1/27. The spectrum of dilated cardiomyopathy. The Johns Hopkins experience with 1,278 patients.This report describes the evaluation of 1,278 patients referred to The Johns Hopkins Hospital with dilated cardiomyopathy. After a careful history and physical examination, selected laboratory tests, and endomyocardial biopsy, a specific diagnosis was made in 49% of cases. In 16% of cases the biopsy demonstrated a specific histologic diagnosis. myocarditis and coronary artery disease were the most frequent specific diagnoses; 51% of patients were classified as idiopathic. Thus a rigorous and systematic search can demonstrate an underlying cause for approximately one-half of patients with unexplained cardiomyopathy. Endomyocardial biopsy plays a crucial role in this evaluation. Six cases are presented which demonstrate the utility of endomyocardial biopsy in specific clinical situations. In addition to its routine use in monitoring rejection in heart transplant recipients, endomyocardial biopsy is indicated in the evaluation of possible infiltrative cardiomyopathy, in differentiating restrictive cardiomyopathy from constrictive pericarditis, and in diagnosing and monitoring doxorubicin cardiotoxicity. The importance of diagnosing myocarditis remains controversial, and disagreement persists about the utility of immunosuppressive therapy in these patients. A combination of clinical and histologic features can divide patients with myocarditis into 4 subgroups--acute, fulminant, chronic active, and chronic persistent. This classification provides prognostic information and may identify those patients who may respond to immunosuppression, as well as those likely to have adverse outcomes from such treatment. The continued development of novel molecular techniques may allow endomyocardial biopsy to provide greater prognostic and therapeutic information in the future.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/27. sarcoidosis presenting as an intramedullary spinal cord lesion.OBJECTIVES: sarcoidosis affects the spinal cord in only 0.43% of patients with sarcoidosis. Usually there is systemic involvement prior to the development of cord lesions. We present a case of sarcoid isolated to the intramedullary spinal cord, which was a diagnostic and therapeutic challenge. We review the case and then present a review of the literature with an emphasis on presentation, diagnosis and treatment. methods: We have reviewed a patient who presented with an isolated sarcoid granuloma affecting the cervical spinal cord. All pertinent history and physical information was extracted from the patient's chart and through patient interview. Laboratory, radiographic and pathological investigations are presented. RESULTS AND CONCLUSIONS: Fourteen patients have been reported with isolated intramedullary spinal cord sarcoidosis. Current practice supports the role of surgery for biopsy; mainstay of treatment is corticosteroids.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
3/27. Sinonasal disease in patients with sarcoidosis.sarcoidosis is a chronic granulomatous disease of unclear etiology with a propensity to involve the lower respiratory tract, but may also involve the upper respiratory tract. Histologically, it is characterized by non-caseating granulomas of various organ systems. Although nasal and sinus involvement is uncommon, patients with sarcoidosis presenting with nasal and sinus complaints may have sinonasal sarcoidosis or simply rhinosinusitis. We reviewed the cases of six patients with pulmonary sarcoidosis who developed chronic sinonasal disease. All six patients had intranasal findings consistent with sinonasal sarcoidosis, but only four had histologic evidence of sinonasal sarcoidosis. These four patients continue to require extensive therapy including topical steroids, systemic steroids, intralesional steroid injections, and nasal irrigations. We conclude that patients with histologically proven sinonasal sarcoidosis present a significant therapeutic challenge because their symptoms and physical findings are often persistent despite aggressive medical and surgical therapy. Their recalcitrant sinonasal disease is thought to result from the destruction of cilia and mucus-producing glands by the granulomatous process.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
4/27. pneumothorax complicating pulmonary emphysema.Clinical and roentgenographic findings were compared in patients 40 years of age and over and in those under 40 who were treated for acute unilateral pneumothorax. dyspnea and anxiety were pominent in the older individuals, although pneumothoraces were usually small. Because physical findings were often unreliable, roentgenograms were required. In the presence of pulmonary emphysema, loss of retractility prevented total collapse of the underlying lung. Increased intrapleural pressure caused over-expansion of the chest wall and the depression of the diaphragm without much mediastinal shifting. Partial collapse of emphysematous lobes demonstrated bullae that were not previously obvious. Respiratory failure developed in five patients over 40 years of age, but four of them recovered after relief of the pneumothorax. mortality for the group was low and related to associated pulmonary diseases.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
5/27. The role of MRI and nerve root biopsy in the diagnosis of neurosarcoidosis.OBJECTIVES: Neurological involvement occurs in 5-15% of patients with sarcoidosis and isolated "neurosarcoidosis" occurs in less than 1% of all cases. Classical clinical presentations have been described, such as bilateral facial palsy, but often the disease presents insidiously with varied signs and symptoms. We present a patient who required biopsy of a lumbar nerve root for diagnosis of chronic, progressive neurosarcoidosis and review the literature with an emphasis on diagnosis. methods: We have reviewed a patient who presented with signs and symptoms related to infiltration of her meninges and nerve roots by sarcoidosis. All pertinent history and physical information was taken from interviews with the patient and review of her chart. Laboratory, radiographic, and pathological investigations are presented. RESULTS AND CONCLUSIONS: A high index of suspicion is required for the diagnosis of neurosarcoidosis. gadolinium-enhanced MRI is useful but the findings are often nonspecific, and there should be a low threshold for biopsy whenever the diagnosis is considered.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
6/27. Nontraumatic, nonneoplastic subglottic stenosis.During a 20-year period, 12 patients with nontraumatic, nonneoplastic subglottic stenosis were seen at the Mayo Clinic. The etiologic factors were relapsing polychondritis, amyloidosis, sarcoidosis, and Wegener's granulomatosis. Because of the diverse initial presentation of the disease, the clinician should consider that the stenosis is a manifestation of a systemic disorder and carry out an otolaryngologic and physical examination with the appropriate roentgenograms and blood and urine tests. Treatment, if a systemic disease is proved, consists of appropriate medication. Surgery may be necessary, depending on the nature of the lesion. Small strictures may not need to be treated.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/27. sarcoidosis within a pituitary adenoma.A 54 year old man presented with frontal headaches for one year. A CT scan of the head revealed a pituitary mass. He denied a change in vision or galactorrhea, but did have decreased frequency of erections and a recent episode of renal stones. On physical exam, the cranial nerves were normal. Visual field exam revealed mild bilateral temporal defects. The genitalia were normal and the testes were soft. Laboratory evaluation revealed: Na, 134 mM/l; K, 6.7 mM/l; Cl, 104 mM/l; HCO3, 22 mM/l; BUN, 47 mg/dl; Cr, 8.3 mg/dl; Ca, 12.5 mg/dl; Phos, 5.5 mg/dl; prolactin, 32.0 ng/ml; T4, 4.46 microg/dl; TSH, 2.07 microU/ml; LH, 18.1 mIU/ml; FSH 3.2 mIU/ml; alpha subunit 1.6 ng/ml; testosterone 255 ng/dl; cortisol, 20.3 microg/dl; cortisol after 250 microg cortrosyn, 38.5 microg/dl (time 60 minutes); growth hormone, 1.4 ng/ml; IGF-1, 47 ng/ml; PTH, <1 pg/ml; 25-hydroxyvitamin D, 14 ng/ml; 1,25-dihydroxyvitamin D, 69 pg/ml. These results were felt to be consistent with a non-PTH-mediated hypercalcemia, such as humoral hypercalcemia of malignancy, or a vitamin d-mediated hypercalcemia, such as lymphoma, sarcoidosis or tuberculosis. head MRI demonstrated a 3.5 x 3.5 x 2.5 cm heterogeneous mass enlarging the sella, deforming the clivus and compressing the cavernous sinus, basilar artery and left side of the optic chiasm. There was a small focus of high signal in the superior part of the mass on the T1-weighted image from either a proteinaceous cyst with early calcium deposition or sub-acute blood. These radiographic findings were felt to be consistent with a pituitary adenoma. The patient was treated with intravenous hydration and thyroxine 50 microg daily and underwent a transsphenoidal resection of the pituitary lesion. Pathologic examination revealed a pituitary adenoma with multiple granulomas and crystalline material; this was consistent with sarcoid within the adenoma. Post-operatively, the serum LH fell to 5.5 mIU/ml. A subsequent transbronchial biopsy revealed multiple non-caseating granulomas. A serum ACE level was elevated at 132.6 U/l. He received oral prednisone 60 mg daily with resolution of the hypercalcemia. Neurosarcoidosis occurs in 5 to 15% of patients with sarcoidosis and can involve the hypothalamus and pituitary gland. This is the first reported case of sarcoidosis occurring within a pituitary adenoma.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
8/27. Sarcoid granulomatous nephritis occurring as isolated renal failure.A woman had clinically isolated renal failure caused by granulomatous sarcoid nephritis. At the onset of her illness, there were no historical, physical, or clinical features to suggest a definite causative diagnosis. After a renal biopsy specimen disclosed noncaseating epithelioid granulomas, a course of steroid therapy resulted in prompt disappearance of uremic symptoms and amelioration of her renal failure. Although leukopenia, delayed cellular immunity, and the response to steroids increased the suspicion that the patient had sarcoidosis, it was not until identical granulomas were obtained via mediastinal node biopsy that the diagnosis was confirmed. sarcoidosis may occur as isolated renal failure. Renal biopsy is indicated to ensure early diagnosis and prompt treatment of this steroid-responsive lesions.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
9/27. A 28 year old woman with ventricular tachycardia and an abnormal chest radiograph.A 28 year old white woman with no medical history presented to the emergency room with symptomatic non-sustained ventricular tachycardia. She was asymptomatic up to a few days before presentation. Her physical examination was essentially normal and hence did not help with the differential diagnosis of the problem. Bronchoscopic transbronchial biopsy led to the final diagnosis of cardiac sarcoidosis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
10/27. Presumed ocular sarcoidosis.BACKGROUND: sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Ocular manifestations commonly occur in patients with sarcoidosis, with a granulomatous anterior uveitis as the most-prevalent ocular sign. Acute symptoms of uveitis, such as pain, photophobia, lacrimation, or redness, may be absent. Without early detection and timely treatment, this "silent uveitis" may cause permanent ocular damage. case reports: Two patients came in for routine eye examinations, with no symptoms of anterior uveitis. The first, a 36-year-old man, had a bilateral granulomatous anterior uveitis. The uveitis was treated with topical corticosteroids, with no complications. The second case involved a 44-year-old woman with chronic, recurrent, bilateral, non-granulomatous anterior uveitis. Despite treatment with topical and oral corticosteroids. the patient had a prolonged course with recurrent episodes leading to secondary sequelae, including glaucoma and cataract. Both patients were co-managed with internal medicine, and in each case, systemic workups were consistent with sarcoidosis. CONCLUSION: Anterior uveitis often manifests as the initial presentation of sarcoidosis. Without acute symptoms, the detection and diagnosis may be delayed, leading to visual deterioration. The diagnosis of sarcoidosis may be difficult, owing to the lack of definitive diagnostic criteria and a variety of presentations. Histologic confirmation may not always be possible or practical. However, a range of serological and radiological tests, when combined with physical and ophthalmic evaluation, can lead to the presumed diagnosis of sarcoidosis. Aggressive treatment is imperative in order to prevent permanent structural damage to the eye resulting from this idiopathic inflammation.- - - - - - - - - - ranking = 0.09173040230916keywords = physical (Clic here for more details about this article) |
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