Meital Adi

Unsuspected serious abdominal trauma after falls among community-dwelling older adults

BACKGROUND In elderly community-dwelling patients who experience ground-level falls, fractures or brain injury are the major concern. Serious abdominal injury is seldom contemplated. AIM Identify all such patients presenting after a simple fall and admitted with serious blunt abdominal trauma to a single academic medical centre. DESIGN Retrospective chart analysis. METHOD All patients with both diagnoses aged 65 years or more admitted over 1 year to the department of medicine, geriatrics, surgery or urology were identified. RESULTS Out of 546 patients screened, three cases of ground-level falls leading to splenic rupture, isolated gallbladder rupture with gallstone ileus and perinephric hematoma were found (0.55%) and are reported. CONCLUSIONS Falls in elderly patients are exceedingly common mandating recognition of even rare complications. Physicians should be more aware of the possibility of occult and serious consequences of blunt abdominal trauma after falls among older adults, albeit rare.

Volumetric analysis of the maxillary, sphenoid and frontal sinuses: A comparative computerized tomography based study☆

OBJECTIVE To study volume characteristics of the maxillary, sphenoid and frontal sinuses among healthy Caucasians adults, using computed tomography (CT) scans. METHODS A retrospective, case series study in a single academic center, CT scans of 201 consecutive adult subjects, performed between January and September 2014, were reviewed for the volume and dimensions of the paranasal sinuses. Patients with documented sinus pathology or lack of pneumatization were excluded. The study population was subdivided by gender and age (50 men age 25-64; 51 men age ≥65; 50 women age 25-64, and 50 women age ≥65). RESULTS The mean volume of maxillary, sphenoid and frontal sinuses in the four groups were 12.75±4.38 cc; 4.00±1.99 cc and 2.92±2.57 cc, respectively. In both genders, older patients demonstrated a significantly lower volume of the maxillary and sphenoid sinuses (14.81±3.96 cc vs. 11.82±4.28 cc and 4.84±1.97 vs. 3.84±1.89 cc respectively; p<0.001). No age related difference was found in the frontal sinus. Males had significantly larger sinus volumes than females (p<0.001): maxillary 14.38±(4.64) vs. 12.23±(3.82) cc, sphenoid 4.74±(2.06) vs. 3.55±(1.73) cc, frontal 3.74±(2.97) vs. 3.21±(2.79) cc. No synergistic effect of age and gender was found. CONCLUSION Volumes of the paranasal sinuses correlates with age and gender. Age related volume degeneration is expected in the maxillary and sphenoid sinuses. This volume reduction may influence future surgical and therapeutic approaches in the geriatric population.

Low-back pain, lassitude and loss of appetite

Lesson White blood cells, Erythrocyte sedimentation rate and C-reactive protein are sensitive tools to discover rare, but potentially serious pyogenic vertebral osteomyelitis, a disease whose incidence is increasing.

Spontaneous Neck Hematoma in a Patient with Fibromuscular Dysplasia: A Case Report and a Review of the Literature

Background. Fibromuscular dysplasia (FMD) is a vascular disease that may present as aneurysms in the cervical arteries. Spontaneous neck hematoma is a rare life threatening medical condition. This is the first report of neck hematoma in a patient with FMD. Methods and Results. We present a case of a 69-year-old woman, with diagnosed cervical FMD and a 3-day history of sore throat and neck pain, who presented with enlarging neck hematoma. No active bleeding was noticed on CT angiography, airway was not compromised, and patient was managed conservatively. Next day, invasive angiography was performed, and no bleeding vessel was demonstrated. Patient has improved and was discharged after 5 days of hospitalization. We have discussed the different etiology of this condition, focusing on systemic vascular diseases. Conclusion. Complaint of neck pain in a patient with a FMD should raise suspicion for possible neck hematoma. Conversely, spontaneous neck hematoma without clear etiology should raise suspicion for a systemic vascular disease.

Mobile Menace: Floating Aortic Arch Thrombus

A healthy, nonsmoking 72-year-old man presented with a history of a change in bowel habits followed by rectal bleeding. Colonoscopy demonstrated a rectosigmoid cancer. A preoperative staging computed tomography scan revealed a large (1.2 cm) intraluminal free (unconnected to the wall) filling defect in the proximal descending aorta (Figure A) and some ipsilateral pleural effusion. Multiple splenic infarcts, which were asymptomatic, were seen (Figure B). Transesophageal echocardiography confirmed the presence of a mobile mass, but the cardiac cavities, valves, and aortic wall were normal. No cause of arterial hypercoagulability other than the tumor was found. Thoracotomy was performed and a fragile thrombus was successfully removed. One month later, low-molecular-weight heparin was temporarily discontinued and a large penetrating

Dysphagia and Dysphonia in a Patient With Cancer

A patient with cancer undergoing chemotherapy via Portacath presented with severe progressive dysphagia and dysphonia. Unilateral paresis of the 9, 10, 11, and 12th cranial nerves was found (Collet-Sicards syndrome or Villarets syndrome), associated with ipsilateral jugular vein thrombosis identified by imaging. The use of central venous catheters is increasing, and even rare, hitherto unreported, complications need to be recognized. After catheter removal, the patient slowly improved with low-molecular weight heparin treatment and time.

An unusual presentation of acute Q fever

Learning points for clinicians Acute Q fever is a common zoonotic infection with a worldwide distribution. Even rare manifestations may be encountered and need to be recognized. Barring parasitic infestations, peripheral blood eosinophilia in the course of infectious diseases is distinctly uncommon. Acute Q fever may very rarely present with significant peripheral blood or pleural fluid eosinophilia. Acute Q fever may cause granulomatous lymphadenitis with mediastinal lymphadenopathy which may mimic lymphoma or sarcoidosis. Oral doxycycline constitutes an effective treatment and these rare manifestations are entirely reversible. A healthy 68-year-old man presented with fever (38.3°C), dyspnea, dry cough and 5 kg weight loss over 10 days. On admission right lung rales and splenomegaly were found, without lymphadenopathy (LN). Chest X-ray showed right middle lobe (RML) infiltrate, small pleural effusion and bilateral hilar LN. Laboratory tests showed: Hb 12 g/dl, platelets 186 × 109/l, WBC 12 × 109/l with 4.6 × 109/l neutrophils and …

Extensive hematoma and the liver

A 66-year-old man had a ground level fall on his back and was admitted in July 2014 after developing an extensive (58 × 25 cm) hematoma over his lower back and flanks. He had a long history of resected carcinoid of the small bowel (1998), recurring in 2005 and treated since with octreotide. In late 2012, …

All in His Head: An Unexpected Space-occupying Lesion

Figure (A) Coronal, contrast-enhanced, T1-weighted, head showed a left parietal ring-enhancing multilocular lesion showed restricted diffusion on axial diffusion-we seen on apparent diffusion coefficient (ADC) imaging. Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and participated in writing the manuscript. Requests for reprints should be addressed to Ami Schattner, MD, Professor and Head, Department of Medicine, Kaplan Medical Center, POB 1, Rehovot 76100, Israel. E-mail address: amimd@clalit.org.il

Unremitting abdominal pain: obscure until the first CT.

Chronic intermittent or steady abdominal pain in adults is commonly encountered and may be due to a large variety of syndromes many of them with no demonstrable anatomical abnormality (irritable bowel syndrome, functional dyspepsia), but some involving occult structural, neoplastic or inflammatory conditions that may present a considerable diagnostic difficulty. We present a patient with a clinical entity that deserves better recognition, first suspected by its typical imaging findings. A healthy elderly patient presented with several months’ history of diffuse abdominal pain of mild to moderate intensity becoming relentless with time with no associated weight loss, fever or anorexia. Examination, X-rays, laboratory tests, gastroscopy and colonoscopy were normal and no diagnosis was reached over several months. On admission, abdominal CT revealed lymphadenopathy (up to 3.0×1.5 cm) and …