Wing Keung Cheung

Efficacy of magnetic resonance diffusion tensor imaging and three-dimensional fiber tractography in the detection of clinical manifestations of central nervous system lupus

Systemic lupus erythematosus (SLE) is an autoimmune disease frequently associated with neuropsychiatric manifestations. No follow-up case report has characterized white matter alterations in patients with neuropsychiatric lupus erythematosus (NPSLE) before and after treatment. In this study, a 16-year-old NPSLE patient with severe neuropsychological symptoms was treated with steroid pulse therapy, and was scanned with conventional magnetic resonance (MR) and diffusion tensor imaging (DTI) at onset and 17months after treatment. Conventional MR images showed diffuse brain atrophy and focal vasogenic edema in the putamen, but they did not reveal abnormalities in the corpus callosum. Region-of-interest analysis of DTI images showed that fractional anisotropy and fiber tracts increased significantly, while axial diffusivity, radial, and mean diffusivity decreased significantly in the corpus callosum after treatment. The results indicated that the vasogenic edema was present in the corpus callosum at onset and was significantly reduced after treatment. These changes were generally compatible with the patients clinical manifestations. Hence, we concluded that MR-DTI and fiber tractography are helpful to reveal the relationship between white matter alterations and neurological dysfunctions in NPSLE patients.

Spontaneous rupture of the short gastric artery after vomiting

Spontaneous rupture of the short gastric artery is an extremely rare event that can cause abdominal apoplexy or spontaneous hemoperitoneum. For the emergency physician, simultaneous restoration of circulatory volume and a rapid diagnosis remain central to a successful outcome in such critical cases. We reported a 21-year-old man who initially presented with watery diarrhea and abdominal fullness followed by vomiting after the ingestion of alcohol but was later diagnosed with hemoperitoneum, resulting in hemorrhagic shock due to spontaneous rupture of the small branches of the short gastric artery. The patient underwent emergency exploratory laparotomy with a good outcome. Abdominal apoplexy should be considered in the differential diagnosis of unexplained hemorrhagic shock with an abrupt onset of severe abdominal pain associated with vomiting.

Unilateral Acute Pyelonephritis Associated with a Neglected Pessary

To the Editor: For many years, pessaries of various types have been used for the management of gynecological conditions including stress urinary incontinence, vaginal vault prolapse, cystocele, enterocele, rectocele, and preoperative preparation for pelvic organ prolapse in older women. Acute pyelonephritis and urosepsis caused by neglected pessaries are rare conditions. Herein, is reported a case of unilateral acute pyelonephritis due to a neglected pessary in an older woman.

Primary leptomeningeal melanoma

Primary melanoma of the central nervous system is a rare melanocytic tumor typically located in the leptomeninges. We report a 57-year-old woman with an intracranial leptomeningeal melanoma who presented with myoclonic seizures. Brain CT scan and MRI revealed a hemorrhagic intracranial tumor. The tumor was completely removed and leptomeningeal melanoma was proven pathologically. Follow-up imaging studies up to 19 months showed no recurrence of the disease. Here we present radiological, gross, and pathological images of leptomeningeal melanoma, discuss its characteristics, and review the relevant literature.

PYOGENIC LIVER ABSCESS IN OLDER ADULTS: COMPARISON WITH YOUNGER INDIVIDUALS

To the Editor: We would like to thank Dr. Shou-Jin Pu and colleagues for sharing their research letter; we are appreciative of their work, ‘‘Pyogenic Liver Abscess in Older Patients: Comparison with Younger Patients,’’ in which they compared older and younger adults with pyogenic liver abscess (PLA). Fever and chills were less frequent in older adults than in younger adults. Atypical clinical features are a possible explanation for absence of fever and chill in older adults with this serious infection, and physicians need to be alert for early diagnosis, especially emergency physicians. In one study, older adults had a few days of fever before their hospital visit. They were taken to the hospital earlier, because their families were concerned about their constitutional symptoms, such as fever, fatigue, and anorexia. There may be more cases of diabetes mellitus in the older group with PLA because diabetes mellitus is more prevalent in the elderly population. Diabetes mellitus, biliary stones, malignancy, liver cirrhosis, and alcoholism were the risk factors for PLA in older adults. Younger individuals were more likely to be male and have alcoholism and a cryptogenic etiology than older adults. On admission, older adults had significantly less right-upper abdominal tenderness than younger individuals. Pu and colleagues reported that there was no significant difference in therapeutic procedures with drainage between these two groups and that a positive culture of Klebsiella pneumoniae and Escherichia coli was more frequent in older than younger adults. The most frequent pathogen in one study was K. pneumoniae, whereas E. coli is the most common pathogen reported worldwide. K. pneumoniae has been reported as the leading pathogen of PLA in Asia, and there is a trend for causative pathogen to change from E. coli to K. pneumoniae in Western countries. Over the past 70 years, PLA has been seen predominantly in younger individuals, but it has recently become more common in older adults. Mortality was 9.5% in older patients, which was lower than in a previous study because of advanced imaging techniques and new antibiotics. The relationship between mortality in PLA and age is controversial. Some series found no significant difference, but some revealed higher mortality in older adults, possibly because of more comorbidities in this population. PLA continues to be a significant cause of morbidity and mortality, especially in older adults with diabetes mellitus. To reduce morbidity and mortality, adequate antibiotics, such as ceftriaxone with or without metronidazole and good control of blood glucose with early adequate drainage are mandatory. Surgery should not be delayed if medical treatment or percutaneous drainage fails. Once again, we thank Dr. Pu and colleagues for their present and future study of PLA in older adults.

Emphysematous Infections of the Prostate and Scrotum in an Older Adult in a Nursing Home

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors participated in study concept and design and acquisition, analysis, and interpretation of data. NM wrote the manuscript. Sponsor’s Role: None.

Incarcerated Incisional Hernia: Strangulated Transverse Colon with Perforation Associated with Abscess Formation

We wish to thank Mrs. Aki Watanabe and Mrs. Naoko Koizumi, Department of Clinical Cell Biology and Medicine, Chiba University Graduate School of Medicine, for their valuable technical assistance. This work was supported by the Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan for the Research on Measures for Intractable Diseases. Conflict of interest: All authors have no conflict of interests. Author Contributions: Ide, Yamamoto, Fujimoto: data analysis and interpretation, acquisition of subjects and data. Takemoto: data interpretation, manuscript preparation. Ide, Kobayashi: data acquisition. Yokote: discussion, review and editing of manuscript. Sponsor’s Role: The sponsor had no role in this study.

Hiatal Hernia with Gastric Volvulus and Small Bowel Strangulation

1. Sarti GM, Haddy RI, Schaffer D et al. Black hairy tongue. Am Fam Physician 1990;41:1751–1755. 2. Avcu N, Kanli A. The prevalence of tongue lesions in 5150 Turkish dental outpatients. Oral Dis 2003;9:188–195. 3. Harada Y, Gaafar H. Black hairy tongue. A scanning electron microscopic study. J Laryngol Otol 1977;91:91–96. 4. Akay BN, Sanli H, Topcuoglu P et al. Black hairy tongue after allogeneic stem cell transplantation: An unrecognized cutaneous presentation of graftversus-host disease. Transplant Proc 2010;42:4603–4607. 5. Luo Y, Zou P, Li QB et al. Black hairy tongue associated with allo peripheral blood hematopoietic stem cell transplantation. Chin Med J 2010;123:1807–1808. 6. Thompson DF, Kessler TL. Drug-induced black hairy tongue. Pharmacotherapy 2010;30:585–593. 7. Cheshire WP Jr. Unilateral black hairy tongue in trigeminal neuralgia. Headache 2004;44:908–910. 8. McGrath EE, Bardsley P, Basran G. Black hairy tongue: What is your call? CMAJ 2008;178:1137–1138. 9. Langtry JAA, Carr MM, Steele MC et al. Topical tretinoin: A new treatment for black hairy tongue (lingua villosa nigra). Clin Exp Dermatol 1992;17:163–164. 10. Tamam L, Annagur BB. Black hairy tongue associated with olanzapine treatment: A case report. Mt Sinai J Med 2006;73:891–894.

Ruptured Abdominal Aortic Aneurysm in an Elderly Man

gia have difficulty tolerating regular doses of drugs, current pharmacological options are limited. This case demonstrates an interesting change in the clinical manifestation of chronic fibromyalgia alongside progressive cognitive impairment. Consistent with research that suggests that there are abnormalities in pain processing in individuals with fibromyalgia, damage to cerebral structures and impairment in neurone transmission in dementia syndromes may explain the improvements in this individual’s symptoms. This observation may be of clinical interest because it may provide a proof of concept that a process that severely interferes with pain processing (among other higher cognitive functioning) can starkly improve fibromyalgia symptoms. A medication that is able to improve the abnormalities in pain processing so dramatically, without affecting cognition, would be of clinical interest.

Small Bowel Obstruction Secondary to a Mushroom Bezoar

endothelial function toward endothelial dysfunction. Accordingly, strong evidence suggests a link between inflammation, endothelial dysfunction, and poor outcomes after a vascular accident. Thus, the relationship between higher serum GGT levels and poor functional outcomes after IS in an older population may account, at least in part, for the higher mortality after vascular accidents in elderly adults. These data support the usefulness of GGT for risk assessment in elderly adults and may be of value in secondary prevention strategies.