1/10. Lamotrigine overdose presenting as anticonvulsant hypersensitivity syndrome.OBJECTIVE: To describe the laboratory and physical manifestations of lamotrigine toxicity presenting as anticonvulsant hypersensitivity syndrome. CASE SUMMARY: A 49-year-old white man presented to our institution with a two-day history of low-grade fever, erythema, and edema involving the periorbital area. Five days earlier, he had been placed on lamotrigine treatment for bipolar disorder. He inadvertently received four daily doses of lamotrigine 2700 mg each. physical examination was significant for periorbital edema and discrete and confluent blanching red macules and papules involving the face, trunk, and extremities. Laboratory tests revealed leukocytosis, hepatitis, and acute renal failure. With normalization of the laboratory results, the eruptions and edema gradually resolved. DISCUSSION: Lamotrigine toxicity can lead to periorbital edema, rash, and multiorgan system abnormalities. This presentation has clinical and laboratory similarities with anticonvulsant hypersensitivity syndrome, which suggests that at some threshold concentration the amount of lamotrigine may overwhelm the body's ability to metabolize the drug, leading to a similar hypersensitivity reaction. Lamotrigine is a relatively new agent, and this report may provide useful insights on evaluating the clinical toxicology of this agent. CONCLUSIONS: Healthcare providers should be aware that lamotrigine overdose may present with multiorgan involvement, similar to anticonvulsant hypersensitivity syndrome.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/10. Renal infarction: an uncommon mimic presenting with flank pain.A 39-year-old woman arrived to the emergency department complaining of a constant, progressive, left flank pain, with no beneficial effect from spasmolytic and nonsteroidal antiinflammatory drugs. Two years before, she suffered another episode of right flank pain and stranguria, but instrumental examinations (ultrasonography, urography) remained negative. Besides a mild tenderness in the left flank, physical examination was normal. Blood chemistry panel showed leukocytosis (17.2 x 10(3) mL, neutrophils 82.8%) and a slight increase of serum lactate dehydrogenase (LDH) (543 U/L versus 230 to 460 U/L). Urinanalysis showed a slight hemoglobinuria (0.5 mg/dL), and sediment contained some red cells and leukocytes. Diagnostic examinations (ultrasonography, computed tomography) showed a left renal nonhomogeneous space-occupying lesion, orientative for renal malignancy. She was transferred to the urology department and operated. Both intraoperatory and histological diagnosis was ischemic infarction and, after exclusion of all possible underlying causes, final diagnosis was idiopathic renal infarction. Diagnostic procedures and literature reports are discussed.- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
3/10. Cutaneous promyelocytic sarcoma at sites of vascular access and marrow aspiration. A characteristic localization of chloromas in acute promyelocytic leukemia?Extramedullary disease (EMD) is a rare clinical event in acute promyelocytic leukemia (APL). Although the skin is involved in half of the reported EMD cases, the occurrence of cutaneous promyelocytic sarcoma (PS) has been described very rarely. We report here three cases of PS which have the peculiarity of appearing at sites of punctures for arterial and venous blood and marrow samples (sternal manubrium, antecubital fossa, wrist over the radial artery pulse, catheter insertion scar). At presentation, all patients had hyperleukocytosis and a morphologic diagnosis of microgranular acute promyelocytic leukemia variant confirmed at the genetic level by demonstration of the specific chromosomal translocation t(15;17). A BCR3 type PML/RARa transcript was documented in the two patients for whom diagnostic RT-PCR was available. patients had morphologic bone marrow remission at the time the PS appeared. A predilection for the development of cutaneous PS at sites of previous vascular damage has been noted, but the pathogenesis remains largely unknown. A potential role for all-trans retinoic acid has been advocated, although one of the three patients in our series had received no ATRA. A review of the literature revealed six similar cases and hyperleukocytosis at diagnosis was a consistent finding in all of them. A careful physical examination of these particular sites in the follow-up of patients at risk, as well as cutaneous biopsy and laboratory examination of suspected lesions are strongly recommended.- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
4/10. Crohn's disease in a patient with acute spinal cord injury: a case report of diagnostic challenges in the rehabilitation setting.diagnosis of the abdominal emergency in tetraplegic and high paraplegic patients remains challenging. Classic peritoneal signs, such as a rigid abdomen, rebounding, guarding, and Murphy's sign may be absent, whereas subtle physical, laboratory, or radiologic abnormalities may be the only evidence for an acute abdomen. Our report describes the course of a 70-year-old man with C5 American Spinal Injury association class A tetraplegia who developed a perforated cecum secondary to Crohn's disease. We review the visceral and somatic sensory pathways for abdominal pain with emphasis on the challenges in assessing the acute abdomen in a patient with spinal cord injury (SCI). Recommendations for the assessment of the acute abdomen in an individual with SCI will be provided. This is the first reported case of Crohn's disease in an individual with an acute SCI. It shows the importance of maintaining high clinical suspicion for unexpected intraabdominal processes that may lead to significant morbidity and mortality if left undiagnosed.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
5/10. Abdominal attack of hereditary angioedema associated with marked leucocytosis. A case report.Hereditary angioedema (HAE) attacks are not usually associated with an increase of peripheral blood leucocytes. In a 25-year-old woman suffering from HAE a marked leucocytosis (31,000/mm3) with polynucleosis was observed during a severe attack of the disease. awareness of the underlying disease, physical examination and the results of instrumental investigations allowed for appropriate treatment avoiding invasive procedures. A leucocytosis of the severity observed in our patient suggests that the abdominal attack of HAE can involve the peritoneum as well as the intestinal mucosa. Thus, in a patient with an attack of abdominal pain the presence of leucocytosis does not exclude the diagnosis of HAE.- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
6/10. Anaplastic thyroid carcinoma associated with granulocyte colony-stimulating factor: report of a case.A 75-year-old woman was hospitalized due to a right axillary mass. She had undergone a resection of thyroid carcinoma 13 years earlier, followed by two subsequent operations for recurrent thyroid disease. A physical examination revealed a right axillary mass associated with skin ulceration. Persistent bleeding was observed at the skin ulcer associated with the right axillary lymph node, despite conservative treatment for the lesion. Surgery was thus performed to control persistent bleeding from the axillary ulcer, and a histopathological examination resulted in a diagnosis of poorly differentiated thyroid carcinoma. The postoperative course was uneventful, but marked leukocytosis and extensive skin metastases were recognized 30 days postoperatively. A systemic examination revealed no other lesions associated with marked leukocytosis, but elevated levels of granulocyte colony-stimulating factor were noted in a blood examination. As a result, her general condition deteriorated rapidly and the patient died 2 weeks after the onset of leukocytosis.- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
7/10. fever and leukocytosis: physical manifestations of bipolar affective disorder?1. fever and leukocytosis are occasionally observed in patients with psychiatric disorders. A thorough medical evaluation does not always reveal the origin of these abnormalities. 2. We report the case histories of three patients with bipolar affective disorder and an abnormal DST who had fever and leukocytosis during the acute phase of their illness. No organic etiology could be found. 3. All three patients responded to ECT with resolution of the depression, the fever, and the leukocytosis, and normalization of the DST. 4. We propose that fever and leukocytosis may be rare physical manifestations of bipolar affective disorder, particularly in patients with abnormal DST.- - - - - - - - - - ranking = 5keywords = physical (Clic here for more details about this article) |
8/10. Refractory anemia with an excess of blasts developed into overt leukemia with leukothrombocytosis.A 72-year-old man with refractory anemia with an excess of blasts developed overt leukemia with leukothrombocytosis. Hematological and physical findings closely resembled those of an accelerated or blastic phase of chronic myelocytic leukemia. The cytogenetic anomaly of i(17q) was observed during the course. The present case is suggestive of the diversities of myelodysplastic syndromes (MDS), including relationships between MDS and myeloproliferative disorders (MPD) and acute leukemia.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/10. fever, leukocytosis, and referred thigh pain.The patient, a 43-year-old man with insulin-dependent diabetes mellitus, presented four days after sustaining a dog bite on his right hand, complaining of excruciating, intermittent, right thigh pain. He was febrile (temperature, 38.3 degrees C [101 degrees F]) and had a leukocyte count of 27.8 x 10(9) per liter (27,800 per mm3). On physical examination, he had a 2-cm open wound with minimal purulent drainage on the fourth digit of his right hand. He had some limited range of motion of the right hip and focal muscular tenderness in the medial thigh, but no other infectious or neurologic findings. A radiographic evaluation included chest, lumbar, right femur, and pelvic films and a computed tomographic (CT) scan of the abdomen; all were normal. In addition, a nuclear medicine scan showed no signs of infection. A CT scan and a magnetic resonance image (MRI) of the pelvis were done (Figures 1 and 2).- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
10/10. Primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage.We report a case of primary iliopsoas abscess successfully treated by ultrasonographically guided percutaneous drainage. A 56-year-old man presented at our hospital with lumbago, right-sided back pain, fever (temperature 38.5 degrees C) and chills. On physical examination, we found dark red skin, swelling, and tenderness localized at the right side at the back of his waist. Laboratory examination showed leukocytosis (white blood cell count 9700/mm3) with a leftward shift and elevated c-reactive protein (5.2 mg/dl). ultrasonography (US), computed tomography (CT), and magnetic resonance imaging revealed a hypodense lesion in the right iliopsoas muscle extending to the subcutaneous tissue. About 50 ml of thick yellow pus was obtained by ultrasonographically guided aspiration drainage. A drain catheter was inserted in the abscess cavity. Laboratory findings improved and clinical symptoms abated rapidly after drainage. On the twenty-first day after drainage, US and CT showed that the abscess was no longer present. The patient was discharged after 32 days of hospitalization. As possible primary diseases causing iliopsoas abscess, such as digestive tract disease, tuberculosis, and osteomyelitis, were not found, we diagnosed the disease as primary iliopsoas abscess. Although surgical drainage has been performed in most reported cases of iliopsoas abscess, this case report shows that ultrasonographically guided percutaneous drainage is also effective for treating primary iliopsoas abscess if it is diagnosed early enough.- - - - - - - - - - ranking = 14.171243464328keywords = physical examination, physical (Clic here for more details about this article) |
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