Plaque psoriasis following Kawasaki disease and varicella

We describe the case of a 15-month-old boy with Kawasaki disease who developed varicella 7 days after the beginning of the disease and diffuse plaque psoriasis after 43 days. Associations between Kawasaki disease and psoriasis, between Kawasaki disease and varicella and between varicella and psoriasis have all been reported in the literature. The triple association of Kawasaki disease, varicella and psoriasis is very rare. Neither the double nor the triple associations are well known among a diverse group of practitioners.

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A differential diagnosis for annular lesions: contact dermatitis to transdermal rivastigmine patches

Description

During an appointment for an unrelated condition at a dermatology clinic, a 75-year-old man was noted to have a number of annular lesions on his trunk. The patient mentioned that he had been prescribed transdermal rivastigmine patches (Alzest 4.6mg/24h) for memory impairment 4 months previously. These were applied and left on for 24 hours before being replaced. He noticed that each patch left a red, pruritic area.

The patient was otherwise well, his only medication being an antihypertensive. He did not have any drug allergies or sensitivity to plasters.

On examination, there were multiple annular lesions scattered over his trunk with a predilection for the flanks (figure 1). These demonstrated an evolution of clinical features; more recent lesions were erythematous, inflamed plaques (figure 1A) which progressed into brown, postinflammatory patches (figure 1B) which gradually faded. All the lesions were well demarcated, circular and approximately 40 mm in diameter.

...

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Sepsis caused by acute phlegmonous gastritis based on a group A Streptococcus

Abstract

We present a case of 45-year-old male with acute phlegmonous gastritis (APG) based on a hemolytic group A Streptococcus. APG is a rare and often a potentially fatal disease, which is characterized by a severe bacterial infection of the gastric wall. Because APG is a rapidly progressive disease, it comes with high mortality rates. Patients with an early diagnosis may undergo successful treatment and have a survival benefit. As soon as the diagnosis of APG is suspected, aggressive and adequate antibiotic treatment in combination with surgical intervention should be considered.

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Cutaneous resurfacing around a permanent tracheostoma with an internal mammary artery perforator flap

Abstract

When soft tissue reconstruction near a permanent tracheostoma is needed, transfer of a thin and pliable flap is preferable in order to avoid occlusion of the newly created tracheostomal opening. Although microsurgical fasciocutaneous flap transfer may be desirable for such reconstruction, it is not always an option due to lack of recipient vessels for vascular anastomosis or a patient's poor medical condition that would prohibit a lengthy procedure. An alternative option is the internal mammary artery perforator flap, which is easy to elevate, has a long arc of rotation, and has a reliable blood supply. Here, we report three cases of cutaneous resurfacing around a permanent tracheostoma with an internal mammary artery perforator flap.

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An unusual presentation of Merkel cell carcinoma: a case report

Abstract

Merkel cell carcinoma (MCC) is a rare, aggressive carcinoma that usually arises in sun-exposed regions. MCC is a primary neuroendocrine tumor that arises in the skin. This report describes an unusual case of MCC on the buttocks that was treated with excision, radiation and chemotherapy. Physicians should consider MCC as a differential diagnosis when encountering a rapidly growing, painless lesion. Early diagnosis and treatment may improve patient survival rates.

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Intraductal papillary mucinous neoplasm originating from a heterotopic pancreas within the jejunum: a case report

Abstract

We report a case of intraductal papillary mucinous neoplasm arising within the heterotopic pancreatic tissue which was found incidentally in the jejunum during surgery for bowel obstruction. A 54-year-old female patient was admitted to our hospital due to sudden abdominal pain. In preoperative findings, we diagnosed bowel obstruction and performed surgery. Intra-operative findings showed adhesive intestinal obstruction, we performed synechiotomy for adhesion release. During surgery, when searching the small intestine, we coincidentally found a tumor in the jejunum and partial resected the jejunum. Pathological examination revealed a 1.2 cm × 1.0 cm × 1.0 cm white yellow nodule with cystic spaces. Histological examination demonstrated heterotopic pancreatic tissue consisting of well-formed lobules of pancreatic acini and cystically dilated ducts containing intraductal papillary neoplasm. Moreover, in immunohistochemical staining, MUC5AC was diffusely expressed, but not MUC1, MUC2 and MUC6.

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Thyroid paraganglioma: a case series of a rare head and neck tumor

Abstract

Thyroid paragangliomas are rare neuroendocrine tumors. We present two cases analyzing their clinical presentation and pathology findings. A 44-year-old woman presented with a 33 mm left thyroid lobe mass. A 27-year-old male presented with a 27-mm right thyroid lobe mass and a FNA biopsy suggesting a follicular thyroid tumor. Both patients underwent total thyroidectomy. Vigorous bleeding was noted on the first case. Histologic sections revealed encapsulated tumors, whereas immunochemical stains were positive for chromogranin A, synaptophysin and NSE and negative for thyroglobulin, calcitonin, CEA and S-100. After an 18- and 12-month follow-up, respectively, both patients have no signs of local recurrence or distant metastasis. Preoperative diagnosis of thyroid paragangliomas was never attained in this series. Immunohistochemistry is mandatory for proper differential diagnosis. For the surgeon, the operation is technically demanding mainly due to the increased vascularity and friability of the tumor.

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Ultrabiomicroscopy Anterior Segment Evaluation of Ocular Contusive Trauma Caused by Pressurized Bottled Drink Caps: A Case Report

We report the case of a patient presented to the emergency department because of a contusive trauma from a pressurized bottled drink cap. During the visit, the patient indicated that he had been hit in his left eye by a cork while he was opening a sparkling wine bottle. He underwent a total ophthalmology examination. He had an important reduction of visual acuity, corneal swelling, Descemet's folds, and hyphema. Therefore, we decided to perform ultrabiomicroscopy (UBM) of the anterior segment to study the endothelial damage and Descemet's membrane. UBM images confirmed the direct biomicroscopy, highlighting the damaged location.
Case Rep Ophthalmol 2018;9:365–368

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Making a difference – providing healthcare to undocumented immigrants

Washington and Oberdorfer published a case report entitled, "A 5-year old boy with miliary and osteoarticular tuberculosis," in BMJ Case Reports. The case was can important reminder of a clinical lesson, and a good outcome. "Seven months after discharge, the patient had persistent limited ROM, but was otherwise asymptomatic…. [F]amily agreement to surgery was still pending." However, on presentation, "[The patient] was febrile, tachycardic, tachypnoeic… and [had] a weight of 12 kg (<5%)…. [The patient] was in moderate distress, with bilateral lung ronchi, mild subcostal retractions, severe low back lordosis, right hip tenderness and limited and painful active and passive ROM of the right hip…. He was unable to stand without assistance." The patient was from Myanmar and "had moved to Thailand without documentation to live with his father approximately 2 months prior to presentation." This is mentioned by the authors only because, "[T]he patient revealed having received unknown evaluation and treatment in Myanmar and… The healthcare system in Myanmar… is among the world's poorest performing."

This is important to mention because Thailand is, "the only country in the world where migrants there illegally have the same healthcare rights as nationals."^[1] Migrants make up about 6% of the Thai population, and the only barrier to healthcare access is whether they can buy into a plan, costing about $58 USD. While a few European countries with universal health care (UHC) allow undocumented migrants to access health care in the same way as citizens, they have additional requirements including residence for at least three months.

In the United States, "Undocumented immigrants with routine health needs who are not covered through family members' insurance currently obtain care from a patchwork of Federally Qualified Health Centers, private charities, and hospital emergency departments, or go without." ^[2] This issue is further complicated by the fact that, even when undocumented immigrants are eligible for government-sponsored health care, many delay seeking healthcare for fear of immigration repercussions…. Policies that discourage undocumented immigrants from obtaining healthcare… can both increase costs and have serious public health effects."

In the EU there is, "no clear EU provision for undocumented migrants' right to healthcare or to other basic social needs and that Member States… are increasingly using it as a tool to discourage the entry of new migrants." These barriers can include the requirement of health care providers to report undocumented immigrants to the immigration authority, language problems, difficulties in continuity of care, lack of knowledge about the health care system and other barriers.^[3]

In this case, it is obvious that the patient was better served by being an undocumented immigrant in Thailand than he would have been in the United States or European Union. The need to provide care for undocumented immigrants is obvious from a standpoint of human rights and public health. As described by the authors in their "learning points," "International borders do not stop infectious diseases." Health care professionals have an obligation to care for the health of the patients that present to them, not merely those who possess adequate documentation.

 

BMJ Case Reports invites authors to submit global health case reports that describe the complexities of caring for immigrants in diverse situations. These cases could focus on:

-How healthcare policies affect individual patients
-Successful interventions for providing access to undocumented immigrants
-Challenges to providing healthcare for undocumented immigrants

Manuscripts may be submitted by students, physicians, nurses and allied health professionals to BMJ Case Reports at casereports.bmj.com. For more information, review our guidance on how to write a global health case report and look through our online collection.

 

To read more about undocumented immigrants and migrant health at BMJ Case Reports, please review:

–Illegal immigration: the puzzling role of several risk factors for rhabdomyolysis
–A Rohingya refugee's journey in Australia and the barriers to accessing healthcare
–Atopic dermatitis complicated by severe impetigo in a Syrian refugee infant

 

To read more about undocumented immigrant healthcare from other sources, please review:

^[1] Yan W. Only one country offers universal health care to all migrants. NPR. 2016 Mar 31.
^[2] Fernandez A, Rodriguez RA, 2017. Undocumented immigrants and access to health care. Jama Internal Medicine. 2017 Apr 1;177(4):536-7
^[3] Brady H, Humphris R, Newall D, Phillmore J. Public health aspects of migrant health: a review of the evidence on health status for refugees and asylum seekers in the European Region. 2015.

The post Making a difference – providing healthcare to undocumented immigrants appeared first on BMJ Case Reports blog.

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Extended release bupivacaine formulations for postoperative analgesia: an update

Purpose of review New formulations of local anesthetics with sustained release and longer duration of action are being developed to improve patient outcomes following surgery. This review summarizes the efficacy and safety of the three most recently developed extended-release formulations of the local anesthetic, bupivacaine. Recent findings Bupivacaine liposome injectable suspension (EXPAREL) encapsulates bupivacaine in biodegradable liposomes. It is currently the only extended-release formulation of bupivacaine approved by the FDA for infiltration of the tissues during surgery and for interscalene nerve block analgesia following shoulder surgery. SABER-Bupivacaine and HTX-011, are extended-release bupivacaine products in active development. Available data suggest relative safety and efficacy of all three formulations, although more data are needed to define their indications and dosing. Summary Extended-release bupivacaine formulations are promising alternatives to prolong duration of analgesia. To date, only EXPAREL has been approved by the FDA for tissue infiltration during surgery and for interscalene nerve block. Correspondence to Admir Hadzic, MD, PhD, Professor, Department of Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Schiepse bos 6, 3600 Genk, Belgium. E-mail: admir@nysora.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Ring artefacts in cranial CT

Description 

A ring or arc artefact in a CT is a hardware related artefact that occurs due to a defective or miscalibrated detector. It is more common with third-generation CT scanners with solid-state detectors. It appears as complete circles (sequential scans), annular rings (multiple circles) or partial rings (helical/multislice CT) at the same spot near the isocentre in multiple sections.1 2 Recognising this artefact is important as it may be subtle and misinterpreted as a pathological entity by the novice clinician.3 This artefact is usually more clearly visualised in the soft-tissue window of CT scans (video 1) than in the bone window (video 2).

Video 1

Serial sections of the scan (soft-tissue window) showing ring artefact.

Video 2

Serial sections of the scan (bone window) showing ring artefact.

Presented here is a case where an...

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Rare cause of manic period trigger in bipolar mood disorder: testosterone replacement

Hypogonadotropic hypogonadism is a rare congenital disorder characterised by the deficiency and the absence of puberty and infertility. It is caused by the deficient production, secretion or action of gonadotropin-releasing hormone, which is the master hormone regulating the reproductive axis. Gonadotropin-releasing hormone or gonadotropin injections and testosterone replacement therapy are required in the treatment of this disorder. Psychiatric symptoms and disorders may be seen with the use of anabolic androgenic steroids. In this case report, we present a case report in which a patient had behavioural symptoms in childhood and develops bipolar disorder after testosterone replacement therapy. This patient was reached to the remission by increasing the doses of psychiatric drugs without interfering with hormonal therapy. It should be considered that patients receiving testosterone replacement therapy may develop bipolar disorder or trigger mood changes in bipolar mood disease, so behavioural and mood state changes should be closely followed in patients who have bipolar mood disease.

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Acquired generalised lipodystrophy and type 1 diabetes mellitus in a child: a rare and implacable association

Lipodystrophy syndromes are frequently associated with marked degree of insulin resistance and lipoatrophic diabetes. Although acquired generalised lipodystrophy (AGL) has been known to be associated with various autoimmune disorders, type 1 diabetes mellitus (T1DM) is very rarely reported to occur with AGL. Combination of AGL and T1DM can lead to a totally different phenotype with very difficult-to-treat diabetes and progressive complications of both the conditions. We report a case of AGL with T1DM with poor diabetes control despite high doses of insulin, metformin and pioglitazone. Our case further progressed to develop complication of retroperitoneal fibrosis, not hitherto reported with AGL.

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Patient with native valve infective endocarditis and concomitant bacterial myopericarditis

A 39-year-old man with known mitral regurgitation (MR) presented with chest pain, nausea and dizziness. Troponin of 5801 ng/L and scooped ST segments indicated myopericarditis. Cardiac MRI demonstrated an epicardial late gadolinium enhancement pattern consistent with a significantly myocarditic syndrome. Initially afebrile, the patient reported fevers a week earlier when abroad where he received amoxicillin.

The patient then began spiking temperatures and infective endocarditis (IE) was confirmed following blood cultures positive for Streptococcus sanguinis and Transoesophageal echocardiography (TOE) showing a vegetation on the anterior mitral valve leaflet. Patient underwent 6 weeks of intravenous benzylpenicillin and on resolution he was discharged to await valve surgery.

A model is proposed where septic embolism from IE caused bacterial myopericarditis, triggering the initial presenting complaint. It is suggested that prior antibiotic therapy and paracetamol suppressed the systemic symptoms of IE.

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Neuroleptic malignant syndrome following reintroduction of an antipsychotic after overdose

Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse drug reaction. We report a case of NMS potentially induced by dehydration in a female patient suffering from schizoaffective disorder. We discuss possible aetiologies and triggering factors alongside the existing literature.

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