Large left ventricular pseudoaneurysm and spontaneous recanalized coronaries

35 year old with ruptured lateral wall of Left ventricle (LV) resulting in large pseudo aneurysm contained within the pericardium [Figure 1]. There was free flow of blood between the LV and pseudoaneurysm.He underwent endoventricular patch plasty of the defect after opening the wall of aneurysm [Figure 2].Open in a separate windowFigure 1Mid esophageal four chamber view showing pseudoaneurysmOpen in a separate windowFigure 2Opened pseudoaneurysmal cavity and the defect in left ventricle lateral wall     

An Unusual Cause of Thigh Swelling: Tuberculosis of the Pubis

A 53-year-old malnourished man, presented to the emergency room with 2 months of poor appetite, malaise, high spiking fevers, 10 Kg weight loss and night sweats; he also noted progressive exertional dyspnea and anterior chest pain developing over the last 2 days. On physical examination he was afebrile, had 90/60 arterial pressure, 100 × min heart rate, pulsus paradoxus, jugular vein engorgement, sudden inspiratory splitting of the second heart sound, and soft heart sounds on auscultation. A contrasted tomography of the thorax showed a large pericardial effusion with pericardial contrast enhancing and no pulmonary opacities. Histologic examination of pericardial tissue showed multinucleated giant cells with scarce acid-fast bacillae, and on pericardial culture grew Mycobacterium tuberculosis.A 53-year-old malnourished man with no significant past medical history had worked his entire life as a farmer in rural Colombia. He went to a local emergency room because of 2 months of poor appetite, malaise, high spiking fevers, 10 Kg weight loss, and night sweats. He also had progressive exertional dyspnea and anterior chest pain for 2 days. On physical examination he was afebrile, arterial pressure 90/60, and heart rate 100/min. A pulsus paradoxus, jugular vein engorgement, soft heart sounds, and sudden inspiratory splitting of the second heart sound were found. A computed tomographic scan of the thorax showed a large pericardial effusion with pericardium contrast enhancing but no pulmonary opacities (Figures 1 and ​and22 ). A transthoracic echocardiography confirmed pericardial tamponade (Figures 3 and ​and44 ) that led to pericardiocentesis, which yielded 2,200 mL of reddish liquid with 5.9 gm/dL total protein; 2,300 leukocytes/mL (70% Lymphocytes); glucose 2 mg/dL; and an adenosine deaminase level of 234 U/L. Histologic examination of pericardial tissue showed granulomas with multinucleated giant cells (Figure 5 ) and scarce acid-fast bacillae (Figure 6 ); culture of pericardium grew Mycobacterium tuberculosis. A test for human immunodeficiency virus was negative. He was started on four antituberculosis medications plus Prednisone, and discharged 2 weeks after admission. Unfortunately, 2 months later he was readmitted because of constrictive pericarditis, and a pericardiectomy was performed. After 6 months of anti-TB therapy, the patient remained well.Open in a separate windowFigure 1.Coronal view of thorax CT showing a large amount of pericardial effusion with pericardium contrast enhancing.Open in a separate windowFigure 2.Axial view of thorax CT showing a large amount of pericardial effusion with pericardium contrast enhancing.Open in a separate windowFigure 3.Transtoracic echocardiographic image of the heart showing a large pericardial effusion.Open in a separate windowFigure 4.Transthoracic echocardiography showing the surface of the heart with a shaggy appearance, with frond-like structures extending to the parietal pericardium.Open in a separate windowFigure 5.Histologic examination of pericardial tissue showing granulomas with multinucleated giant cells.Open in a separate windowFigure 6.Ziehl-Neelsen stain showing scarce acid-fast bacillae.     

Prototheca wickerhamii Cutaneous and Systemic Infections

Prototheca wickerhamii, an environmental alga, rarely causes human infections. We present a case of Prototheca wickerhamii cutaneous and systemic infections in an 85-year-old male with adrenal insufficiency. This organism was identified by morphological features and microbiological tests. The patient was successfully treated with ketoconazole.An 85-year-old male presented with a fever lasting for 2 days. He had a history of adrenal insufficiency with prednisolone use for 2 years. Pruritic erythematous maculopapules on his lower extremities appeared 1 year ago. On examination, he was febrile, tachycardic, and tachypneic. Multiple erythematous plaques were accompanied by papules, shallow ulcers, and crusts on his four limbs (Figure 1). Empirical piperacillin/tazobactam therapy was initiated. Blood cultures obtained on admission were positive after 3 days of incubation. Gram stain revealed spherical Gram-positive organisms of various sizes (Figure 2). A subculture on a blood agar plate showed milky white yeast-like colonies (Figure 3). A lactophenol cotton blue wet mount preparation disclosed characteristic endosporulating sporangia (Figure 4). The organisms isolated from both blood and cutaneous wound cultures were identified as Prototheca wickerhamii using the API 20C identification system (bioMérieux, Marcy l’Etoile, France). Ketoconazole therapy was started on hospital Day 6. His clinical condition and cutaneous lesions improved with ketoconazole for a total of 4 weeks.Open in a separate windowFigure 1.Multiple erythematous plaques are accompanied by papules, shallow ulcers, and crusts on his right upper limb and left lower limb.Open in a separate windowFigure 2.Gram stain of blood culture reveals spherical Gram-positive organisms of various sizes resembling yeast. Magnification, ×1,000.Open in a separate windowFigure 3.Milky white yeast-like colonies are observed on blood agar plate after incubation at 35°C for 3 days.Open in a separate windowFigure 4.Wet-mount preparation with lactophenol cotton blue discloses spherical sporangia containing multiple endospores with symmetrical arrangement. Magnification, ×1,000.Prototheca wickerhamii is an achlorophyllic alga and is ubiquitous in nature, which can cause human infections. The definite diagnosis usually depends on morphological identification of the organisms in wet slide preparations of cultures and/or direct identification in tissue specimens.¹     

Isolated Itching of the Genitals

A 38-year-old man, returned from Ivory Coast 2 months ago and presented with a 3-month history of pruritus exclusively on the scrotum. Itching was continuous during the day and no pruritus was described in his wife and son. Clinical examination of the genitals revealed several nodules on the scrotum, a chancrous lesion was seen on the penis, and multiple excoriations were noted. Dermoscopy exam with a dermatoscope of the whole body was performed and no papules, nodules, or burrow were found. Microscopic examination of several superficial skin samples obtained by scraping in the peri-genital area revealed one adult of Sarcoptes scabiei. The patient and his relatives were successfully treated with Ivermectin 200 μg/kg with a second dose 2 weeks later. Very rare cases are described on localized scabies (scalp, feet) and they mainly occurred in an immunocompromised patient unlike this patient who does not have any immunosuppression.A 38-year-old man, returned from Ivory Coast 2 months ago and presented with a 3-month history of pruritus exclusively on the scrotum. Itching was continuous during the day and no pruritus was described in his wife and son. It is to be noted that since the pruritus appeared, he stopped sexual contact with his wife. Clinical examination of the genitals revealed several nodules on the scrotum (Figure 1 ), a chancrous lesion was seen on the penis (Figure 2 ), and multiple excoriations were noted. Dermoscopy exam with a dermatoscope of the whole body, including the finger webs, the flexor surfaces of the wrists, the elbows, and the axillae was performed. No papules, nodules, or burrow were found. Microscopic examination of several superficial skin samples obtained by scraping in the peri-genital area revealed one adult of Sarcoptes scabiei (Figure 3)¹; the patient and his relatives were successfully treated with Ivermectin 200 μg/kg with a second dose 2 weeks later.² He was seen in follow-up 1 month later and the symptoms had resolved. Very rare cases are described on localized scabies (scalp, feet), and they mainly occurred in an immunocompromised patient unlike this patient who does not have any immunosuppression.³Open in a separate windowFigure 1.Nodules on the scrotum.Open in a separate windowFigure 2.Chancrous lesion on penis and nodules on the scrotum.Open in a separate windowFigure 3.Sarcoptes scabiei (200×) revealed by microscopic examination of samples obtained from skin scrapings.     

Disseminated Intra-Abdominal Hydatidosis

We present the case of a 26-year-old male Peruvian patient who presented with disseminated intra-abdominal hydatidosis. The patient was treated with surgical removal of the cysts and prolonged medical treatment with albendazole.A 26-year-old male patient from the highlands of Peru was admitted with a 2-month history of early satiety, nausea, and progressive dyspnea. The physical examination showed decreased breath sounds on the left lung and abdominal distention with multiple painless palpable masses. The chest X-ray showed a well-defined rounded cystic pulmonary lesion located in the left lower lobe (Figure 1A). The abdominal computed tomography scan revealed multiple thin-walled abdominal cystic lesions in the liver and spleen and within the abdominal cavity (Figure 1B and ​andC).C). A serum Western blot test was positive for hydatidosis. Multiple hydatid cysts were surgically removed (Figure 1D). The patient was treated with a prolonged course of albendazole with good clinical evolution.Open in a separate windowFigure 1.(A) Rounded cystic lesion located on the left lobe of the lung. (B) Multiple intra-abdominal cystic lesions. (C) Multiple intrahepatic, splenic, and intra-abdominal cystic lesions. (D) Macroscopic aspect of surgically removed intra-abdominal hydatid cysts.Hydatidosis caused by Echinococcus granulosus remains a major public health problem in developing countries. Disseminated intra-abdominal hydatidosis is an infrequent condition that usually results from the rupture of a liver cyst, with subsequent seeding of protoscolices in the abdominal cavity.¹ There is no standard treatment for this disorder; careful surgical removal of the cysts and prolonged medical treatment with albendazole with or without praziquatel are recommended.²     

Histoid Leprosy

Histoid leprosy is rare type of lepromatous leprosy characterized by unique clinical, histopathological, and microbiological features. It is characterized by cutaneous and subcutaneous nodules. Histoid leprosy cases represent probable resistant bacilli and a highly active lepromatous process. These cases may act as reservoirs of the disease and lead to further spread of leprosy. Continual occurrence of these cases does not bode well for eradication of leprosy.A 20-year-old young male, an agricultural laborer, complained of multiple asymptomatic shiny nodules all over the body. The lesions were present for the last 1 year. He had two episodes of epistaxis in the last 6 months that were treated symptomatically. The nodules were distributed predominantly over the trunk and thighs. Family history was non-contributory. He did not take any form of treatment for his skin lesions. Clinical examination revealed multiple discrete, skin-colored, shiny cutaneous and subcutaneous nodules over the trunk and limbs. The nodules varied in size from 0.5 to 1.0 cm (Figure 1 ); there was no impairment of pain, touch, or temperature sensation. There was no thickening of peripheral nerves. Slit skin smear from the nodule revealed plenty of acid fast bacilli, with a bacteriological index of 6+. Histopathology of the nodule showed atrophic epidermis with a subepidermal grenz zone. The dermis revealed sheets of spindle cells arranged in a whorled, crisscross/storiform pattern (Figure 2 ). Fite''s stain showed numerous acid fast bacilli (Figure 3). The patient was diagnosed with the histoid variant of lepromatous leprosy. He was treated with multibacillary–multidrug therapy (MB-MDT) comprising of monthly rifampicin and daily dapsone and clofazimine for a period of 1 year. The patient responded well to the treatment.Open in a separate windowFigure 1.Multiple skin-colored nodules on the trunk.Open in a separate windowFigure 2.High-power (40×) view of the histopathology showing the spindle cells in a whorled pattern.Open in a separate windowFigure 3.Oil immersion (100×) view of the Fite''s stain showing the macrophages with acid fast bacilli.Histoid leprosy is a distinct and rare variant of lepromatous leprosy, and it was described by Wade¹ in 1963. It is characterized by unique clinical, histopathological, and microbiological features. This form of leprosy is fairly common in patients on dapsone monotherapy and irregular treatment.² Sometimes, it can arise de novo as well. The clinical features include cutaneous and subcutaneous nodules and plaques. The nodules are well-demarcated, and the skin surrounding the lesions is apparently normal. The histopathological features are distinct and contribute to the nomenclature of the condition. The most prominent feature is the presence of numerous spindle-shaped histiocytes arranged in interlacing bands, whorls, and tight curlicues.²Histoid leprosy cases represent probable resistant bacilli and a highly active lepromatous process. Continual occurrence of these cases does not bode well for a country like India, where leprosy was eliminated as a public health problem in 2005.³ These cases may act as reservoirs of the disease and lead to further spread of leprosy. Early diagnosis and management of these cases are important in this era of leprosy eradication.     

Lymphoscintigraphy in Unilateral Lower Limb and Scrotal Lymphedema Caused by Filariasis

Lymphedema is the edema that results from chronic lymphatic insufficiency. Lymphatic filariasis is caused by the filarial nematodes Wuchereria bancrofti, Brugia malayi, and Brugia timori. Lymphatic filariasis is common in tropical and subtropical regions. Early diagnosis and prompt therapy can be implemented using lymphoscintigraphy. Our patient is a 15-year-old boy presenting with a 3-month history of hydrocele. The patient was referred to us to rule out any lower limb lymphatic obstruction as the patient is from an endemic area. Tc Sulfur colloid (filtered) lymphoscintigraphy showed abnormal tracer collection in the scrotum and penis. There is associated dermal backflow or stasis in the left thigh region extending just above the knee, suggesting partial obstruction of left inguinal lymphatic channels.Lymphatic filariasis is common in tropical and subtropical regions.¹ A 15-year-old boy presented with 3 months of scrotal edema. Although residence in a tropical area raises a high suspicion for lymphatic filariasis caused by Wuchereria bancrofti, which can usually be diagnosed with an antigen detection card test, this patient was evaluated for lymphatic obstruction. Imaging was performed with one millicurie (mCi) of filtered Technetium sulfur colloid (Figure 1 ). Four intradermal injections were given in the first and second webspaces of each foot in equal divided doses. After a brisk walk, whole body anterior and posterior images were acquired immediately and 2 hours later using a dual head variable angle Gamma camera. Images showed abnormal tracer collection in the scrotum and penis with associated unsuspected dermal backflow/stasis in the left thigh region extending just above the knee. Lymphoscintigraphy was consistent with early partial obstruction of left inguinal lymphatics. A computed tomographic scan of the abdomen (Figure 2 ) showed soft tissue stranding in the lower anterior abdominal wall and left inguinal region suggestive of inflammatory changes (cellulitis) with bilateral scrotal edema. Microscopic examination of the surgically removed left spermatic cord showed a filarial nematode (W. bancrofti) (Figure 3). Although both W. bancrofti and Brugia malayi exist in Kerala, B. malayi rarely produces scrotal involvement or swelling above the knee. Lymphatic filariasis may be acute or chronic by presentation. Acute lymphangitis, often recurrent, is characterized by fever, chills, and erythema. Adult worms (macrofilariae) are usually concentrated in the inguinal and scrotal lymphatics, and thus lower limb and inguinal symptoms are more common, although the upper limbs and breasts may also be affected rarely. Chronicity may manifest as limb lymphedema, hydroceles, and chyluria.Open in a separate windowFigure 1.Bilateral lower limb lymphoscintigraphy with filtered Tc Sulfur colloid. The initial images of both lower limbs show good progression of colloid particles through bilateral lower limb lymphatic channels. There is normal visualization of the bilateral inguinal group of lymph nodes in initial images. However, there are fewer left inguinal lymph nodes. Liver is visualized normally. Delayed image showed abnormal tracer collection in the scrotum and penis (depicted with annotation “Sc”). There is dermal backflow or stasis in the left thigh region (marked as DB in anterior and posterior views) extending up to the knee. Thus, lymphoscintigraphy was suggestive of early partial obstruction of the left inguinal lymphatics.Open in a separate windowFigure 2.(A) Transaxial (B) coronal sections of CT abdomen shows soft tissue stranding (marked as STS) in the lower anterior abdominal wall and left inguinal region suggestive of inflammatory changes (cellulitis), better seen in coronal view. A few enlarged lymph nodes were also noted along the left common femoral artery and in the bilateral inguinal region of average measurement 8 × 1 cm in its short axis. Bilateral scrotal oedema noted (marked as SE).Open in a separate windowFigure 3.Showing the cross-sectional view of a filarial nematode in the left spermatic cord, with surrounding intense eosinophilic inflammatory infiltrate (magnification, ×400). U = denotes uterine tubes, M = the musculature, I = the intestinal loop and C is the cuticle.     

Tinea nigra Presenting Speckled or “Salt and Pepper” Pattern

A 7-year-old Caucasian female resident of the southern coast of Brazil presented dark spots on the left palm that converged to a unique macule with speckled pattern at about 1 month. The mycological exam and the fungi culture were typical of Hortaea werneckii, the agent of the superficial mycosis Tinea nigra. The patient received butenafine hydrochloride 1% for 30 days, resulting in a complete remission of the lesion. At a follow-up visit 12 months after treatment, there was no lesion recurrence. We describe a form of rare geographical Tinea nigra with a speckled pattern. The “salt and pepper” aspect should be taken into consideration when the mycosis was suspected.A 7-year-old Caucasian female child, who was a resident of Itapema town on the northern coast of Santa Catarina State, Brazil, presented dark spots on the left palm about 1 month before the exam; they converged to a unique macule with speckled pattern, with a 1.5 × 2.0-cm diameter and geographic shape (Figure 1).Open in a separate windowFigure 1.Black macule with geographic shape and speckled pattern on the left palm of the Caucasian patient.The mycological exam revealed septate, dematiaceous hyphae, and presence of yeast-like cells with spores. The fungi culture in Sabouraud''s agar showed a moist, shiny, rough, and black colony. The fungi in the culture were identified as Hortaea werneckii (Figure 2).Open in a separate windowFigure 2.Presence of annelloconidia with pigmented filaments (Magnification: 400×).The topical treatment with butenafine hydrochloride 1% for 4 weeks caused complete remission of lesions, with no recurrence during follow-up for 1 year.Reports of Tinea nigra have been rare since the first publication by Cerqueira in 1916.^1,2 This cosmopolitan dermatomycosis usually affects Caucasian patients, such as in the present report. We describe a form of rare geographic Tinea nigra with a speckled pattern.The “salt and pepper” aspect should be taken into consideration when the mycosis is suspected.     

An Ethiopian Woman with an Incidental Finding During a Cesarean Section

This patient shows a rare phenomenon of schistosomal ova deposition on the serosal side of the small bowel without any pathology seen on the mucosal side of the small and large bowels. The patient was diagnosed accidentally during an elective cesarean section, when small nodules were seen on the small bowel surface.A 26-year-old human immunodeficiency virus (HIV)-negative woman of Ethiopian descent was admitted for an elective cesarean section. During the operation, multiple nodules were noticed on the serosal surface of the small bowel (Figure 1 ). An excisional biopsy of a nodule showed granulomatous inflammation with eosinophils around an egg (Figure 2 ).Open in a separate windowFigure 1.Multiple nodules on the surface of the small bowel.Open in a separate windowFigure 2.A granulomatous eosinophilic inflammation surrounding a Schistosomal ovum (H&E, 400×).The patient immigrated to Israel 15 years before admission and was asymptomatic, except for mild chronic constipation and episodic dysuria. She denied hematuria, hematochezia, abdominal pain, tenesmus, and documented urinary tract infections. She could not recall an episode of rash or fever (representing Katayama fever). Physical examination and laboratory studies were normal, except for significant persistent eosinophilia of up to 2,200 cells/μL. Serology tests (immunoblot and FAST enzyme-linked immunosorbent assay [ELISA] in-house tests; Centers for Disease Control and Prevention) for Schistosoma mansoni were positive. Ultrasonography study of the abdomen was normal. Repeated stool examinations for ova were negative, and colonoscopy study was normal. Direct examination of rectal snip and terminal ileum biopsies were negative for ova, and pathology showed normal mucosa. Praziquantel was administered without side effects.Peritoneal schistosomiasis is a rare, albeit under-reported phenomenon, which has been described with all three species of the parasite. It can be asymptomatic, like in the case presented, or cause ascites, weight loss, constipation, and infertility.¹ Ova can reach the peritoneum by migration through the vessel wall or bloodstream embolization. Invasion can also occur through the fallopian tubes in cases of genital schistosomiasis.² Ova located on the serosal side of the small bowel, especially with the absence of any pathology in the mucosal side of both the small bowel and the rectum, is unique.     

Rhinoschleroma

A 39 year-old man came to our institution because of a five-year history of a progressive painful growing mass on his left nostril, which cause airway obstruction with ulceration. Because of a suspicion of malignancy, surgery (mass resection and subtotal nasal reconstruction) was performed. Histologic samples ruled out malignancy, and tissue cultures for fungus and mycobacteria were negative, but regular aerobic cultures were positive for Klebsiella rhinoscleromatis. The patient was given a six-month regimen of ciprofloxacin, and a dramatic improvement was observed.A 39 year-old man who had lived his entire life in rural Colombia and who had no significant medical history except for a minor trauma in his left cheek and temporal region more than 10 years ago. He came to our institution with a history of five years of a growing painful mass on his left nostril, which caused airway obstruction. At physical examination, he had an erythematous mass with central ulceration, purulent discharge, adherent to deep tissues, producing partial obstruction of the left eye visual field, and complete obliteration of the left nostril (Figure 1A and ​andB).B). Computed tomography of the face was performed and showed a mass that originated from the left middle turbinate, invaded the medium maxillary sinus and orbital wall, and extended to the intraocular fat in close contact with the ocular globe.Open in a separate windowOpen in a separate windowOpen in a separate windowOpen in a separate windowFigure 1.A and B, Patient with an erythematous mass with central ulceration, purulent discharge, adherent to deep tissues, producing partial obstruction of the left eye visual field, and complete obliteration of the left nostril. C, Histologic samples from the patient showing groups of large vacuolated histiocytes containing gram-negative bacteria (Mikulicz cells), many of which had Russell bodies (eosinophilic, homogenous inclusions found in a plasma cell undergoing excessive synthesis of immunoglobulin; haematoxylin and eosin 400×) (arrows). D, Patient after treatment at the recent follow-up before he was scheduled for a definitive nasal reconstruction.A biopsy and culture were not performed. However, because of a suspicion of malignancy, a surgical mass resection was performed that included the left nasal bone, and the orbital and maxillary sinus wall; all orbital structures were preserve. The same day, a subtotal nasal reconstruction with an antebrachial free flap was performed. The patient showed an uneventful postoperative course.Histologic samples from the mass and borders ruled out malignancy, but showed groups of large vacuolated histiocytes containing gram-negative bacteria (Mikulicz cells), many of which had Russell bodies (eosinophilic, homogenous inclusions found in a plasma cell undergoing excessive synthesis of immunoglobulin arrows (Figure 1C). Tissue cultures for fungus and mycobacteria were negative, but regular aerobic cultures were positive for Klebsiella rhinoscleromatis.A six-month regimen of ciprofloxacin (750 mg every 12 hours) was started, and the patient showed dramatic improvement. At the most recent follow-up, there were no signs of relapse of infection, and the patient was scheduled for a definitive nasal reconstruction (Figure 1D).     

A 41-Year-Old Woman with Migratory Panniculitis

A 41-year-old woman had two months of intermittent migratory swellings in the trunk, face, and limbs associated with erythema, pruritus, and pain. Laboratory analysis showed moderate eosinophilia. The triad of eosinophilia, migratory lesions (nodular panniculitis), and raw fish consumption was highly suggestive of cutaneous gnathostomiasis. She was successfully treated with albendazole (400 mg twice a day for 21 days) and showed complete and permanent resolution of the lesions.A 41-year-old woman had two months of intermittent migratory swellings in the trunk, face, and limbs associated with erythema, pruritus, and pain. The skin lesions were recurrent, typically lasting 1–2 weeks before spontaneous resolution. She denied fever, chills, or other clinical signs. She reported regular consumption of undercooked raw fish and shellfish. Physical examination showed palpable, non-pitting swelling in the right arm (Figure 1) and left leg, this leg showed subcutaneous hemorrhage (Figure 2). Laboratory analysis showed moderate eosinophilia (960 cells/mm³). The triad of eosinophilia, migratory lesions (nodular panniculitis), and raw fish consumption was highly suggestive of cutaneous gnathostomiasis.Open in a separate windowFigure 1.Right arm of the patient showing non-pitting swelling.Open in a separate windowFigure 2.Left leg of the patient showing non-pitting swelling and subcutaneous hemorrhage.Two weeks before arrival, she received a single dose of ivermectin (200 μg/kg) and showed no resolution. She was given albendazole (400 mg twice a day for 21 days) and showed complete and permanent resolution of the lesions. Gnathostomiasis is a food-borne zoonosis secondary to ingestion of raw fish or shellfish contaminated with larvae of Gnathostoma spp. It is observed mainly in tropical regions, and increasingly in Latin America particularly Mexico.^1,2 Previous studies showed slightly more relapses in patients treated with ivermectin.³ Few clinicians outside of disease-endemic areas are familiar with gnathostomiasis. Therefore, diagnosis is often missed, which can lead to potentially serious consequences.²     

Baseline neutrophil-lymphocyte ratio is associated with outcomes in patients with castration-resistant prostate cancer treated with Docetaxel in South China

The aim of this study is to investigate the association between baseline neutrophil-to-lymphocyte ratio (NLR) and progression-free survival (PFS), overall survival (OS) and radiological response in castration-resistant prostate cancer patients treated with docetaxel.Forty-one prostate cancer patients who were treated with docetaxel were selected. Univariable and multivariable Cox regression models were used to predict the association of baseline NLR as a dichotomous variable with PFS and OS after chemotherapy initiation.In Kaplan–Meier analysis, the median PFS (9.8 vs 7.5 months, P = .039, Fig. ​Fig.1)1) and OS (17.6 vs 14.2 months, P = .021, Fig. ​Fig.2)2) was higher in patients who did not have an elevated NLR than in those with an elevated NLR. In univariate analysis, the pretreatment NLR was significantly associated with PFS (P = .049) and OS (P = .023). In multivariable analysis, patients with a NLR of >3 were at significantly higher risk of tumor progress (hazard ratio 2.458; 95% confidence interval 1.186–5.093; P = .016) and death (hazard ratio 3.435; 95% CI 1.522–7.750; P = .003)than patients with a NLR of ⩽3.Open in a separate windowFigure 1Kaplan–Meier curves for progression-free survival of prostate cancer patients categorized by the neutrophil-to-lymphocyte ratio.Open in a separate windowFigure 2Kaplan–Meier curves for overall survival of prostate cancer patients categorized by the neutrophil-to-lymphocyte ratio.NLR may be an independent predictor of PFS and OS in castration-resistant prostate cancer patients treated with docetaxel. The findings require validation in further prospective, big sample-sized studies.     

Myriad manifestations of Williams syndrome

4 months male child presented with failure to thrive. On general examination child had normal O2 saturation with characterstic elfin facies. Further evaluation of the patient showed major manifestations of Williams syndrome in form of supravalvar aortic stenosis, branched pulmonary artery stenosis along with cardiomyopathy. Although the entity is known, this article shows comprehensive diagnostic workup with the aid of multimodality imaging techniques. The genetic diagnosis of Williams syndrome was confirmed using fluroscent in situ hybridisation techniques (FISH). In this patient most of the manifestations of elastin vasculopathy were noted in the form of involvement of ascending aorta, pulmonary arteries and myocardium. We also want to emphasis the importance of echocardiography in newborn patients with dysmorphic facies as Williams syndrome can be easily missed in neonatal period.A 4 month old male child presented with symptoms of heart failure and poor weight gain. On examination, O₂ saturation in both limbs was 99% and there was no significant blood pressure difference in all four limbs. He had a characterstic ‘elfin facies’ with a sunken nasal bridge, a long philtrum, wide mouth, prominent lower lip, small chin and low set ears (Fig. 1). 2D echocardiography showed situs solitus, concentric left ventricular hypertrophy with mild narrowing in the supravalvular region (Fig. 2) with systolic gradients of 26 mm Hg across the segment (Fig. 3) (Online Video 1). The right pulmonary artery (RPA) after its origin showed significant short segment stenosis with peak systolic gradients of 32 mmHg. The left pulmonary artery (LPA) after its origin showed mild narrowing (Figs. 4 and 5) (Online Video 2). Cardiac CT demonstrated supravalvular aortic stenosis (SVAS) with hour glass appearance of the aorta (Figs. 6 and 7) with bilateral pulmonary artery stenosis (PAS) involving RPA more than LPA (Figs. 8 and 9). Fluorescent in-situ hybridization (FISH) studies (Fig. 10) showed heterozygous deletion of elastin gene (Chromosome 7q11.23) and confirmed the diagnosis of Williams syndrome (WS).Open in a separate windowFig. 1Characterstic elfin facies.Open in a separate windowFig. 22D echocardiography showing mild narrowing in the supravalvular region.Open in a separate windowFig. 3Doppler showing gradients of 26 mm Hg across narrowed supravalvular region.Open in a separate windowFig. 42D echocardiography with color Doppler showing bilateral PAS.Open in a separate windowFig. 5Doppler investigation showing peak systolic gradients of 32 mmHg across the narrowed segment of RPA.Open in a separate windowFig. 6Cardiac CT with 3D reconstruction showing supravalvular aortic stenosis (SVAS).Open in a separate windowFig. 7Cardiac CT (Coronal section) showing SVAS.Open in a separate windowFig. 8Cardiac CT (Transverse section) showing bilateral PAS.Open in a separate windowFig. 9Cardiac CT with 3D reconstruction showing bilateral pulmonary artery stenosis (PAS) involving RPA more than LPA.Open in a separate windowFig. 10Fluorescent in-situ hybridization studies showing deletion of elastin gene (Chromosome 7q11.23).Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.ihj.2015.02.026.The following are the Supplementary data related to this article:Video 1: Subcostal view showing turbulence in supravalvar region of aorta and the branched pulmonary arteries.Click here to view.^{(1.3M, mp4)}Video 2: High parasternal view showing confluent pulmonary arteries with turbulence across the branched pulmonary arteries.Click here to view.^{(853K, mp4)}WS is a genetic disorder occurring with a frequency of 1 in 20,000–50,000 live births. Manifestations of WS include congenital heart disease, hypertension, dysmorphic facial features, infantile hypercalcaemia and mental retardation. Apart from supravalvular AS and branched PA stenosis other cardiac abnormalities observed are bicuspid aortic valve, mitral valve regurgitation, coarctation of the aorta, ventricular or atrial septal defects. In neonates, cardiovascular symptoms were evident in 47% of WS children.1 PA stenosis often tends to regress spontaneously and SVAS tends to progress with time. In this patient most of the manifestations of elastin vasculopathy were noted in the form of involvement of ascending aorta and pulmonary arteries. The concentric left ventricular hypertrophy observed in our patient may be an expression of hypertrophic cardiomyopathy which is known to be associated with WS.1 In neonatal period all newborn patients with dysmorphic facies should be evaluated with echocardiography so that the cardiac abnormalities are not missed.     

Soporte circulatorio con ECMO venoarterial en paciente con cardiomiopatía de Takotsubo biventricular

Takotsubo cardiomyopathy is an entity characterized by acute and transient ventricular dysfunction, which is usually related to a triggering event (emotional or physical stress), and usually presents with regional systolic dysfunction of the left ventricle, however up to 30% may be biventricular. Depending on its severity in some cases the disease can condition refractory cardiogenic shock to management with inotropics and vasopressors, so for these cases circulatory assistance devices should be considered. We present the case of a young patient who had pulmonary valve change with biological prosthesis, which seven weeks after surgery went to the emergency department with pericardial effusion and tamponade physiology secondary to postpericardiotomy syndrome. For this reason pericardial window was practiced, however during the procedure she presented biventricular Takotsubo cardiomyopathy which conditioned cardiogenic shock with severe mitral and tricuspid regurgitation, and refractivity to medical treatment as well as intraaortic balloon pump, requiring circulatory support with venoarterial ECMO for 5 days.Key words: Takotsubo cardiomyopathy, Ventricular dysfunction, Cardiogenic shock, Venoarterial ECMO

Se presenta el caso de una paciente de 37 años de edad con antecedente de doble lesión pulmonar (predominio de estenosis) a quien se le realizó cambio valvular pulmonar por prótesis biológica sin complicaciones perioperatorias. Egresada a domicilio asintomática con función biventricular conservada. Sin embargo, seis semanas después de procedimiento quirúrgico cursó con disnea de medianos a pequeños esfuerzos, edema de miembros pélvicos ascendente y dolor tipo pleurítico, razón por la cual acudió al servicio de urgencias, en donde ingresó con tendencia a hipotensión, frote pericárdico, edema importante de extremidades, electrocardiograma con taquicardia sinusal, complejos QRS con bajo voltaje y alternancia eléctrica. La radiografía de tórax y el ultrasonido pulmonar, con derrame pleural bilateral importante. Laboratorios relevantes con: porción N-terminal del propéptido natriurético tipo B (NT-proBNP) 2,305 pg/ml, troponina de alta sensibilidad 2,3 ng/ml y proteína C reactiva (PCR) 121 mg/l. Se realizó ecocardiograma dirigido, con reporte de derrame pericárdico global de 49 mm con variabilidad transmitral en el 53%, transtricuspídea del 39%, colapso de aurícula derecha y función biventricular conservada sin trastornos de la movilidad. Ante repercusión hemodinámica se decidió realizar ventana pericárdica drenando 1,000 cc de líquido seroso, así como colocación de sondas endopleurales drenando 1,200 cc de líquido seroso, ambos con reporte citoquímico de exudado de características inflamatorias con cultivo negativo. Posterior a ventana pericárdica fue trasladada a terapia posquirúrgica, en donde se recibió hipotensa con datos de hipoperfusión sistémica. Se realizó nuevo electrocardiograma, que evidenció alargamiento del intervalo QTc, así como inversión de ondas T en cara anterior (Fig. 1); ecocardiograma que mostró función biventricular deprimida, ventrículo izquierdo con acinesia en región media y apical con hipercinesia compensatoria del tercio basal en todas sus caras; fracción de expulsión del ventrículo izquierdo (FEVI) en el 15% por Simpson modificado, strain –3%, (Fig. 2), FEVI tridimensional en el 20%; ventrículo derecho con acinesia en tercios basal y apical, e hipercinesia basal, así mismo con fracción de acortamiento del ventrículo derecho (FACVD) del 15%, sugestivo de cardiomiopatía de Takotsubo biventricular sin obstrucción del tracto de salida del ventrículo izquierdo (Fig. 3). Así mismo, se reportó insuficiencia mitral y tricuspídeas severas asociadas a tethering (Figs. 4 y ​y5).5). Se realizó nueva medición de troponinas con elevación hasta 3,200 ng/ml y NT-proBNP 4,000 pg/ml. En cuanto al perfil hemodinámico, en choque cardiogénico, por lo que se inició manejo con doble inotrópico (levosimendán y dobutamina) y doble vasopresor (norepinefrina y vasopresina); sin embargo persistió con índice cardiaco en 1.4 l/min y datos de hipoperfusión sistémica, por lo que se decidió colocar balón de contrapulsación intraaórtica (BIAC). A pesar de la terapéutica empleada la paciente continuó en choque cardiogénico refractario con compromiso respiratorio requiriendo intubación orotraqueal y presentando disfunción hepática y renal, por lo que 12 horas posteriores a inicio de terapia con BIAC se agregó soporte con membrana de oxigenación extracorpórea (ECMO) por canulación femoral venosa y femoral arterial, titulando el flujo hasta 2.5 l/min. Durante el soporte circulatorio cursó con adecuada evolución, con estabilización hemodinámica, lográndose retirar las aminas e inotrópicos en las primeras 4 horas, con posterior mejoría de función renal y hepática, así como disminución de la congestión pulmonar y logrando extubación en las primeras 48 horas. En cuanto a la función biventricular, con clara mejoría progresiva (hasta lograr FEVI del 35%, integral tiempo velocidad (ITV) 14 cm, velocidad «s» mitral lateral 8 cm/s y FACVD del 30%), con remisión de las alteraciones segmentarias de la contractilidad y disminución en la severidad de las valvulopatías (hasta ser de grado ligero), sin complicaciones relacionadas a la ECMO, por lo que se suspendió la terapia a los cinco días de manera exitosa.Open in a separate windowFigura 1Electrocardiograma de la paciente posterior a ventana pericárdica con hallazgos sugerentes de cardiomiopatía de Takotsubo.Open in a separate windowFigura 2Strain de ventrículo izquierdo posterior a ventana pericárdica con hallazgos sugerentes de cardiomiopatía de Takotsubo.Open in a separate windowFigura 3Aproximación apical de cuatro cámaras en donde se observan los hallazgos sugerentes de cardiomiopatía de Takotsubo biventricular.Open in a separate windowFigura 4Aproximación apical de cuatro cámaras en donde se observa insuficiencia valvular mitral secundaria a tethering.Open in a separate windowFigura 5Aproximación apical de cuatro cámaras en donde se observa insuficiencia valvular tricuspídea secundaria a tethering.Posteriormente se trasladó a piso de cardiología, en donde se realizó resonancia magnética cardiaca, reportándose sin trastornos de la movilidad, función biventricular conservada, sin insuficiencia valvulares y con bioprótesis pulmonar normofuncionante.     

An Unusual Cause of Breast Lump: Isolated Tuberculosis of the Breast

A 60-year-old woman presented with a painful lump of 4 months duration in her right breast. She denied any history of breast trauma or family history of breast cancer. Physical examination detected a firm, tender mass in the upper inner quadrant of her right breast without an associated sinus tract. Cytology from fine-needle aspiration of the swelling showed epithelioid cells, lymphohistocytic aggregates, and necrosis. Diagnosis was confirmed by the identification of acid-fast bacilli in tissue sections using Ziehl-Neelsen staining.A 60-year-old woman presented with a painful lump of 4 months duration in her right breast. She denied any history of breast trauma or family history of breast cancer. There was no history of weight loss. Physical examination detected a firm, tender mass in the upper inner quadrant of her right breast without any associated sinus tract (Figure 1A). No palpable ipsilateral axillary lymph nodes were found. Routine investigations revealed a marginally elevated erythrocyte sedimentation rate (24 mm/hr). Plain radiograph of the chest was unremarkable. A right breast ultrasound revealed the lesion having irregular margins and central necrotic areas with debris (Figure 1B). The result of a tuberculin skin test was strongly positive (17 mm). Cytology from fine-needle aspiration of the swelling showed epithelioid cells, lymphohistocytic aggregates, and necrosis (Figure 1C). Diagnosis was confirmed by the identification of acid-fast bacilli in tissue sections using Ziehl-Neelsen staining (Figure 1D). Serological tests for human immunodeficiency virus (HIV) I and II were negative. After confirmation of the diagnosis, the patient received four-drug antituberculosis treatment, including rifampicin, isoniazid, pyrazinamide, and ethambutol, for 2 months followed by rifampicin and isoniazid for 4 additional months. The patient responded satisfactorily to the prescribed treatment and the disease showed no signs of recurrence 1 year after treatment.Open in a separate windowFigure 1.(A) Breast lump in the upper inner quadrant of right breast near the nipple; (B) US image of the breast shows hypoechoic lesion with irregular margins and internal echoes; (C) Fine-needle aspiration cytology from the breast mass of the patient showing epithelioid granuloma in the background of degenerated lymphocytes, histiocytes, and necrosis (hematoxylin and eosin stain, ×400); (D) Numerous acid-fast bacilli in the background of necrosis (Ziehl-Neelsen stain, ×1,000).Isolated breast tuberculosis (TB) is an uncommon entity, even in TB-endemic areas. Although it principally affects women of reproductive age, elderly patients may rarely be affected as occurred in this case and the nodular form of TB of the breast may appear to mimic carcinoma, leading to difficulties in diagnosis.^1,2 The gold standard for diagnosis of the disease is detection of Mycobacterium tuberculosis, by using Ziehl-Neelsen staining or culture. Although rare, breast TB should be included in the differential diagnosis of breast lesions.     

Split Right Coronary Artery Its Definition and Its Territory

We report here, for perhaps the 1st time in the English-language literature, the extent of the territory fed by the anterior bifurcation of the (anomalous) split right coronary artery (RCA). A 64-year-old man presented with an occlusion of the anterior bifurcation of a split RCA—which resulted in an infarct that involved both the inferoseptal left ventricular wall and the anterior right ventricular free wall. Split RCA is the same anomaly as the improperly named “double right coronary artery.” In reality, there are not 2 RCAs, but only split portions of the posterior descending branch of the RCA, with 2 separate proximal courses.Key words: Coronary vessel anomalies/diagnosis, myocardial infarction/diagnosis/physiopathologyIn December 2007, a 64-year-old hypertensive man, a chronic smoker with dyslipidemia, presented at the hospital 6 hours after the onset of chest pain. In the emergency room, an electrocardiogram (ECG) showed a pre-existing right bundle branch block with new Q waves in the inferior leads and ST-segment elevation in the anterior precordial leads (Fig. 1). Cardiac enzymes were elevated (creatine kinase, 702 U/L; creatine kinase MB, 91.1%; cardiac troponin T, 0.344 ng/mL). An echocardiogram on admission showed basal inferior and mid-inferior akinesia with anterior right ventricular wall hypokinesia. The anterior left ventricular wall contracted normally.Open in a separate windowFig. 1 Electrocardiogram on admission.Due to the presumptive diagnosis of acute anterior myocardial infarction, the patient was immediately studied by means of coronary angiography, which showed a normal left coronary artery (Fig. 2), a split right coronary artery (RCA) with proximal occlusion of the anterior bifurcation, and no distal filling through collateral vessels (Fig. 3). The posterior subdivision of the RCA led to a small upper posterior descending branch and a large posterolateral branch (Fig. 3). The occluded anterior subdivision was entered and dilated; a 2.75 × 14-mm Endeavor® stent (Medtronic, Inc.; Minneapolis, Minn) was deployed, which resulted in recovery of TIMI-3 flow while antegrade filling of the posterior descending branch showed on angiography (Fig. 4). Follow-up ECGs showed gradual resolution of the ST-T changes (Fig. 5).Open in a separate windowFig. 5 Two days after angioplasty, an electrocardiogram shows that ST-T changes are beginning to resolve.Open in a separate windowFig. 4 Immediately after angioplasty, antegrade filling of the more distal posterior descending branch appears upon angiography.Open in a separate windowFig. 3 Angiogram on admission shows total occlusion (arrow) of the split anterior bifurcation of the right coronary artery.Open in a separate windowFig. 2 Angiogram on admission shows near-normal left coronary artery.     

Disseminated Dermal Leishmaniasis Caused by Leishmania siamensis In a Systemic Steroid Therapy Patient

Leishmania siamensis infection was recently reported from Thailand. Clinical presentation of L. siamensis infections is generally related to human immunodeficiency virus infection. Herein, disseminated dermal L. siamensis infection in a systemic steroid therapy patient from Myanmar is described.A 60-year-old male Burmese living in Yangon had never traveled abroad. He developed fever, multiple infiltrative erythematous nodules on his body 3 months before coming to Thailand. He visited a physician in Yangon and was diagnosed as Sweet''s syndrome. The patient was treated with prednisolone for 2 months without improvement.Repeat biopsy showed diffuse histiocytic infiltrate and multinucleated giant cells in the upper and deep dermis. Many rounds to oval small organisms were present in histiocytes and fibrous stroma. He was diagnosed as histoplasmosis and was treated with itraconazole, his general condition was improving, however the cutaneous lesions worsened (Figure 1A and ​andB).B). Laboratory testing for antinuclear antibodies, anti-human immunodeficiency virus (HIV), C-reactive protein were negative or within normal limits.Open in a separate windowFigure 1.Disseminated dermal leishmaniasis caused by Leishmania siamensis. Multiple erythematous, shiny infiltrative plaques and nodule on face, trunk, and extremities were observed (A). Infiltrative erythematous nodules, ulcers were observed on some nodules (B).New skin biopsy showed numerous small yeast-liked organisms, and some of these organisms were contained small basophilic dots in the cytoplasm opposite to nuclei (Figure 2). This finding suggested that it was Leishmania. Polymerase chain reaction (PCR) using a primer set annealed specifically to the 18S rRNA gene of the internal transcribed spacer1 (ITS1) of Leishmania sp. Leishmania siamensis was identified by nucleotide sequencing of the PCR products compared with sequences of L. siamensis previously reported (accession no. {"type":"entrez-nucleotide","attrs":{"text":"JQ001751","term_id":"367461079"}}JQ001751) and has showed to be 100% identical.¹ All specimens used to culture for Leishmania were negative.Open in a separate windowFigure 2.Histopathological examination of the skin biopsy from the patient, hematoxylin and eosin (H&E) staining reveals numerous intracellular organisms containing nucleus and bar-shaped kinetoplast (arrow). This indicated amastigotes of Leishmania parasites infection (100×).After a final diagnosis of disseminated dermal leishmaniasis was established, the patient was treated with intravenous amphotericin B 60 mg per day for 40 days. His cutaneous lesions markedly regressed. He was discharged without any medication. When he returned for follow-up 2 months later, he reported that he had gained weight and appetite. Few skin lesions still remained but they were flattened and decreased in size.Leishmaniasis has been described as an opportunistic infection in immunocompromised patients. Leishmaniasis in glucocorticoides-treated patients has been reported in three cases infected with Leishmania infantum.² Leishmania siamensis infection was described mostly in acquired immunodeficiency syndrome (AIDS) patients from Thailand. This is the first autochthonous leishmaniasis caused by this novel species in Myanmar.     

ICD Leads Extraction and Clearing of Access Way in a Patient With Superior Vena Cava Syndrome: Building A Tunnel

Central vein disease is defined as at least 50% narrowing up to total occlusion of central veins of the thorax including superior vena cava, brachiocephalic, subclavian, and internal jugular vein. Thrombosis due to intravascular leads occurs in approximately 30% to 45% of patients early or late after implantation of a pacemaker by transvenous access.In this case, we report a male patient, 65-years old, hypertensive, type 2 diabetic, with atherosclerotic disease, coronary artery disease, underwent coronary artery bypass surgery in the past 10 years, having already experienced an acute myocardial infarction, bearer automatic implantable cardioverter defibrillator for 8 years after an episode of aborted sudden death due to ischemic cardiomyopathy, presenting left superior vena cava syndrome. The use of clopidogrel and rivaroxaban for over a year had no benefit on symptoms improvement.After atrial and ventricular leads extraction, a new shock lead was positioned in the right ventricle using active fixation and a new atrial lead was positioned in the right atrium, passing inside of the stents. Two days after the procedure the patient was asymptomatic and was discharged.Central vein disease is defined as at least 50% narrowing up to total occlusion of central veins of the thorax including superior vena cava, brachiocephalic, subclavian, and internal jugular vein.¹ Obstruction can be caused by invasion or external compression of the superior vena cava by adjacent pathologic processes involving the lung, lymph nodes, and other mediastinal structures or by thrombosis within the superior vena cava.² In the past, infectious lesions were common causes; however, nowadays malignancy and the use of intravascular devices and cardiac pacemakers have become the main causes.^2,3 Thrombosis due to intravascular leads occurs in approximately 30% to 45% of patients early or late after implantation of a pacemaker by a transvenous access.⁴ Several patients may be asymptomatic because they develop efficient collateral circulation. The incidence of pacemaker-induced superior vena cava syndrome has been reported to be less than 0.1%.⁵ In the meantime, the superior vena cava syndrome associated with internal leads may be a benign condition, or a debilitating and sometimes intractable complication. Furthermore, there is no consensus on a standard care management.⁶Angioplasty and stent placement have been established as a less invasive but equally effective alternative to open surgical treatment.⁷ Meanwhile, angioplasty is potentially associated with lead damage and dysfunction. The trapping and crushing of leads by a stent would be an insolvable situation if the device gets infected. A percutaneous approach consisting of lead removal, stent implantation, and reimplantation of leads has been described with good results over the short and medium term follow-up.⁸ Long-term efficacy of this approach is still unknown. A recent study reported that percutaneous stent implantation after lead removal followed by reimplantation of leads is a feasible alternative therapy for pacemaker-induced superior vena cava syndrome, although some cases may require repeat intervention.⁹In this case, we report a male patient, 65-years old, hypertensive, type 2 diabetic, with atherosclerotic disease, coronary artery disease, underwent coronary artery bypass surgery in the past 10 years, having already experienced an acute myocardial infarction, bearer automatic implantable cardioverter defibrillator (ICD) (Fig. ​(Fig.1)1) for 8 years after an episode of aborted sudden death due to ischemic cardiomyopathy, presenting left superior vena cava syndrome with the following symptoms: arms, neck, and face edema, besides development of swollen collateral veins on the chest wall, shortness of breath, and cough (the ethics committee composed by Paola Baars Gomes Moises, Luis Marcelo Rodrigues Paz, Humberto Cesar Tinoco e Jonny Shogo Takahashi, approved the execution of the case). Informed consent was signed by the patient.Open in a separate windowFIGURE 1Previous automatic implantable cardioverter defibrillator (A), (B), (C), and (D).The use of clopidogrel and rivaroxaban for over a year had no benefit on symptoms improvement. The computed tomography angiography of the thoracic venous system showed a noted marked diameter reduction with irregular opacification in the brachiocephalic veins and distal half of the superior vena cava. This structure had normal caliber and was well opacified from the confluence with the azygos vein continuing along the jugular and subclavian veins. Exuberant collateral circulation was noted through the superficial veins in the chest wall, intercostal veins, paraspinal, and mediastinal. The strategy adopted was the extraction of the “double coil” shock lead positioned in the ventricle and the explant of the atrial lead, as well as the generator, to perform the patency of the route and the consequent improvement of symptoms. The leads were extracted after the introduction of the guides on both electrodes, dilation of the initial and middle portions of the left subclavian vein, clockwise and counterclockwise rotation of the leads, besides manual traction. The leads were extracted without any complications and the brachiocephalic vein where they were placed was partially obstructed, confirmed after infusion of non-iodinated contrast (Fig. ​(Fig.2).2). We opted first of lead extraction because the implantation of stents in this vein could fracture the electrodes.Open in a separate windowFIGURE 2Leads extraction without (A), (B), (C) and the left subclavian and brachiocephalic veins where they were placed has been partially unobstructed, confirmed after infusion of non-iodinated contrast (D).The puncture of the right subclavian vein and the right femoral vein were performed, with an introduction of a short sheath 6F in each vein. Thereupon, hydrophilic wire guide (Aqualiner, Nipro Corporation, Japan) was introduced, as well as, an “over the wire” pig tail catheter. Venography with non-iodinated contrast through both accesses was performed. The superior vena cava had an unbridgeable thrombus (Fig. ​(Fig.3A3A and B) just above the right atrium, with only a tortuous and very narrow path between the superior vena cava and the brachiocephalic vein. The guidewire Aqualiner was replaced by another wire (road runner, Cook Medical, Rio de Janeiro, Brazil) due to this increased support and the femoral short sheath was replaced by 6F long sheath with 90 cm. A hydrophilic tip catheter (Slip-Cath Beacon Tip Hydrophilic Catheter, Cook Medical) was inserted to overcome the occlusion with success at this stage of the procedure (Fig. ​(Fig.3C–E).3C–E). After several tries, this catheter was captured by a lassoer catheter (Multi-Snare, B. Braun Interventional Systems Inc., Rio de Janeiro, Brazil) inserted into the brachiocephalic vein through the left subclavian vein puncture (Fig. ​(Fig.3F).3F). The guide wire was replaced by a fixed core wire guide (Fig. ​(Fig.3G3G and H) (Amplatz, Cook Medical) and angioplasty was performed with noncompliant balloon catheter, thus requiring the implantation of 2 self-expanding stents 28 mm × 60 mm (sinus-XL Stent, Optimed, Medizinische Instrumente GmbH, Ettlingen, Germany) in the left subclavian vein, brachiocephalic trunk, and the superior vena cava followed by dilation with balloon catheter of 26 mm × 4 cm (Zelos PTA – Balloon Catheter, Optimed, Medizinische Instrumente GmbH, Ettlingen, Germany). A venography ensured the access to ICD implantation (Fig. ​(Fig.44A–F).Open in a separate windowFIGURE 3Angiography of the venous system showing the superior vena cava with an unbridgeable thrombus just above the right atrium (A) and (B). A tip hydrophilic catheter was inserted to overcome the occlusion, with success at this stage of the procedure (C), (D), and (E). The tip hydrophilic catheter was captured by a lassoer catheter inserted into the brachiocephalic vein through the left subclavian vein puncture (F). The guide wire was replaced by a fixed core wire guide (G) and (H).Open in a separate windowFIGURE 4Angioplasty with noncompliant balloon catheter (A) and (B). Implantation of 2 self-expanding stents (C), in the left subclavian vein, brachiocephalic trunk, and the superior vena cava, followed by dilation with balloon catheter (D), and venography (E) and (F), ensuring the access to ICD implantation. A new “mono coil” shock lead was positioned in the apex of the right ventricle (G) and a new atrial lead was positioned in the right atrium (H), passing inside of the stents.A new “mono coil” shock lead was positioned in the apex of the right ventricle using active fixation and a new atrial lead was positioned in the right atrium, passing inside of the stents. Both were fixed in the pectoral muscles and connected to the ICD generator (Fortify ICD DR, St. Jude Medical, Rio de Janeiro, Brazil) (Fig. ​(Fig.4G4G and H). In the day after the procedure, the symptoms were no longer present and the patient was discharged on the second day after the procedure. Until the present time of follow-up (3 months) the patient remained asymptomatic. The patient was discharged using aspirin, clopidogrel, and rivaroxaban.     

Cutaneous Leishmaniasis “Chiclero's Ulcer” in Subtropical Ecuador

An 18-year-old female presented with a severe ulcerative lesion on her right ear of 6 weeks duration. Her right ear was edematous and erythematous with a large, painless ulcerative lesion covering a third of the pinna and satellite papular lesions on the posterior. She was diagnosed with chiclero''s ulcer. A skin smear stained with Diff-quik showed abundant Leishmania parasites. Chiclero''s ulcer is a rare clinical presentation and is typically severe and difficult to treat. Physicians in Ecuador recommend administering prolonged intramuscular Glucantime. Side effects are common and can be severe resulting in low patient compliance. Because of preferences of the patient and the large volume needed for her weight, we recommended topical treatment with a lotion of Glucantime mixed half and half with white Merthiolate. After applying this lotion to the lesion 3 to 4 times a day for 6 weeks, the lesion healed.An 18-year-old female presented with a severe ulcerative lesion on her right ear of 6 weeks duration. The lesion began in December 2011 as an itchy papular mosquito bite that enlarged to a nodule and later formed an ulcerative lesion covering a large part of the auricle. The patient came from Puerto Quito-Pichincha, a subtropical rainforest located in the Pacific region of Ecuador, where cutaneous leishmaniasis (CL) is endemic.¹ She visited a local physician who diagnosed erysipelas and prescribed oral ciprofloxacin and clindamycin for 10 days and fucidic acid as a topical ointment; however, the lesion showed no improvement. After completing 2 weeks of antibiotics she visited our department. The patient''s right ear was edematous and erythematous with a large, painless ulcerative lesion covering a third of the pinna and satellite papular lesions on the posterior (Figure 1A). She was diagnosed with chiclero''s ulcer. A skin smear stained with Diff-quik showed abundant Leishmania parasites (Figure 2). She was otherwise healthy. Her weight was 85 kg.Open in a separate windowFigure 1.(A) Lesion upon first clinical observation. (B) Resulting healed site of lesion after topical lotion.Open in a separate windowFigure 2.Leishmania bodies (amastigotes) present in a stained smear of the “chiclero''s ulcer” specimen.American tegumentary leishmaniasis is endemic in Ecuador and is reported in tropical and subtropical ecological regions from the Pacific side and Amazonian region; human cases are also diagnosed in some interandean valleys. Cutaneous leishmaniasis in Ecuador presents in several clinical variants, though the typical ulcerative form is most common. Other presentations such as nodular, pian bois, diffuse, recidiva cutis, erysipeloid, disseminated, and chiclero''s ulcer are rare.² The mucosal form is a very rare presentation in the subtropical regions of Pacific Ecuador and appears to be restricted to the Amazonian rainforest.Most CL presentations are self-healing within a period of 6 to 12 months, except diffuse cutaneous and recidiva cutis. Chiclero''s ulcer is a rare clinical presentation and is typically severe and difficult to treat, needing two or three schedules of intramuscular antimonial pentavalent. Physicians in Ecuador recommend administering prolonged intramuscular Glucantime. Side effects are common and can be severe resulting in low patient compliance. These side effects include myalgia, arthralgia, fever, asthenia, and anorexia. Because of preferences of the patient and the large volume (21 mL or 4 ampoules/day) needed for her weight, we recommended topical treatment with a lotion of Glucantime mixed half and half with white Merthiolate. After applying this lotion to the lesion three to four times a day for 6 weeks, the lesion healed (Figure 1B). Our goal is to report this unusual case of CL and its atypical yet effective topical treatment. Gathering the information for such a case and presenting it in a clinical image will serve for physicians to be aware of this cutaneous variant, demonstrate alternative treatment methods of CL, and augment the body of knowledge in this field.     

Estimation of Under-Reporting of Visceral Leishmaniasis Cases in Bihar, India

We report a 40-year old man in Uganda with ulcerated skins lesions, hypotension, and anaphylaxis caused by bites of safari ants. Treatment was successful. Physicians should be aware of anaphylaxis caused by ant bites.A 40-year old man came to the emergency department at St. Mary''s Hospital-Lacor in Gulu, Uganda. This is a rural hospital with limited resources. He had a history of alcohol abuse and had spent the preceding night sleeping in the bush. While asleep, he had been attacked by safari ants. He was unrousable and could not provide a medical history. Ants were still visible on his skin (Figure 1A). On examination, there were multiple erosions all over his body (Figure 1A). The patient had a Glasgow Coma Score of 6. His blood glucose level was 13 mg/dL (reference range = 70–100 mg/dL). A complete blood count was normal except for a leukocyte count of 12.4 × 10⁹/L (reference range = 4 × 10⁹/L–11 × 10⁹/L). Biochemical tests were not available.Open in a separate windowFigure 1.A, Multiple ulcers on the abdomen, shoulders, arms, neck, and head of the patient. Safari ant crawling on the hand and thumb (arrow) of the patient. B, Safari ant crawling on the bed sheet. This figure appears in color at www.ajtmh.org.He was resuscitated with two liters of Ringer''s lactate solution, followed by 2.5 liters/24 hours. His hypoglycemia was managed with 20 mL of 50% dextrose. Because the cause of the hypotension was not known, he was given 200 mg of hydrocortisone intravenously. Dopamine (5 μg/kg/minute) was given as an inotropic support agent. After blood cultures were obtained, he was treated with ampicillin and gentamicin. After five days, he improved sufficiently and was discharged. Blood cultures were negative, and we made a diagnosis of anaphylaxis secondary to ant bites with a possible secondary infection.Safari ants (Figure 1B) (order Hymenoptera, family Formicidae, genus Dorylus) (also known as driver ants, army ants, and Siafu) are found in central and eastern Africa and parts of Asia. Each anthill can contain up to 20 million ants. The venom of the ant has a protein component and an alkaloid component. The protein component causes anaphylaxis and the alkaloid component causes painful effects of the ant bite. Systemic (including anaphylaxis) symptoms are more common after multiple bites.¹ Anaphylactic reactions under these circumstances can be fatal.²