1/6. Children with condylomata acuminata.BACKGROUND. The modes of transmission of genital human papillomavirus (HPV) infection in children are controversial. Studies have varied in reporting suspicion of sexual abuse in children with condylomata acuminata from zero to 90.9%. Possible modes of transmission include sexual, from mother to infant in utero, passage through an infected birth canal, infection of a nongenital type virus to the genital area, and nonsexual acquisition from a fomite. methods. Seven children, ranging in age from 2 to 12 years, who had genital HPV infections were assessed for sexual abuse. An interview with each child was conducted and an examination with a colposcope of the external genitalia was performed. A shave biopsy of a representative genital lesion was obtained. The tissue was sent for HPV typing. RESULTS. Six of the children had perianal warts; the seventh had a labial lesion. Five of the children (71%) had been sexually abused as determined by the history, physical examination, or an investigation by child Protective Services. Five had HPV type 6 or 11, one had HPV type 16 or 18, and one had a novel HPV type. CONCLUSIONS. Genital types of HPV (6 or 11, 16 or 18, and others) should alert the family physician to proceed with a careful assessment for sexual abuse. This study supports the findings of other reports that genital HPV infection can be the result of sexual abuse and points out the usefulness of HPV typing.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/6. Cases from the Osler Medical Service at Johns Hopkins University.A 47-year-old white woman with a history of stage III squamous cell carcinoma of the anus was transferred to Johns Hopkins Hospital for further evaluation of renal failure, hemolytic anemia, and thrombocytopenia.The patient was first diagnosed with squamous cell carcinoma of the anus 1 year before admission. She was treated with external beam radiation of the pelvis and two cycles of mitomycin C-based chemotherapy (a cumulative dose, 34 mg/m(2)). Her clinical course was complicated by clostridium difficile colitis and myositis successfully treated with prednisone.Three months before admission, the patient developed dysuria. Her creatinine increased from normal to 1.7 mg/dL, and microscopic hematuria was present. A renal ultrasound and an abdominal computed tomographic scan showed no abnormalities or obstruction. One month before admission, she underwent a cystoscopy, which showed only radiation-induced changes in the bladder. Two weeks before admission, the patient became delirious and was taken to a hospital, where she was found to be anemic, with a hematocrit level of 23.7%, and thrombocytopenic with a platelet count of 110,000/mm(3). Her creatinine level was 5.9 mg/dL. Previous values of hematocrit, platelet count, and serum creatinine were normal.On admission at Johns Hopkins Hospital the patient had no complaints. She was afebrile on physical examination and had normal vital signs. head, neck, chest, cardiovascular, and abdominal examinations were normal. There was skin pallor, but no echymoses or petechiae. She was alert and oriented with normal mental status. Her neurologic examination was normal. Laboratory data showed a white blood cell count of 6390/mm(3), a hematocrit level of 26.5%, and a platelet count of 26,000/mm(3). Her blood urea nitrogen level was 57 mg/dL, creatinine level was 4.0 mg/dL, and lactate dehydrogenase was 550 U/L (reference, 115 to 275 U/L). urinalysis showed innumerable red blood cells and large protein. A peripheral blood smear showed fragmented red blood cells, schistocytes, no abnormal white blood cells, and few platelets. There was no radiographic or clinical evidence of relapse of her squamous cell carcinoma.What is the diagnosis?- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/6. Grade 3 vulvar and anal intraepithelial neoplasia in a hiv seropositive child--therapeutic result: case report.A case report of a hiv seropositive 8-year-old child with vulvar and anal border neoplasia, both grade 3, and the adopted therapeutic management are presented. The mother reported the history of a progressively growing verrucous lesion in the vulva since the age of three and a half years. On physical examination a pigmented and elevated lesion was observed in the whole vulvar region extending to the anal region and intergluteal sulcus. After biopsies and anatomic pathological examination, antiretroviral therapy, adequate for age, and topical application of podophyllotoxin associated with Thuya officinalis extract was started. Three months afterwards vaporization and CO2 laser excision were performed in five sequential sessions, thereafter associated with topical imiquimod application. After the first two sessions of laser therapy early relapses occurred. After four weeks of imiquimod use, already a significant improvement of the lesions was observed, making the following laser therapy sessions easier. We conclude that antiretroviral therapy associated with podophyllotoxin and Thuya was not effective regarding regression of the lesions. laser therapy alone led to early relapses. The local use of imiquimod associated with laser was effective in decreasing and controling the lesions.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/6. Expectant management of anal squamous dysplasia in patients with hiv.PURPOSE: Anal squamous dysplasia is commonly found in patients with hiv infection. There is no satisfactory treatment that eradicates this premalignant lesion with low morbidity and low recurrence. This study reviews a series of patients with hiv and an abnormal anal examination who had squamous dysplasia and who have been followed with physical examination alone and with repeat biopsies as necessary for new or suspicious lesions. methods: We reviewed the charts of 40 hiv-positive men who had squamous dysplasia of the anal canal and anal margin, focusing on history, physical findings, histologic diagnosis, and the occurrence of invasive squamous-cell carcinoma. RESULTS: Forty hiv-positive men (mean age, 39 years) were followed for anal squamous dysplasia. Biopsies revealed dysplasia, which was usually multifocal. The grade of dysplasia varied, but 28 of 40 patients had at least one area of severe dysplasia. All patients had a follow-up period greater than one year (mean, 32 months; range, 13-130 months). Three patients developed invasive carcinoma while under surveillance, and these were completely excised or cured with chemoradiation. CONCLUSIONS: Extensive excision for dysplasia in the context of hiv confers high morbidity and questionable benefit, and other treatments are of uncertain value. In a group of patients followed expectantly, most did not develop invasive cancer, and in those who did, early cancers could be identified and cured. physical examination surveillance for invasive carcinoma may be acceptable for following patients with hiv and biopsy-proven squamous dysplasia.- - - - - - - - - - ranking = 1.0440245680246keywords = physical examination, physical (Clic here for more details about this article) |
5/6. carcinoma of the anal canal.J.W. is a 68-year-old white female who noted an "anal growth" 1 year prior to admission. She also complained of bleeding from her rectum when she was constipated. She attributed these symptoms to hemorrhoids. She noted increasing pain and more bleeding 1 month prior to admission. Locally applied hemorrhoid remedies gave her no relief. She was then admitted to a hospital where a biopsy of the anal mass was performed, and then referred to Rush-Presbyterian-St. Luke's Medical Center. On physical examination the patient was noted to be obese. There was no inguinal lymphadenopathy. There were no abdominal masses or hepatosplenomegaly. Rectal examination revealed a 3 X 4 cm mass protruding from the anus. Examination and protoscopy done under anesthesia revealed this mass to be approximately 4 X 5 cm and arising from the proximal anal canal. The mass was freely moveable and bled spontaneously when manipulated. Pelvic examination revealed a normal uterus and adnexa with no obvious tumor involvement of the vagina. Proctoscopic examination revealed no tumor proximal to the lesion described. Further evaluation included a liver-spleen scan that was negative for metastatic disease and intravenous pyelogram that showed no lesions. A barium enema revealed only diverticula. A gallium scan showed marked uptake at the area of the anal tumor but no other lesions. The chest x-ray was within normal limits. A CT scan of the abdomen and pelvis revealed no masses or lymphadenopathy. The CEA was 1.3 ng/ml. The patient underwent concomitant radiation therapy and chemotherapy. Over a 4-week period the patient received 5000 rads to the anal region. In addition, during the first week of radiation therapy and the fourth week of radiation therapy, the patient received 5-fluorouracil, 800 mg/m2 by continuous infusion for 5 days. In addition, the patient received mitomycin C, 15 mg/m2 on the first day of the first week of chemotherapy and the first day of the last week of chemotherapy. During the treatment period, the patient had mild diarrhea, perineal desquamation, and mild ulceration at the site of the anal tumor. During the third week of treatment, the patient had a white blood cell count nadir of 2800 and a platelet count of 86,000 per cubic millimeter. Her symptoms were managed with local emolients and antidiarrheal medications.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
6/6. Failure of oral nitrate and calcium channel blocker therapy to prevent 5-fluorouracil-related myocardial ischemia: a case report.BACKGROUND: myocardial ischemia induced by 5-fluorouracil (5-FU) is a relatively rare, but potentially serious, occurrence. Some case reports have indicated that recurrent ischemia may be prevented if 5-FU is resumed after pretreatment with antianginal therapy. methods: A 54-year old woman was diagnosed with stage IIA squamous cell carcinoma of the anus. Treatment with concurrent radiation and chemotherapy (mitomycin-C and 5-FU) was initiated with curative intent. RESULTS: The patient had no evidence of underlying coronary artery disease based on history, physical examination or ECG. Approximately 48 h after initiation of 5-FU infusion the patient developed anginal pain associated with ECG changes compatible with ischemia. After resolution of ischemia and ruling out of myocardial infarction, coronary arteriography demonstrated normal coronary arteries. In an attempt to prevent myocardial ischemia, calcium channel blocker and nitrate therapy was started, but anginal pain with ECG change recurred when 5-FU was resumed. This necessitated selection of an alternative chemotherapy regimen. CONCLUSIONS: Even in the presence of normal coronary arteries, antianginal therapy may not preclude the occurrence of potentially serious 5-FU induced myocardial ischemia. For patients who experience 5-FU-induced myocardial ischemia, development of alternative chemotherapy regimens should be considered.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |