Systemic lupus erythematosus (SLE) may have protean manifestations, including necrotizing lymphadenitis. After describing an illustrative case, we discuss the incidence, clinical features, and pathologic findings of SLE-associated necrotizing lymphadenitis. METHODS A case of SLE associated with necrotizing lymphadenitis is reported. The patients clinical presentation, course, and response to therapy is detailed. The literature on lupus lymphadenitis is reviewed. RESULTS A young man who presented with a febrile illness characterized by multifocal necrotizing lymphadenitis is described. Glomerulonephritis, meningo-encephalitis, pericarditis, and hemolytic anemia evolved. The diagnosis of SLE was based on the clinical features, positive antinuclear antibody (ANA), and characteristic renal biopsy. High dose corticosteroids and cyclophosphamide induced a complete remission. In recent series from the literature the prevalence of lymphadenopathy was 12% to 59% of patients with SLE. The most common nodal groups involved were cervical (43%), mesenteric (21%), axillary (18%), and inguinal (17%). Lymph node pathology was characterized by paracortical foci of necrosis and infiltration by histiocytes, lymphocytes, plasma cells, and immunoblasts. The hematoxylin body, an amorphic aggregate of basophilic material, was pathognomonic of lupus lymphadenitis. The necrotizing lymphadenitis of SLE is pathologically similar to Kikuchi-Fujumoto disease (KFD), a distinctive, self-limited form of necrotizing lymphadenitis. The pathologic and clinical literature support a close link between SLE and KFD. CONCLUSIONS SLE can be complicated by necrotizing lymphadenitis, with distinctive pathologic features. Lupus lymphadenitis and KFD share some common clinical and pathologic features, supporting a relationship between the disorders.

Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study

PURPOSE The oral case presentation is an essential part of clinical medicine, but teaching medical students to present clinical data remains difficult. Presentation skills depend on the ability to obtain, process, and organize patient data. Clinical reasoning is fundamental to the development of these skills. We compared a clinical reasoning curriculum with standard ward instruction for improving presentation skills and clinical performance. SUBJECTS AND METHODS Between October 1998 and May 1999, 62 third-year medical students at three hospitals were assigned to a 4-week clinical reasoning curriculum (n = 27) or a control group (n = 35) that underwent routine instruction. The curriculum consisted of four 1-hour group sessions and 1 hour of individual videotaped instruction, and taught students to use the principles of clinical reasoning, such as generation and refinement of diagnostic hypothesis, interpretation of diagnostic tests, and causal reasoning, to determine data for inclusion in the oral presentation. We videotaped students presenting two standardized case histories; one at baseline and a second 4 weeks later. Two independent evaluators who were blinded to the group assignments reviewed the videotapes and scored them for presentation quality and efficiency, and general speaking ability. RESULTS Mean (+/- SD) presentation times at baseline were similar in the two groups (intervention group: 8 +/- 2 minutes; control group: 8 +/- 2 minutes; P = 0.74). Presentation time in students who were taught clinical reasoning decreased by 3 +/- 2 minutes, but increased by 2 +/- 2 minutes in control students. The difference in the changes between the groups was statistically significant (mean difference = 4 minutes; 95% confidence interval [CI]: 3 to 5 minutes; P <0.001). Presentation quality scores at baseline were similar in both groups (intervention group: 17 +/- 8 points; control group: 20 +/- 7 points; P = 0.11). Students who were taught the clinical reasoning curriculum had an improvement of 9 +/- 6 points in the quality of their presentations, while control students had an improvement of 2 +/- 7 points (on a scale of 4-36). The difference in the changes between the groups was statistically significant (mean difference = 4 points; 95% CI: 1 to 7 points; P = 0.04). CONCLUSION A clinical reasoning curriculum, in combination with video-based individual instruction, improves the efficiency and quality of oral presentations, and may augment clinical performance.

Nursing in Japan

and attended daily rounds with the housestaff and interacted with nurses. l Nursing Science on the topic of “Nurses’ Involvement with Ethics Committees in U.S. Hospitals” Moderating a panel of researchers at an international nursing research conference sponsored by the Japanese Academy of Nursing Science Talking about the role of the clinical nurse specialist to graduate nursing students at St. Luke’s College of Nursing and the Tokyo University School of Nursing Attending meetings of the Psychiatric Liaison Nursing Interest Group Speaking about nursing ethics at Tokyo University Consulting with the international liaison nurse at the Japanese Nursing Association This proximity to the work and homes of the doctors and nurses provided a unique opportunity to observe their lives and work on adaily basis. Through the University of California, San Francisco, contacts made before our departure, and various associations made while in Japan, activities such as the following were made possible far one of us (M.J.T.): l Addressing the Ethics Steering Committee of the Japanese Academy of

Primary pulmonary hypertension and human immunodeficiency virus infection in a non-hemophiliac man

We describe clinical and postmortem findings in a 44-year-old man with pulmonary hypertension and infection with the human immunodeficiency virus (HIV-1). Plexogenic angiopathy and veno-occlusive lesions were present, in addition to a mild, patchy pulmonary interstitial lymphoid infiltrate. The clinical data for 14 previously reported cases of HIV-associated primary pulmonary hypertension are summarized. We speculate that these vascular changes may be due to damage from a specific immune response to HIV.

Aortoesophageal fistula after perigraft abscess with characteristic CT findings.

Aortoesophageal fistula is a rare cause of massive gastrointestinal hemorrhage, and may occur as a sequela to prosthetic replacement of the thoracic aorta. Esophageal compression necrosis with leakage of microorganisms into the proximal suture line is probably central to pathogenesis. Like the more common aortoduodenal fistula, diagnosis by traditional radiographic and endoscopic methods is difficult. We report here such a fistula, in which computed tomographic soft tissue abnormalities were characteristic of perigraft abscess; fistulization occurred subsequently. CT holds potential for being a sensitive study to show localized perivascular infection, an important precursor to aortoenteric fistula, and as such should be positive early in the development of a fistula.

Ethics in Japanese health care: a perspective for clinical nurse specialists.

Bioethical issues relevant to nurses in Japan are described in this article. Significant Japanese values and behavior patterns, the impact of religion on ethical concerns, patient and family roles in illness, and relationships with the physician are described. Within this context, Japanese nursing involvement in ethics and selected ethical issues are explored with examples.

The Eyes Have It

A 69-year-old man presented to the emergency department 2 hours after awakening with slurred speech. He also reported difficulty chewing, blurry vision in both eyes, generalized weakness, and unsteady gait.

Paraneoplastic Leukemoid Reaction as Marker for Transitional Cell Carcinoma Recurrence

A case of a 78-year-old man with transitional cell carcinoma and a paraneoplastic leukemoid reaction. The leukocytosis was present at the diagnosis of carcinoma. It dissipated with complete tumor resection, was absent when a surveillance computed tomography scan showed no evidence of recurrence at 6 months, and had returned with tumor recurrence at 8 months. This case demonstrates that a paraneoplastic leukemoid reaction can be used as a tumor marker in cases of transitional cell carcinoma when a leukemoid reaction is found at presentation.

Barrett's ulcer of the esophagus. Previously unrecognized cause of acquired esophagorespiratory fistula

Acquired fistulas between the esophagus and tracheobronchial tree are usually associated with malignancy of the esophagus, lung, or trachea. Less commonly, fistulas result from trauma or inflammation involving these structures. Untreated fistulas of any cause lead to fatal complications of aspiration. Although the prognosis in cases of malignant fistula is poor, the recognition and surgical management of nonmalignant fistulas may result in cure. An acquired esophagobronchial fistula resulting from a Barretts ulcer of the esophagus, a previously unreported cause, is described, and the differential diagnosis and treatment of nonmalignant esophagorespiratory fistulas are discussed.

Case records of the Massachusetts General Hospital. Case 10-2011. A woman with fever, confusion, liver failure, anemia, and thrombocytopenia.

Dr. Andrea L. Russo (Medicine): A 60-year-old woman was admitted to this hospital because of fever, confusion, liver failure, anemia, and thrombocytopenia. The patient had been in her usual state of health, with a history of hepatitis C virus infection and cirrhosis, until 2 to 3 weeks before admission, when low-grade fevers developed and relatives noted she was acting strangely, with slurred speech and urinary incontinence. Approximately 3 days before admission, increasing confusion and diarrhea developed. The day before admission, emergency medical services were called, and she was taken to another hospital. On examination, she was restless and oriented to person and place; her speech was slurred and her verbal responses to questions were confused. The temperature was 38.2°C, the blood pressure 127/63 mm Hg, the pulse 125 beats per minute, the respiratory rate 25 breaths per minute, and the oxygen saturation 97% while she was breathing ambient air. The sclera were icteric; the abdomen was tender without rigidity, and bowel sounds were present; there were ecchymoses on her abdomen and legs, with trace edema of the legs. Asterixis was present; the remainder of the examination was reportedly normal. The level of d-dimer was 19.18 μg per milliliter (reference range, 0.0 to 0.49), and plasma levels of glucose, globulin, magnesium, and ammonia and tests of renal function were normal; other results are shown in Table 1. Urinalysis showed cloudy urine with 2+ blood and 1+ protein; results were otherwise normal. Screening tests revealed immunity to hepatitis A and B viruses, the presence of cannabinoids in the urine, and occult blood in the stool. An electrocardiogram revealed sinus tachycardia (121 beats per minute). Chest radiography showed elevation of the right hemidiaphragm and minimal atelectasis at the base of the right lung. Computed tomography (CT) of the head without the administration of contrast material showed postoperative changes in the left frontal lobe, which were consistent with the surgical evacuation of an intracranial hemorrhage in the past and were unchanged from the findings on a CT examination performed 2 years earlier, after a fall. An abdominal ultrasonographic examination showed sludge in the gallbladder and pericholecystic fluid, with no clear evidence of Murphy’s sign or hepatic or portal-vein thrombosis. Cultures of the blood were sterile. Ceftriaxone, vancomycin, rifaximin, vitamin K, Case 10-2011: A Woman with Fever, Confusion, Liver Failure, Anemia, and Thrombocytopenia