This case report describes a 30-month-old boy with scurvy who sustained a traumatic injury to his left thigh. He presented with left hip and thigh pain two weeks after a fall. Examination revealed limited range of motion, warmth, and inability to bear weight on the left leg. Radiographs showed signs of scurvy like Wimberger's ring and Frenkel line. Vitamin C supplementation provided no improvement and MRI showed subperiosteal abscess and osteomyelitis in both femurs and tibias. Debridement of the left femur found only subperiosteal blood. The patient's vitamin C level was very low and he eventually healed after two months of vitamin
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
This document discusses complications that can occur during MRI, endoscopy, and dental procedures when sedation or anesthesia is used. It provides data on adverse events and deaths from studies in the United States and United Kingdom. Risk factors discussed include the type of sedation used, the age of the patient, and procedures occurring outside of an operating room. The need for proper patient monitoring during non-operating room anesthesia is emphasized.
1. A 55-year-old man presented with left eye ptosis and diplopia, symptoms of third cranial nerve palsy. Laboratory tests found elevated white blood cell count. Bone marrow biopsy revealed granulocytic hyperplasia and a positive test for the Philadelphia chromosome, confirming a diagnosis of chronic myelogenous leukemia (CML).
2. This is the first reported case of CML initially presenting solely as third cranial nerve palsy. While cranial neuropathies have been reported in other types of leukemia and lymphoma, this nerve palsy manifestation has not previously been associated with CML.
3. CML may present atypically with isolated cranial nerve pals
- AL amyloidosis is characterized by abnormal light chains produced by plasma cells that misfold and deposit as amyloid in tissues like the heart, kidneys, liver, and nervous system. This can cause organ dysfunction.
- Cardiac involvement is common and causes restrictive cardiomyopathy. Symptoms include heart failure, arrhythmias, and conduction abnormalities. Biomarkers, echocardiogram, cardiac MRI, and endomyocardial biopsy are used in diagnosis.
- Prognosis is poor if cardiac involvement is present, with median survival of less than 2 years with heart failure symptoms. Treatment involves chemotherapy and stem cell transplantation to suppress the plasma cell disorder causing amyloid deposition.
Incidence and risk factors between TBI/SCI and venous thromboembolismAmit Agrawal
Patients with traumatic brain injury (TBI) or spinal cord injury (SCI) have an increased risk of venous thromboembolism (VTE). The reported incidence of VTE in studies of TBI and SCI patients varies widely from 1-54% depending on factors like injury severity and use of prophylaxis. The true incidence is difficult to determine due to limitations of studies and many cases being asymptomatic. VTE risk is highest in the acute phase after injury.
Anemo 2010 - Inghilleri - Anemie preoperatorie valutazione e trattamentoanemo_site
This document summarizes guidelines for evaluating and treating preoperative anemia. It finds that preoperative hemoglobin level is the strongest predictor of blood transfusion need after surgery. Guidelines recommend determining hemoglobin levels for elective surgery patients around 28 days before the procedure. Treatment for preoperative anemia depends on the underlying cause, and may include oral or intravenous iron, erythropoietin stimulating agents, or addressing nutritional deficiencies. The goal is to optimize hemoglobin levels before elective surgery to reduce the risk of blood transfusions.
Anemia is common in cancer patients, occurring in 30-86% of cases depending on malignancy type and Hb level definition of anemia. Anemia can be caused by the disease itself through cytokine-mediated effects on erythropoiesis or nutritional deficiencies, or be treatment-related due to chemotherapy, radiotherapy or other drugs. Erythropoietin treatment is effective at reducing transfusion needs and improving quality of life by increasing Hb levels and reducing fatigue in the majority of anemic cancer patients. However, some patients do not respond due iron deficiency or other factors. Iron supplementation can help improve response rates to EPO treatment.
Patients with systemic autoimmune diseases such as lupus and rheumatoid arthritis have a striking increase in risk to develop vascular complications such as myocardial infarction and stroke. Immune dysregulation characteristic of these diseases appears to play a prominent role in this enhanced risk.
In this presentation, Dr. Mariana Kaplan highlights the role of the immune system in the development of vasculopathy and premature atherosclerosis in systemic autoimmunity and discuss potential strategies to prevent these devastating complications.
Key Topics Include:
- To review the epidemiology of premature vascular disease in systemic autoimmunity
- To review the pathogenic mechanisms that lead to vascular damage in patients with autoimmunity
- To discuss potential therapeutic strategies to prevent/treat vascular damage in patients with autoimmune diseases
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
This document discusses complications that can occur during MRI, endoscopy, and dental procedures when sedation or anesthesia is used. It provides data on adverse events and deaths from studies in the United States and United Kingdom. Risk factors discussed include the type of sedation used, the age of the patient, and procedures occurring outside of an operating room. The need for proper patient monitoring during non-operating room anesthesia is emphasized.
1. A 55-year-old man presented with left eye ptosis and diplopia, symptoms of third cranial nerve palsy. Laboratory tests found elevated white blood cell count. Bone marrow biopsy revealed granulocytic hyperplasia and a positive test for the Philadelphia chromosome, confirming a diagnosis of chronic myelogenous leukemia (CML).
2. This is the first reported case of CML initially presenting solely as third cranial nerve palsy. While cranial neuropathies have been reported in other types of leukemia and lymphoma, this nerve palsy manifestation has not previously been associated with CML.
3. CML may present atypically with isolated cranial nerve pals
- AL amyloidosis is characterized by abnormal light chains produced by plasma cells that misfold and deposit as amyloid in tissues like the heart, kidneys, liver, and nervous system. This can cause organ dysfunction.
- Cardiac involvement is common and causes restrictive cardiomyopathy. Symptoms include heart failure, arrhythmias, and conduction abnormalities. Biomarkers, echocardiogram, cardiac MRI, and endomyocardial biopsy are used in diagnosis.
- Prognosis is poor if cardiac involvement is present, with median survival of less than 2 years with heart failure symptoms. Treatment involves chemotherapy and stem cell transplantation to suppress the plasma cell disorder causing amyloid deposition.
Incidence and risk factors between TBI/SCI and venous thromboembolismAmit Agrawal
Patients with traumatic brain injury (TBI) or spinal cord injury (SCI) have an increased risk of venous thromboembolism (VTE). The reported incidence of VTE in studies of TBI and SCI patients varies widely from 1-54% depending on factors like injury severity and use of prophylaxis. The true incidence is difficult to determine due to limitations of studies and many cases being asymptomatic. VTE risk is highest in the acute phase after injury.
Anemo 2010 - Inghilleri - Anemie preoperatorie valutazione e trattamentoanemo_site
This document summarizes guidelines for evaluating and treating preoperative anemia. It finds that preoperative hemoglobin level is the strongest predictor of blood transfusion need after surgery. Guidelines recommend determining hemoglobin levels for elective surgery patients around 28 days before the procedure. Treatment for preoperative anemia depends on the underlying cause, and may include oral or intravenous iron, erythropoietin stimulating agents, or addressing nutritional deficiencies. The goal is to optimize hemoglobin levels before elective surgery to reduce the risk of blood transfusions.
Anemia is common in cancer patients, occurring in 30-86% of cases depending on malignancy type and Hb level definition of anemia. Anemia can be caused by the disease itself through cytokine-mediated effects on erythropoiesis or nutritional deficiencies, or be treatment-related due to chemotherapy, radiotherapy or other drugs. Erythropoietin treatment is effective at reducing transfusion needs and improving quality of life by increasing Hb levels and reducing fatigue in the majority of anemic cancer patients. However, some patients do not respond due iron deficiency or other factors. Iron supplementation can help improve response rates to EPO treatment.
Patients with systemic autoimmune diseases such as lupus and rheumatoid arthritis have a striking increase in risk to develop vascular complications such as myocardial infarction and stroke. Immune dysregulation characteristic of these diseases appears to play a prominent role in this enhanced risk.
In this presentation, Dr. Mariana Kaplan highlights the role of the immune system in the development of vasculopathy and premature atherosclerosis in systemic autoimmunity and discuss potential strategies to prevent these devastating complications.
Key Topics Include:
- To review the epidemiology of premature vascular disease in systemic autoimmunity
- To review the pathogenic mechanisms that lead to vascular damage in patients with autoimmunity
- To discuss potential therapeutic strategies to prevent/treat vascular damage in patients with autoimmune diseases
Management of Anemia in cancer patientsAjeet Gandhi
Anemia in cancer patients are important both in terms of quality of life as well as response to therapy. Cause of anemia is multi-factorial and its management is critical in optimizing best outcomes of cancer patients
Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J....Brussels Heart Center
This document summarizes a presentation given by Dr. Remes on the surgical treatment of atrial fibrillation. It discusses the pathophysiology of AF and reviews studies on the Cox Maze procedure. Dr. Remes presents data on success rates of different Cox Maze variations and predictors of recurrence. Minimally invasive surgical approaches for AF ablation including pulmonary vein isolation are discussed. Energy sources for ablation like bipolar radiofrequency are highlighted. Guidelines for lone AF surgery are reviewed. In conclusion, the document provides an overview of the state of the art in surgical treatment of AF.
The document discusses trends in medical imaging and its role in modern medicine. It notes that medical imaging is becoming less invasive, more precise, and helps integrate complex clinical information to aid diagnosis and treatment. Molecular imaging allows recognition of molecules involved in diseases and monitoring of treatment response at the molecular level. The document outlines various radiotracers and medical imaging techniques used today as well as areas of emerging research.
Transplanting cardiac amyloidosis when to refer for heart transplantdrucsamal
1. Transplantation, including heart transplant (OHT) plus stem cell transplant (ASCT) for light chain (AL) amyloidosis or OHT plus liver transplant (OLT) for transthyretin (TTR) amyloidosis, can successfully treat patients with cardiac amyloidosis and heart failure.
2. Patients with AL amyloidosis who died waiting for a heart transplant had more advanced disease and poorer heart function compared to those who received a transplant.
3. Recurrence of cardiac amyloid post-OHT occurred in 19% of AL patients who did not receive chemotherapy beforehand, but none of those treated with chemotherapy had recurrence.
4. Survival after OHT is similar for AL and T
Soft tissue lesions involving the cranio-vertebral junction can cause a variety of symptoms and require a multidisciplinary treatment approach. Key symptoms include neck pain, neurological deficits, and spinal instability. Magnetic resonance imaging is often used to identify the underlying pathology and assess involvement of neural and vascular structures. Management may involve surgical resection to address tumors or infections, restoration of spinal stability, and decompression to relieve pressure on the spinal cord or brainstem. A comprehensive understanding of cranio-vertebral junction anatomy is important for correctly diagnosing and safely treating these complex lesions.
This document discusses the remodeling of the brachial artery (AB) in arterial hypertension (HTA). It covers the following key points:
1. AB remodeling in HTA can be adaptive/compensatory (increasing diameter and wall thickness to maintain luminal area) or maladaptive. Imaging techniques like ultrasound can evaluate AB morphology and function.
2. Spectral Doppler analysis of AB blood flow shows broadening of the spectral envelope in HTA, reflecting increased arterial stiffness. Flow-mediated dilation (%FMD) evaluates endothelial function. Lower %FMD correlates with cardiovascular risk factors and subclinical atherosclerosis.
3. AB remodeling correlates with target organ damage in HTA. Different HTA phenotypes (e
Background: Pancytopenia in the peripheral blood is an indication for further haematological investigations. Bone marrow aspiration and biopsy evaluation along with good clinical correlation is of utmost importance to evaluate the causes of pancytopenia that can help in planning further investigations and treatment. The bone marrow trephine biopsy is indicated when there is a dry tap on marrow aspiration.
This document summarizes research on myeloid cells and cardiovascular health conducted by Matthias Nahrendorf, a professor of radiology. It discusses how myeloid cells like monocytes and macrophages play roles in processes like atherosclerosis, acute myocardial infarction, and infarct healing. The document also explores how the bone marrow and spleen contribute monocytes during inflammation and injury. It summarizes research showing how stress, exercise, and other factors can impact hematopoiesis and myeloid cell production/phenotypes in the bone marrow.
This document discusses high sensitivity cardiac troponin assays and their clinical applications. It summarizes that high sensitivity troponin assays can measure troponin levels in 50-100% of healthy individuals, allowing for monitoring of baseline troponin levels and detection of deteriorating cardiac conditions. These novel assays may become important tools for predicting patient risk of future adverse cardiac events and guiding preventative treatment adjustments. The document also reviews the biology and genetics of cardiac troponins, classification of troponin assay sensitivities, and use of troponin testing to diagnose acute myocardial infarction.
The Coagulopathy of Trauma: A Review of MechanismsEmergency Live
Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways.
1) The document discusses cardiac troponins, including their biochemistry, physiology, sensitivity and specificity as biomarkers of myocardial injury.
2) It describes the causes of elevated troponin levels in humans and animals, including ischemic, toxic and inflammatory causes of myocardial damage.
3) False positive troponin results can occur in renal failure patients, though cardiac troponin I may be more specific than cardiac troponin T for detecting myocardial injury in those with kidney disease.
The Indian Consensus Document on Cardiac BiomarkerApollo Hospitals
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling,
neurohormonal activation, etc.
This document discusses renal complications associated with hematologic malignancies and their treatment. It provides 3 key points:
1) Lymphomatous infiltration of the kidneys is a common but under-recognized complication of malignant lymphomas, seen in up to one-third of patients on autopsy. Bilateral symmetrical kidney enlargement is the most common imaging finding.
2) Chemotherapies used to treat hematologic malignancies can cause acute kidney injury through tumor lysis syndrome or direct nephrotoxicity. Ifosfamide, in particular, is associated with proximal tubule dysfunction and Fanconi syndrome.
3) Long-term renal complications of chemotherapy include chronic kidney disease, which may progress even after
This document is a slide presentation on cardiac amyloidosis given by Dr. Kyle Klarich at the ACC conference in March 2015. It discusses cardiac amyloidosis, how to diagnose it, the different types including AL and TTR amyloidosis, and treatments. The presentation uses patient cases to illustrate clues to diagnosis and shows imaging findings. It emphasizes that amyloidosis is underdiagnosed and diagnostic delay worsens prognosis, and discusses new treatments for both AL and TTR amyloidosis.
This document discusses parathyroid gland function and dysfunction in dialysis patients. It begins with some background on parathyroid glands and how parathyroid hormone (PTH) levels increase in kidney disease patients. It then discusses the sequence of events that lead to elevated PTH, including hyperphosphatemia, hypocalcemia, decreased calcitriol, and increased FGF-23 levels. The document notes that treatment of secondary hyperparathyroidism is important to reduce risks like vascular calcification and mortality. While parathyroidectomy can significantly lower PTH, long-term outcomes need further study and bone biopsies may be needed in some cases to rule out other bone diseases. Overall, the document provides an
This document discusses parathyroid gland function and dysfunction in dialysis patients. It begins with some background on parathyroid glands and how parathyroid hormone (PTH) levels increase in kidney disease patients. It then outlines the sequence of events that leads to elevated PTH, including hyperphosphatemia, hypocalcemia, decreased calcitriol, and increased FGF-23 levels. The document notes that both low calcitriol and high PTH levels occur as chronic kidney disease progresses. It discusses the importance of treating secondary hyperparathyroidism to reduce risks like vascular calcification and mortality. The document reviews studies on PTH levels, bone disease patterns, and outcomes of parathyroidectomy and medical
Avascular Necrosis of Humeral Head after Thalidomide Use: A Report of Two Cas...CrimsonPublishersOPROJ
Avascular Necrosis of Humeral Head after Thalidomide Use: A Report of Two Cases by Ahmad Rezaeian* in Crimson Publishers: Orthopedic Research and Reviews Journal
- Biomarkers such as troponins, copeptin, and natriuretic peptides have become indispensable diagnostic tools in cardiology over the past 60 years.
- Troponins are the gold standard for diagnosing myocardial infarction, while copeptin allows for very early rule-out of MI.
- New biomarkers continue to be discovered through advances in genomics, epigenetics, and other 'omics' fields, with microRNAs showing promise to improve risk stratification and precision medicine for cardiovascular disease.
- Biomarkers have transformed cardiology practice and decision-making, with troponins in particular demonstrating their ability to guide therapies and intervention timing for conditions like ACS.
This case study summarizes the care of an 18-year-old male ("RMR") who suffered a traumatic amputation of his left upper extremity and a fractured left femur due to a motor vehicle accident. The summary includes:
1) Demographic and admission details of the patient including diagnosis of mangled left upper extremity and fractured left femur.
2) Results of diagnostic tests including chest X-ray, bloodwork and surgical management including pre-operative, intra-operative and post-operative phases.
3) Nursing care plan that assesses and plans interventions for issues such as acute pain, impaired mobility, self-care deficits, disturbed body image, and phantom limb pain.
Introduction: Envenomation is a public health problem in developing countries. Neurovascular complications are not exceptional.
Observations: We report two cases of hemorrhagic stroke which complicate an envenomation treated late.
The fi rst patient was 27 years old woman, who had been admitted for right hemiparesis and aphasia two weeks after a viperidae bite.
She was then treated with polyvalent antivenom (FAV-Afrique®).
Management of Anemia in cancer patientsAjeet Gandhi
Anemia in cancer patients are important both in terms of quality of life as well as response to therapy. Cause of anemia is multi-factorial and its management is critical in optimizing best outcomes of cancer patients
Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J....Brussels Heart Center
This document summarizes a presentation given by Dr. Remes on the surgical treatment of atrial fibrillation. It discusses the pathophysiology of AF and reviews studies on the Cox Maze procedure. Dr. Remes presents data on success rates of different Cox Maze variations and predictors of recurrence. Minimally invasive surgical approaches for AF ablation including pulmonary vein isolation are discussed. Energy sources for ablation like bipolar radiofrequency are highlighted. Guidelines for lone AF surgery are reviewed. In conclusion, the document provides an overview of the state of the art in surgical treatment of AF.
The document discusses trends in medical imaging and its role in modern medicine. It notes that medical imaging is becoming less invasive, more precise, and helps integrate complex clinical information to aid diagnosis and treatment. Molecular imaging allows recognition of molecules involved in diseases and monitoring of treatment response at the molecular level. The document outlines various radiotracers and medical imaging techniques used today as well as areas of emerging research.
Transplanting cardiac amyloidosis when to refer for heart transplantdrucsamal
1. Transplantation, including heart transplant (OHT) plus stem cell transplant (ASCT) for light chain (AL) amyloidosis or OHT plus liver transplant (OLT) for transthyretin (TTR) amyloidosis, can successfully treat patients with cardiac amyloidosis and heart failure.
2. Patients with AL amyloidosis who died waiting for a heart transplant had more advanced disease and poorer heart function compared to those who received a transplant.
3. Recurrence of cardiac amyloid post-OHT occurred in 19% of AL patients who did not receive chemotherapy beforehand, but none of those treated with chemotherapy had recurrence.
4. Survival after OHT is similar for AL and T
Soft tissue lesions involving the cranio-vertebral junction can cause a variety of symptoms and require a multidisciplinary treatment approach. Key symptoms include neck pain, neurological deficits, and spinal instability. Magnetic resonance imaging is often used to identify the underlying pathology and assess involvement of neural and vascular structures. Management may involve surgical resection to address tumors or infections, restoration of spinal stability, and decompression to relieve pressure on the spinal cord or brainstem. A comprehensive understanding of cranio-vertebral junction anatomy is important for correctly diagnosing and safely treating these complex lesions.
This document discusses the remodeling of the brachial artery (AB) in arterial hypertension (HTA). It covers the following key points:
1. AB remodeling in HTA can be adaptive/compensatory (increasing diameter and wall thickness to maintain luminal area) or maladaptive. Imaging techniques like ultrasound can evaluate AB morphology and function.
2. Spectral Doppler analysis of AB blood flow shows broadening of the spectral envelope in HTA, reflecting increased arterial stiffness. Flow-mediated dilation (%FMD) evaluates endothelial function. Lower %FMD correlates with cardiovascular risk factors and subclinical atherosclerosis.
3. AB remodeling correlates with target organ damage in HTA. Different HTA phenotypes (e
Background: Pancytopenia in the peripheral blood is an indication for further haematological investigations. Bone marrow aspiration and biopsy evaluation along with good clinical correlation is of utmost importance to evaluate the causes of pancytopenia that can help in planning further investigations and treatment. The bone marrow trephine biopsy is indicated when there is a dry tap on marrow aspiration.
This document summarizes research on myeloid cells and cardiovascular health conducted by Matthias Nahrendorf, a professor of radiology. It discusses how myeloid cells like monocytes and macrophages play roles in processes like atherosclerosis, acute myocardial infarction, and infarct healing. The document also explores how the bone marrow and spleen contribute monocytes during inflammation and injury. It summarizes research showing how stress, exercise, and other factors can impact hematopoiesis and myeloid cell production/phenotypes in the bone marrow.
This document discusses high sensitivity cardiac troponin assays and their clinical applications. It summarizes that high sensitivity troponin assays can measure troponin levels in 50-100% of healthy individuals, allowing for monitoring of baseline troponin levels and detection of deteriorating cardiac conditions. These novel assays may become important tools for predicting patient risk of future adverse cardiac events and guiding preventative treatment adjustments. The document also reviews the biology and genetics of cardiac troponins, classification of troponin assay sensitivities, and use of troponin testing to diagnose acute myocardial infarction.
The Coagulopathy of Trauma: A Review of MechanismsEmergency Live
Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways.
1) The document discusses cardiac troponins, including their biochemistry, physiology, sensitivity and specificity as biomarkers of myocardial injury.
2) It describes the causes of elevated troponin levels in humans and animals, including ischemic, toxic and inflammatory causes of myocardial damage.
3) False positive troponin results can occur in renal failure patients, though cardiac troponin I may be more specific than cardiac troponin T for detecting myocardial injury in those with kidney disease.
The Indian Consensus Document on Cardiac BiomarkerApollo Hospitals
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling,
neurohormonal activation, etc.
This document discusses renal complications associated with hematologic malignancies and their treatment. It provides 3 key points:
1) Lymphomatous infiltration of the kidneys is a common but under-recognized complication of malignant lymphomas, seen in up to one-third of patients on autopsy. Bilateral symmetrical kidney enlargement is the most common imaging finding.
2) Chemotherapies used to treat hematologic malignancies can cause acute kidney injury through tumor lysis syndrome or direct nephrotoxicity. Ifosfamide, in particular, is associated with proximal tubule dysfunction and Fanconi syndrome.
3) Long-term renal complications of chemotherapy include chronic kidney disease, which may progress even after
This document is a slide presentation on cardiac amyloidosis given by Dr. Kyle Klarich at the ACC conference in March 2015. It discusses cardiac amyloidosis, how to diagnose it, the different types including AL and TTR amyloidosis, and treatments. The presentation uses patient cases to illustrate clues to diagnosis and shows imaging findings. It emphasizes that amyloidosis is underdiagnosed and diagnostic delay worsens prognosis, and discusses new treatments for both AL and TTR amyloidosis.
This document discusses parathyroid gland function and dysfunction in dialysis patients. It begins with some background on parathyroid glands and how parathyroid hormone (PTH) levels increase in kidney disease patients. It then discusses the sequence of events that lead to elevated PTH, including hyperphosphatemia, hypocalcemia, decreased calcitriol, and increased FGF-23 levels. The document notes that treatment of secondary hyperparathyroidism is important to reduce risks like vascular calcification and mortality. While parathyroidectomy can significantly lower PTH, long-term outcomes need further study and bone biopsies may be needed in some cases to rule out other bone diseases. Overall, the document provides an
This document discusses parathyroid gland function and dysfunction in dialysis patients. It begins with some background on parathyroid glands and how parathyroid hormone (PTH) levels increase in kidney disease patients. It then outlines the sequence of events that leads to elevated PTH, including hyperphosphatemia, hypocalcemia, decreased calcitriol, and increased FGF-23 levels. The document notes that both low calcitriol and high PTH levels occur as chronic kidney disease progresses. It discusses the importance of treating secondary hyperparathyroidism to reduce risks like vascular calcification and mortality. The document reviews studies on PTH levels, bone disease patterns, and outcomes of parathyroidectomy and medical
Avascular Necrosis of Humeral Head after Thalidomide Use: A Report of Two Cas...CrimsonPublishersOPROJ
Avascular Necrosis of Humeral Head after Thalidomide Use: A Report of Two Cases by Ahmad Rezaeian* in Crimson Publishers: Orthopedic Research and Reviews Journal
- Biomarkers such as troponins, copeptin, and natriuretic peptides have become indispensable diagnostic tools in cardiology over the past 60 years.
- Troponins are the gold standard for diagnosing myocardial infarction, while copeptin allows for very early rule-out of MI.
- New biomarkers continue to be discovered through advances in genomics, epigenetics, and other 'omics' fields, with microRNAs showing promise to improve risk stratification and precision medicine for cardiovascular disease.
- Biomarkers have transformed cardiology practice and decision-making, with troponins in particular demonstrating their ability to guide therapies and intervention timing for conditions like ACS.
This case study summarizes the care of an 18-year-old male ("RMR") who suffered a traumatic amputation of his left upper extremity and a fractured left femur due to a motor vehicle accident. The summary includes:
1) Demographic and admission details of the patient including diagnosis of mangled left upper extremity and fractured left femur.
2) Results of diagnostic tests including chest X-ray, bloodwork and surgical management including pre-operative, intra-operative and post-operative phases.
3) Nursing care plan that assesses and plans interventions for issues such as acute pain, impaired mobility, self-care deficits, disturbed body image, and phantom limb pain.
Introduction: Envenomation is a public health problem in developing countries. Neurovascular complications are not exceptional.
Observations: We report two cases of hemorrhagic stroke which complicate an envenomation treated late.
The fi rst patient was 27 years old woman, who had been admitted for right hemiparesis and aphasia two weeks after a viperidae bite.
She was then treated with polyvalent antivenom (FAV-Afrique®).
Annals of Hematology & Oncology is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts covering various aspects in the field of medicine that includes early to late symptoms, diagnosis, staging, treatment, prognosis, and follow-up of two interrelated medical specialties namely hematology and oncology. This journal also focuses upon the study of blood, the blood-forming organs, and blood diseases, cancer etiology, diagnosis, staging, treatment, drugs, epidemiology, and awareness.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and technology with intent to bridge the gap between academia and research access.
Annals of Hematology & Oncology accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all the related aspects of hematology and oncology.
Adi, a six-year-old boy, is experiencing symptoms of aplastic anemia including paleness, fast heartbeat, loss of appetite, and bleeding from his gums. He has a history of taking chloramphenicol often, which was purchased by his mother. The doctor recommends a complete blood examination and bone marrow aspiration to diagnose Adi's condition and determine appropriate management.
This document describes a case study of a rare case of cardiac metastases from solid papillary carcinoma (SPC) of the breast. A 67-year-old woman with a history of breast cancer underwent surgery to remove a tumor in her right atrium. Pathological examination of the tumor found that it was an invasive SPC of the breast that had metastasized to the heart. Immunohistochemical staining confirmed the diagnosis. Analysis of this case improves understanding of the diagnosis and treatment of metastatic SPC of the breast to rare sites like the heart.
This document summarizes a study examining drug-induced hepatotoxicity in acute lymphoblastic leukemia patients undergoing chemotherapy. The study found that liver enzymes including bilirubin, ALT, ALP, and GGT increased significantly after one month of induction chemotherapy compared to before treatment. Additionally, hematological parameters like hemoglobin, RBC count, and neutrophil count improved after chemotherapy, while blast cells decreased. The study concludes that chemotherapy can cause hepatotoxicity in ALL patients during the induction phase.
Multiple myeloma is a cancer of plasma cells that results in excessive proliferation of monoclonal proteins. It commonly causes lytic bone lesions, anemia, hypercalcemia and renal failure. Diagnosis involves blood and bone marrow tests detecting the monoclonal protein and plasma cell percentage. Staging systems include Durie-Salmon and International Staging System. Treatment involves disease-specific therapies like chemotherapy, steroids, stem cell transplantation and supportive care for complications. Bisphosphonates are the standard treatment for bone disease and fractures may require surgical stabilization.
Enhancing Limb Salvage by Non-Mobilized Peripheral Blood Angiogenic Cell Prec...lifextechnologies
This document describes a study that assessed the efficacy and safety of implanting non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in 6 patients with critical limb ischemia who were not candidates for standard revascularization treatments. The results showed no complications from the procedure. Five patients (83.3%) had improved circulation in the distal limb, with complete healing of ulcers/amputation sites. However, one patient later required an amputation due to foot infection. The preliminary results suggest NMPB-ACPs therapy may be safe and improve circulation, but a larger controlled trial is needed to confirm these findings.
The document discusses two conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). PNH is a complement-mediated hemolytic anemia treated with the drug eculizumab, a C5a inhibitor. aHUS is a complement-mediated thrombotic microangiopathy that can cause stroke, heart attack, and kidney failure, and is also treated with eculizumab. The document asks the reader to identify PNH, aHUS, and the mode of action of eculizumab.
Austin Arthritis is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Arthritis.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances & happenings in all areas of Arthritis. Austin Arthritis accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Arthritis.
Austin Arthritis strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science
Acquired a amyloidosis from injection drug use presenting with atraumatic spl...Dr Amolkumar W Diwan
This case report describes a 58-year-old man with a history of injection drug use who was hospitalized for infective endocarditis and experienced atraumatic splenic rupture. Histopathological analysis of the splenic tissue found evidence of systemic acquired amyloid A amyloidosis, likely resulting from his chronic inflammatory condition of injection drug use. Amyloidosis can develop from chronic inflammatory states and lead to fragile blood vessels and organs like the spleen that are prone to rupture without trauma. This is the first reported case of splenic rupture caused by amyloidosis developing from long-term injection drug use.
Acquired a amyloidosis from injection drug use presenting with atraumatic spl...Dr Amolkumar W Diwan
This case report describes a 58-year-old man with a history of injection drug use who was hospitalized for infective endocarditis and experienced atraumatic splenic rupture. Histopathological analysis of the splenic tissue found evidence of systemic acquired amyloid A amyloidosis, likely resulting from his chronic inflammatory condition of injection drug use. Amyloidosis can develop from chronic inflammatory states and lead to fragile blood vessels and organs like the spleen that are prone to rupture without trauma. This is the first reported case of splenic rupture caused by amyloidosis developing from long-term injection drug use.
A 43-year-old Cambodian man was admitted to the hospital with fever, diarrhea, and jaundice. He reported symptoms of malaise, fever, night sweats, and abdominal pain starting one week prior. Examination revealed jaundice and a tender abdominal mass. Testing showed abnormal liver function and leukocytosis. Imaging found a large mass in the right hepatic lobe. Biopsies of the mass showed debris and inflammatory cells consistent with an abscess. The patient was treated with antibiotics and his condition improved with no identified cause of the abscess found.
Background: A 51-year-old woman had left lower abdomen pain for 18 hours with nausea and vomiting. Prior CT scans suggested pelvic neoplasms. Our hospital's emergency CT showed an enlarged uterus with cystic shadows, right adnexal cysts, and stomach fluid. Physical examination revealed left lower abdomen discomfort. A gynaecological examination revealed a painful, firm pelvic mass of 151210 cm. Further diagnosis is underway. Method: The patient underwent emergency exploratory laparotomy, discovering a twisted, swollen left ovary with a 540° rotation, classified as a benign cyst. It was found that the patient had congenital upper vaginal atresia and bilateral initial uteri. Pain was reduced after surgery, thanks to symptomatic treatment. An abnormal karyotype of 46, XX,1qh+ was found during genetic testing. Result: Fallopian tubes, uterus, and vagina develop from the embryonic accessory mesonephric duct. MRKH syndrome is caused by bilateral accessory mesonephric duct dysplasia and disappearance of the uterus or vagina. MRKH has three types, with Type 1 lacking uterus or vagina. Due to ovarian cyst torsion, this Type 1 MRKH with double initial uterus and upper vaginal atresia needed left adnexa resection. Genetic testing showed a typical female karyotype. MRKH's complex aetiology incorporates chromosomal abnormalities, emphasizing early cytogenetic evaluation for personalized treatment and fertility assistance. Conclusion: Early cytogenetic testing for MRKH syndrome patients is crucial for determining the underlying cause and guiding personalized treatment plans to restore reproductive function and improve quality of life.
Key-words: Double primordial uterus; MRKH syndrome; Upper vaginal atresia; Torsion of left ovarian cyst pedicle
This document provides information about multiple myeloma, including its definition, epidemiology, pathogenesis, clinical presentation, diagnostic criteria, staging system, imaging, laboratory findings, and treatment options. Key points include:
- Multiple myeloma is a neoplastic plasma cell disorder characterized by clonal proliferation of malignant plasma cells in the bone marrow.
- It accounts for 1% of cancers and 13% of hematological malignancies in Western countries. Median age at diagnosis is 70 years.
- Pathogenesis involves genetic alterations in plasma cells following activation in lymph nodes, resulting in monoclonal protein production and bone marrow homing.
- Clinical features include bone lesions, hypercalcemia, renal impairment, anemia, and infections.
Klippel–Trenaunay syndrome is an uncommon genetic condition. The main pathology consists of arteriovenous malformations. It is generally asymptomatic but may present as soft tissue or bony hypertrophy. We hereby present a case of Klippel–Trenaunay syndrome of an 18 year old male patient coming with large venous malformations, lymphangiomas and A-V fistula at lower leg along with soft tissue hypertrophy of right foot. Patient was evaluated clinically and radiologically and a diagnosis of Klippel–Trenaunay syndrome was formed. Patient was given compression stockings and asked to followup regularly.
This document presents a case study of a 36-year-old man admitted to the hospital with fever, abdominal pain, and lack of appetite. Initial tests showed jaundice and liver abnormalities. Further evaluation found a liver abscess. The patient was treated but had a similar prior illness in Malaysia. Tests identified the cause as melioidosis, a tropical disease caused by the bacterium Burkholderia pseudomallei. The patient received long-term antibiotic treatment and follow-up showed the infection had resolved. The presentation discusses the epidemiology, pathogenesis, diagnosis and treatment of melioidosis.
Abstract—In Italy the hydatid disease is more prevalent and new cases are highlighted more frequently in Sicily, Sardinia, (Italy). Aim of this study is to put the indication in search of iaditea nature in both spleen swelling and muscle tendon.
Material and Method Patients observed during the period 2007-2009 at the Surgical Clinic III and Digestive Surgery, Policlinico G Rodolico were explored for Hydatid cyste at various sites. Diagnosis of cysts ecchinococcus occurred primarily for various four reasons either for compression of bodies involved or for eosinophilia or for instrumental investigation or for anaphylactic reaction to rupture of cysts. Biological diagnosis is based on serology rather than isolation of the parasite (indirect diagnosis);
Results Patients attended during the period 2007-2009 Hydatid cyst was found in 0.5% of all cases in liver along with 4 in the lung, 3 in splenic, 2 in the mammary and 2 in the chest wall No 2. The Surgical treatment with the complete removal of the cyst with a satisfactory postoperative course in the absence of cases of relapse of the disease and by following the therapeutic act, the assumption of mebendazole 50mg / kg / day for 3 weeks at a dose of 400mg for 4 months
Conclusions There is a need to define diagnostic methods with high specificity and sensitivity, which can provide a valid diagnostic aid for the cases clinically difficult to diagnose. And the final diagnosis must then also be based on the development of immunological methods that allow the determination of specific antibodies in the serum and their titration and / or the circulating antigen determination.
Magnetic Resonance Imaging Findings in Autoimmune Pancreatitis and Cholangitisasclepiuspdfs
Autoimmune pancreatitis (AIP) is a distinct form of chronic pancreatitis. The presentation and clinical image findings of AIP sometimes resemble those of several pancreatic malignancies, but the therapeutic strategy differs appreciably. The purpose of this article is to discuss its various pancreatic and extrapancreatic imaging finding especially on MRI.
A Lecture for 5th year MDCU medical students
by Associate Professor Dr.Thira Woratanarat
Department of Preventive and Social Medicine,
Faculty of Medicine, Chulalongkorn University
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Primary Health Care Systems (PRIMASYS): Case Study from Thailand, Abridged ve...Thira Woratanarat
Primary health care systems (PRIMASYS): case study from Thailand, abridged version. WHO 2017.
By Thira Woratanarat, Patarawan Woratanarat, Charupa Lekthip
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Unlocking the Secrets to Safe Patient Handling.pdfLift Ability
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Prepared by Prof. BLESSY THOMAS, VICE PRINCIPAL, FNCON, SPN.
Emphysema is a disease condition of respiratory system.
Emphysema is an abnormal permanent enlargement of the air spaces distal to terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
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This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
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About this webinar: This talk will introduce what cancer rehabilitation is, where it fits into the cancer trajectory, and who can benefit from it. In addition, the current landscape of cancer rehabilitation in Canada will be discussed and the need for advocacy to increase access to this essential component of cancer care.
1. J Med Assoc Thai Vol. 98 Suppl. 8 2015 S95
Traumatic Injury in a Child with Scurvy: A Case Report
Chanika Angsanuntsukh MD*, Kulapat Chulsomlee MD*,
Anan Taracheewin MD*, Suphaneewan Jaovisidha MD**,
Thira Woratanarat MD, MMedSc***, Patarawan Woratanarat MD, PhD*
* Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
** Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
*** Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
This case report aimed to describe the clinical presentation, treatments and prognosis of a child who had scurvy
and traumatic injury of the left thigh. A 30-month-old boy had presented with left hip pain two weeks after falling down on the
floor while walking. He developed pain, warmness of the left hip and thigh, and finally was unable to bear weight. He also had
a high fever, gingival hemorrhage, dental caries, petechiae, positive rolling test and limited range of motion of the left hip. The
radiographs revealed Wimberger’s ring and Frenkel line as scurvy. Vitamin C supplement had been prescribed for one week.
However, there was no clinical response and magnetic resonance imaging (MRI) suggested subperiosteal abscess as well as
osteomyelitis of bilateral femurs and tibias. Debridement and biopsy of the left femur were performed and found only
subperiosteal blood. A clinical improvement was noted on the second day after surgery. Vitamin C level was reported at 0.03
mg/dl which was very low. Bacterial culture was negative and the pathological findings were callus formation with hemorrhage.
The patient continued the treatment for two months and all conditions were healed eventually. In severe scurvy with trauma,
prolonged subperiosteal hematoma was susceptible to infection, and may need debridement simultaneously with vitamin C
supplement to shorten the clinical course.
Keywords: Scurvy, Child, Trauma, Injury
Case Report
Correspondence to:
Woratanarat P, Department of Orthopedics, Faculty of Medicine
Ramathibodi Hospital, Mahidol University, Bangkok 10400,
Thailand.
Fax: +66-2-2011599
E-mail: patarawan.wor@mahidol.ac.th
J Med Assoc Thai 2015; 98 (Suppl. 8): S95-S101
Full text. e-Journal: http://www.jmatonline.com
Scurvy is a rare condition caused by vitamin
C or ascorbic acid deficiency. Vitamin C is significantly
required for collagen synthesis by osteoblasts. Patients
with scurvy usually present bleeding gums,
spontaneous subperiosteal bleeding, especially in the
femur and tibia. Symptoms occurred from bleeding
response well after vitamin C supplement, mostly within
a week. Traumatic injury in the patients with scurvy
may increase the severity of subperiosteal bleeding,
and may prolong the clinical course as well as the
treatment responses.Although there were some reports
of various clinical presentations among children with
scurvy(1-5)
, there was limited evidence of traumatic injury
in scurvy. In this case report, the researchers had the
purpose to demonstrate a boy, diagnosed as scurvy,
who sustained an injury at his left thigh and to describe
his clinical presentations, diagnostic tests, clinical
decision, treatment methods, and prognosis.
CaseReport
The patient was a 30-month-old boy living in
Nakhonsawan Province, Thailand. He started to present
left hip pain after two weeks of falling down on the
floor while walking. He was limp without any wound or
external bleeding. On the following day, he complained
left hip pain with warmth of his left thigh. He could not
walk, or move his left lower extremity due to the pain.
His parents had given him an analgesic drug for a few
days but his symptoms got worse. He was brought to
Sawanpracharak Hospital, Nakhon Sawan Province ten
days later. The physical examination revealed afebrile,
left sacroiliac joint tenderness, and limited left hip range
of motion due to the pain. The complete blood count
showed hematocrit 24.9%, mean corpuscular volume
58.2femtoliters,whitebloodcell11,700/mm3
(neutrophil
55%, lymphocyte 36.2%), and platelets 458,000/mm3
.
The erythrocyte sedimentation rate was 47 mm/hr and
C-reactive protein was 17.5 mg/dl. The radiographs
of left femur showed mild soft tissue swelling
without bony lesion (Fig. 1). Two days later after
the check-up, he underwent left hip ultrasonography;
the results showed muscle contusion or myositis with
subperiosteal collection, no left hip joint effusion. The
2. S96 J Med Assoc Thai Vol. 98 Suppl. 8 2015
Fig. 1 The radiographs of left femur showed mild soft
tissue swelling without bony lesion.
Fig. 2 The left hip was in flexion-external rotation
position with the left knee swelling.
orthopedist at Sawanpracharuk Hospital suspected left
femoral osteomyelitis and septic arthritis of the left hip.
Finally, he was referred to Ramathibodi Hospital,
Bangkok. No antibiotic drug was administered at that
time.
Tom was the first-born child from a 40-year-
old mother. He was normally delivered with birth
weight of 3,600 grams. He had a history of asthma
exacerbations, normal growth and development, full
vaccinations, and no history of surgery. His daily diet
was milk and solid foods. He did not consume
vegetables or fruits. His family lived in Nakhon Sawan
Province located in the upper central region of Thailand.
His father was a builder, and his mother was a general
employee. National Health Insurance covered his
medical treatment.
The physical examination at Ramathibodi
Hospital revealed a Thai boy, pale, good consciousness,
irritated and crying. His body weight was 18 kilograms
(>95th
percentile), and height was 91 centimeters (50th
percentile). Other vital signs were temperature of 38.3°
celsius, blood pressure of 130/90 mmHg, pulse rate 120
beats/minute, and respiratory rate of 30 breaths/minute.
The head and neck regions demonstrated dental caries,
and gingival hemorrhage. The cardiopulmonary system
was normal. The abdomen was soft, not tender, and no
hepatosplenomegaly. His skin presented acanthosis
nigricans, minimal perifollicular hemorrhage, and
petichial hemorrhage at the left arm and forearm. The
musculoskeletal system documented inability to bear
weight. The left hip was in flexion-external rotation
position (Fig. 2), had limited range of motion, and a
positive rolling test. The left thigh was swelling, warm
and tender. The left knee was warm, with positive
ballottement test, and limited range of motion according
to level of pain. The distal neurovascular status was
intact. The right lower extremity was normal. The
provisional diagnosis was scurvy and differential
diagnoses were septic arthritis as well as osteomyelitis
of the left femur.
The laboratory investigations were done at
Ramathibodi Hospital. The complete blood count
showed white blood cell 12,970/mm3
(neutrophil 65%,
lymphocyte 27%, monocyte 7%, eosinophil 1%),
hematocrit 22.5%, mean corpuscular volume 57
femtoliters, anisocytosis 2+, microcytosis 2+,
hypochromic 1+; platelets 486,000/mm3
. Electrolytes
analysiswassodium138mmol/L,potassium4.49mmol/
L, chloride 103 mmol/L, and carbondioxide 29.3 mmol/
L. International normalized ratio (INR) was 1.12.
Erythrocyte sedimentation rate was 71 mm/hr, and C-
reactive protein was 54 mg/L. Serum iron was 9 ug/dL
(normal ranged 35.0-150.0 ug/dL). Blood for vitamin C
level was collected. The follow-up radiographs showed
normal joint space of the left hip without epiphyseal or
physeal irregularity.The left femur showed surrounding
soft tissue swelling, osteolytic lesion and a thin
periosteal formation along metaphyseal-diaphyseal
area. There was also soft tissue density around the left
knee indicating intra-articular fluid (Fig. 3). The
ultrasonography of the left lower extremity showed
unremarkable joint fluid at the left hip, heterogenous
echogenicity of the left proximal quadriceps muscles
3. J Med Assoc Thai Vol. 98 Suppl. 8 2015 S97
Fig. 3 On the admission date, the radiographs of the left
femur showed surrounding soft tissue swelling,
osteolytic lesion and thin periosteal formation along
metaphyseal-diaphyseal area. The soft tissue
density around the left knee indicated intra-articular
fluid.
Fig. 4 The ultrasonography of the left lower extremity,
Right: heterogenous echogenicity of the left
proximal quadriceps muscles indicated subperio-
steal fluid collection, and Left: left knee effusion.
Fig. 5 Above: the radiographs on the 4th
day of admission
showed soft tissue swelling, solid periosteal
formation, Frankel line, Pelkan spurs, and
Wimberger’s ring at the left femur, Below: MRI
demonstrated diffused marrow enhancement of
bilateral pelvic bones, sacrums, femurs and tibias
with subperiosteal abscess along the left thigh.
associated with subperiosteal fluid collection and
periosteal reaction. There was also left knee effusion
(Fig.4).
Since osteomyelitis of the left femur and septic
arthritis of the left knee could not be ruled out, the
patient was brought to the operation room for the left
femur and the left knee aspiration. From the left femur,
there was 5 ml of fresh blood. There was 2 ml of clear
fluid with 78 white blood cells (polymononuclear cell
60% and monocyte 40%) followed by fresh blood. The
fluid was sent for bacteria culture. A long leg slab
extended to hip was applied at the left lower extremity.
Intravenous 650-mg cefazolin was administered every
eight hours. Since his hematocrit was only 19.5%, 200-
ml O-group leukocyte-poor blood was given
intravenously rising his hematocrit up to 30%. A
pediatric nutritionist prescribed 100-mg vitamin C three
times a day, multivitamin syrup 5 ml once daily, calcium
carbonate 600 mg twice daily, and zinc sulfate 2.5 ml
twice daily. On the 3rd
admission day, bacterial culture
was negative.
The patient had had a high fever ranged from
38.5-40.0° celsius since the admission. On the 5th
day,
the follow-up radiographs showed soft tissue swelling,
solid periosteal formation, Frankel line, Pelkan spurs,
and Wimberger’s ring at the left femur. However, MRI
of the left femur suggested diffused osteomyelitis of
the entire femurs and tibias bilaterally (Fig. 5). There
were diffused marrow enhancement of bilateral pelvic
bones, sacrums, femurs and tibias with surrounding
periosteal reaction and multiple visualized inguinal
lymph nodes. Diffused subcutaneous soft tissue
swelling was detected from the left hip to the left ankle.
The left femoral shaft revealed subperiosteal
4. S98 J Med Assoc Thai Vol. 98 Suppl. 8 2015
Fig. 6 The skin incision was made on the lateral aspect of
the left thigh, and tissue biopsy was performed.
Fig. 7 From left to right, the radiographs of the left femur
at one, three, and six months after the treatment.
There was profuse callus formation followed by
bone remodeling. The child was fully recovered.
abscess with 2-4 mm in thickness. There were also
moderate joint effusion at the left knee, mild right knee
synovitis, tiny abnormal fat signals within proximal left
tibia, and a small focal cortical bony defect at the right
proximal tibia. As the MRI findings were similar to
typical scurvy, the patient had been observed, and
antibiotic administration had been stopped for three
days. On the 8th
day, the patient still had a high fever
and painful limb. Bone and joint infection on top was
suspected, therefore, the debridement was set up. A
small lateral incision was done at the left thigh (Fig. 6).
The intra-operative findings were subperiosteal blood
and no pus was seen. The tissue biopsy was performed
and a long leg slab was applied. Blood components of
180-ml leukocyte-poor blood and 180-ml fresh frozen
plasma were given postoperatively. The patient was
clinically stable but still had a high fever for a few days.
On the 12th
day of admission, the clinical
manifestation was dramatically improved. The patient
had no fever. Intravenous cefazolin was changed to
oral cephalexin (100 mg/kg/day). Ferrous fumarate 1.2
ml twice daily was prescribed for iron deficiency
treatment. The reported vitamin C level since the
hospital admission was 0.03 mg/dl (below 0.2 mg/dl).
The pathological diagnosis was callus formation with
hemorrhage and mild chronic inflammation. The final
diagnosis was scurvy and iron deficiency. The patient
was discharged on the 14th
day of admission. Home
medications were vitamin C, multivitamin, calcium
carbonate, zinc sulfate, and ferrous fumarate which had
to be continuously taken for two months; cephalexin
for three weeks, and paracetamol for pain rescue.
Two weeks after the hospital discharge, Tom
was active, no gum bleeding, good surgical wound
healing, and solid periosteal formation was seen at the
entire left femur (Fig. 7). Two months later, he was
healthy and ran around without any pain. The
radiographic solid callus formation presented at the
left femur. In the following six months, he was perfectly
well and took vitamin every day. His left femur
remodeled.At the latest follow-up, he was a 5-year-old
kindergarten boy without scurvy recurrence or any
malnutrition problem. His clinical courses were
summarized as Table 1.
Discussion
Scurvy was a disease caused by vitamin C
deficiency. It has been recognized a long time ago(6)
and discovered how to diagnose and prevent(7,8)
. There
are various recommendations and strategies to prevent
vitamin C deficiency in children such as breast milk,
orange juice but the disease still presents sporadically
and is misdiagnosed in many reports according to
different clinical presentations(5,9)
. This study
demonstrated the traumatic complaints in a child
resulting in inability to walk for 3 weeks. Even though
the bleeding gums were accompanied with a history of
limited fruits and vegetables consumption leading to
scurvy diagnosis which prompted treatment, the clinical
course was prolonged with high fever for nearly two
weeks. An infected hematoma, as well as subacute
osteomyelitis was of concern. An irrigation and
drainage procedure evacuated hematoma, which could
be a good media for bacteria. Finally, the clinical
response was dramatic during the following two days.
Traumatic injury in scurvy had limited data about its
clinical course. A previous study from Thailand in
2003(1)
reported the most common clinical presentations
in 28 children were inability to walk (96%), followed by
limb pain (96%) tenderness of lower limbs (86%), and
minor trauma (46%). Other studies(2-4,10-15)
documented
chief complaints mostly gum bleeding, inability to walk,
limb pain or swelling caused by subperiosteal bleeding
(Table 1). In this study, the child had prolonged high
fever for 11 days after taking standard a vitamin C
supplement (300 mg/day). The radiographic findings
showed extensive bone marrow enhancement from
5. J Med Assoc Thai Vol. 98 Suppl. 8 2015 S99
Study Country No. of Age Gender Presentation Duration Vitamin C Vitamin C
cases (year) level* supplement
Ratanachu-ek Thailand 28 1-9 17 M, Inability to walk, 3.9 week 0.31-2.1 150-300
2003(1)
11 F limb pain, minor mg/dl mg/d
trauma, gum bleeding
Choi 2007(9)
Korea 1 5 F Mild fever, thigh 2 week 0.06 mg/dl NA
swelling (0.6-2.0)
Bursali Turkey 1 1 M Inability to walk, NA NA 1,500 mg/d
2009(15)
knees pain,
gumbleeding
Ghedira Tunisia 2 2, 5 2 M Fever, inability to 3 week <3 μmol/l 500 mg/d
Besbes walk, knees swelling, (26.1-84.6)
2010(16)
gumbleeding
Noordin Pakistan 1 4.5 M Fever, inability to 2-3 month NA 250 mg/d
2012(14)
walk, wrist, knee,
ankle swelling
Duvall USA 1 9 M Limp 4 month Undetected Multi-vitamin
2013(13)
(0.4-2.0 mg/dl)
Gongidi USA 1 5 M Fell, leg, wrists, and 4 weeks <0.1 mg/dl NA
2013(12)
back pain (0.6-2.0)
Hag 2013(17)
India 1 6 M Knee swelling 3 month NA 200 mg/d
Rumsey Canada 1 8 M Knees, 3 month 22 μmol/l NA
2013(11)
ankles swelling (23-114)
Kitcha- USA 3 5 2 M, Inability to walk, 1-5 month <0.1, 1.1 mg/dl 300 mg/d
roensakkul 1 F gumbleeding (0.6-2.0)
2014(2)
Pailhous France 2 7 2 M Gum bleeding 1 month <3 μmol/l 500 mg/d
2014(10)
(17-94)
<0.5 mg/l
(5-15)
Sobotka USA 1 10 M Inability to walk, 4 weeks <0.12 mg/dl NA
2014(4)
knee swelling, (0.2-1.9)
gumbleeding
Agarwal India 1 4 M Fever, thigh and 15 day NA NA
2015(3)
knee swelling
This study Thailand 1 2 M High fever, inability to 3 week 0.03 mg/dl 300 mg/d
2015 walk, hip, thigh, knee (0.2-2.0)
swelling, gum bleeding
M = male, F = female, * reference range of vitamin C level in brackets, NA = not available
Table 1. Clinical summary of children with scurvy
pelvis, sacrums, femurs, and tibias. The delayed clinical
responses and severe marrow involvement may occur
from 1) profound subperiosteal bleeding due to
traumatic injury, and substantially low level of vitamin
C, and 2) impending infected hematoma according to
massive subperiosteal bleeding and dental caries.
Compared with other studies(1-4,9-17)
, fever was only 18%
and usually subsided by one week after the treatment(1)
.
The radiographic findings were typically scurvy
characteristics but had more extensive bone marrow
enhancement than other previous reports(9,12,15)
.
The vitamin C level in this study was very low
(0.03 mg/dl or 1.70 mmol/l) when compared with
other studies(1,9,11)
. The deficiency led to abnormal
collagen synthesis, severe symptoms, extensive
subperiosteal bleeding, anemia, and prolonged clinical
course.Vitamin C supplement between 150-300 mg/day
for two months was recommended(1,14)
. Even though
some studies(10,15,16)
used vitamin C of 500-1,500 mg/
day, the dosage does not depend on the severity of its
6. S100 J Med Assoc Thai Vol. 98 Suppl. 8 2015
deficiency. The average duration of recovery after the
treatment ranged from 1-4 weeks(1,13,14)
.
In general, debridement and irrigation is
unnecessary for scurvy treatment. This case report had
prolonged high fever and was suspected to be infected
with hematoma. Normally, fever should subside within
one week(13)
. Therefore, debridement and irrigation was
performed. With this combined treatment, duration of
clinical improvement was 11 days and the patient could
return to normal gait within two months. These findings
are the same as other reports(1,13,14)
with the average
duration of clinical improvement at 2.2 weeks, and the
average duration of return to normal gait at 3.5 weeks.
Injury may increase amount of bleeding in scurvy. If
this condition was left untreated accompanied with
dental caries, hematoma was at risk of infection. This
study demonstrated the usefulness of debridement and
irrigation in scurvy with prolonged high fever suspected
from impending infected hematoma. Debridement and
irrigation in scurvy should be considered in patients
who have clinical unresponsiveness after vitamin C
supplement with highly suspected infected hematoma.
Potential conflicts of interest
None.
References
1. Ratanachu-ek S, Sukswai P, Jeerathanyasakun Y,
Wongtapradit L. Scurvy in pediatric patients: a
review of 28 cases. J Med Assoc Thai 2003; 86
(Suppl3):S734-40.
2. Kitcharoensakkul M, Schulz CG, Kassel R, Khanna
G, Liang S, Ngwube A, et al. Scurvy revealed by
difficulty walking: three cases in young children. J
ClinRheumatol2014;20:224-8.
3. Agarwal A, Shaharyar A, Kumar A, Bhat MS. A
swollen thigh and knee pain in a cerebral palsy
child-Scurvy. Joint Bone Spine 2015 Mar 13. [Epub
ahead of print]
4. Sobotka SA, Deal SB, Casper TJ, Booth KV,
Listernick RH. Petechial rash in a child with autism
and Trisomy 21. PediatrAnn 2014; 43: 224-6.
5. TalaricoV,AloeM,BarrecaM,GalatiMC,RaiolaG.
Do you remember scurvy? ClinTer 2014; 165: 253-
6.
6. Carpenter G. A Case of Scurvy. Proc R Soc Med
1909;2:180-2.
7. Park EA, Guild HG, Jackson D, Bond M. The
recognition of scurvy with especial reference to
the early x-ray changes.Arch Dis Child 1935; 10:
265-94.
8. Desenclos JC, BerryAM, Padt R, Farah B, Segala
C, Nabil AM. Epidemiological patterns of scurvy
among Ethiopian refugees. Bull World Health
Organ1989;67:309-16.
9. ChoiSW,ParkSW,KwonYS,OhIS,LimMK,Kim
WH, et al. MR imaging in a child with scurvy: a
case report. Korean J Radiol 2007; 8: 443-7.
10. Pailhous S, Lamoureux S, Caietta E, Bosdure E,
ChambostH,ChabrolB,etal.Scurvy,anolddisease
still in the news: two case reports. Arch Pediatr
2015;22:63-5.
11. Rumsey DG, RosenbergAM. Childhood scurvy: a
pediatric rheumatology perspective. J Rheumatol
2013;40:201-2.
12. GongidiP,JohnsonC,DinanD.Scurvyinanautistic
child: MRI findings. Pediatr Radiol 2013; 43: 1396-
9.
13. Duvall MG, Pikman Y, Kantor DB, Ariagno K,
Summers L, Sectish TC, et al. Pulmonary
hypertension associated with scurvy and vitamin
deficiencies in an autistic child. Pediatrics 2013;
132:e1699-703.
14. NoordinS,BalochN,SalatMS,RashidMA,Ahmad
T. Skeletal manifestations of scurvy: a case report
from dubai. Case Rep Orthop 2012; 2012: 624628.
15. BursaliA, Gursu S, GursuA,Yildirim T.Acase of
infantile scurvy treated only with vitamin C: a
forgotten disease.Acta Orthop Belg 2009; 75: 428-
30.
16. Ghedira BL, Haddad S, Ben Meriem C, Golli M,
Najjar MF, Guediche MN. Infantile scurvy: two
case reports. Int J Pediatr 2010; 2010: 717518.
17. HaqRU,DhammiIK,JainAK,MishraP,Kalivanan
K. Infantile scurvy masquerading as bone tumour.
AnnAcad Med Singapore 2013; 42: 363-5.