1/5. Spontaneous remission in myelodysplastic syndrome.A 73-year-old man was admitted for investigation of pancytopenia. His physical examination was unremarkable and the bone marrow aspirate was compatible with myelodysplastic syndrome (RAEB). cytogenetic analysis of the bone marrow revealed a trisomy 21. The patient received transfusions of packed red cells, and his condition remained stable for the next 7 months. He was then admitted with a chest infection and was treated with broad-spectrum antibiotics with satisfactory response. During his hospitalization there was a gradual increase in his complete blood count values, which persisted, resulting in a normal peripheral blood after 3 months. A bone marrow aspirate performed at that time revealed normal findings with no karyotypic abnormalities, indicating a spontaneous remission. The patient remained stable for the next 6 months; then he recurred with 20% blasts in his bone marrow and reappearance of trisomy 21 in 42% of the metaphases examined. Several hematologic malignancies with spontaneous remissions have been described to date, but they have generally been short and recurrence is the rule, as in the case described. The role of endogenous cytokines in triggering these spontaneous remissions is under question, as the exact mechanism is unknown.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/5. Facial submandibular cellulitis associated with late-onset group B streptococcal infection.A complete history and systematic physical examination are important first steps in assessing any infant. In some instances these steps may provide immediate clues to a potentially life-threatening illness. This article presents the case of a former 26-week male infant, who presented on day of life 42, 32 weeks gestation corrected, with increased respiratory distress and an evolving lesion on the left lower cheek. The classic location and progressive erythema, warmth, induration, and tenderness in the submandibular region strongly suggested the diagnosis of group B streptococcal (GBS) cellulitis. Despite the presence of concurrent GBS septicemia, the infant had complete resolution of focal and systemic symptoms with 10 days of treatment. One month later, the infant developed pneumonia with respiratory failure, shock, culture-positive septicemia, and presumed meningitis and was again treated with broad-spectrum antibiotics. diagnosis at that time was late-onset group B streptococcal infection. Serotypes were not available to aid in distinguishing between recurrent or persistent GBS versus a new occurrence of late-onset disease. A brief overview of late-onset GBS infections and their cutaneous manifestations, along with a step-by-step guide to physical examination, is provided. The differential diagnosis for facial cellulitis is reviewed with an emphasis on early recognition and treatment in light of the escalated risks for persistent or recurrent GBS infection in infants with GBS cellulitis.- - - - - - - - - - ranking = 2keywords = physical examination, physical (Clic here for more details about this article) |
3/5. A case of superior vena cava syndrome caused by klebsiella pneumoniae.A 27 yr old man presented with productive cough, fever and manifestations of superior vena cava syndrome. He was an alcoholic but had been in good health until 3 days prior to admission. The physical examination, the chest radiograph and the results of the sputum culture were compatible with klebsiella pneumoniae pneumonia of the right upper lobe. The superior vena cava scintigram using technetium-99m showed near total occlusion of the superior vena cava, while sputum cytology, chest computed tomography, and bronchoscopy were all negative for malignant aetiology. Antibiotic therapy brought about slow resolution of the pneumonia and also of the superior vena caval obstruction. The follow-up scintigram showed normalized venous flow of the superior vena cava. To our knowledge, this is the first case of superior vena cava syndrome developed in probable association with klebsiella pneumoniae pneumonia.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/5. Cryptococcal pneumonia complicating pregnancy.In the present report we describe 4 previously healthy women who developed cryptococcal pneumonia during pregnancy, and 1 pregnant woman with cryptococcal meningitis. These cases illustrate a previously uncharacterized spectrum of cryptococcal disease. We also discuss 24 patients previously reported who had cryptococcal meningitis during pregnancy. Finally, we review the available data for each therapeutic option and present an algorithm for management based on appraisals of disease severity and risk to the unborn fetus. This report emphasizes the need for heightened awareness of cryptococcosis in the differential diagnosis of pneumonia, chest pain, and hypoxemia in the pregnant patient, but at present, there are insufficient epidemiologic data to determine whether incidences of pulmonary or disseminated cryptococcosis actually increase during pregnancy. The risk of congenital cryptococcosis to the unborn fetus is low, and the most likely mechanism whereby neonates acquire invasive fungal pulmonary infection is through aspiration. While it is unclear whether there is any real increased risk of spontaneous abortion or premature labor, the data indicate that overall fetal outcome depends on effective treatment of maternal infection. For patients with dense air-space consolidation, progressive pulmonary disease, or dissemination, antifungal therapy is necessary. Optimal treatment is determined by the acuity and severity of the clinical presentation. Amphotericin B (approximately 1 g) with or without flucytosine represents the choice for initial treatment of the more acutely ill patient with disseminated or progressive pulmonary cryptococcosis who requires hospitalization (whether during or after pregnancy). Oral fluconazole appears to be safe and effective alternative therapy after delivery for the less severely ill patient who can be managed on an outpatient basis. While the use of fluconazole during pregnancy generally appears safe in terms of fetal outcome (49, 58), the class C status and single report of fetal malformation (62) preclude confident recommendation for its use during pregnancy. The risks and benefits of this effective and generally less toxic drug should be discussed with the parents and weighed against the use of amphotericin b. For pregnant women with limited pulmonary cryptococcosis (segmental or nodular infiltrates) and no evidence of dissemination, we recommend close follow-up without antifungal therapy similar to the recommendation for normal hosts with minimal disease. However, it is important to note that there is no extensive experience upon which to base this recommendation for pregnant individuals (45, 55, 103, 108). It is prudent to use frequent physical examinations (for example, every 1-2 months), combined with chest roentgenograms and serum cryptococcal antigens to monitor progression and/or development of disease in both the mother and child for approximately 6 months postpartum. In conclusion, cryptococcosis during pregnancy presents a special challenge to the clinician. A balanced therapeutic approach holds great promise for successful maternal and fetal outcomes.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
5/5. legionella bozemanii pneumonia in three patients with AIDS.legionella bozemanii is known to cause pneumonia often in immunocompromised hosts. To our knowledge, we describe the first three cases of L. bozemanii pneumonia in patients with AIDS. At the time of presentation, these patients had varied histories, physical findings, and radiological findings. All three patients had a uniformly excellent response to treatment despite receiving different antibiotic regimens. The cases illustrate the need for thorough diagnostic workups and prompt institution of antibiotic therapy when clinical suspicion for L. bozemanii infection is high.- - - - - - - - - - ranking = 0.10911489867617keywords = physical (Clic here for more details about this article) |