Angiotensin-converting enzyme (ACE) inhibitor-associated angioedema of the stomach and small intestine: a case report

This is a case report on a 45-year old African-American female with newly diagnosed hypertension, who was started on a combination pill of amlodipine/benazapril 10/5 mg. The very next day, she presented at the emergency room (ER) with abdominal pain, nausea and vomiting. Physical exam, complete metabolic panel, and hemogram were in the normal range. She was discharged from the ER after a few hours of treatment with fluid and analgesics. However, she returned to the ER the next day with the same complaints. This time the physical exam was significant for a distended abdomen with dullness to percussion. CT scan of the abdomen revealed markedly thickened antrum of the stomach, duodenum and jejunum, along with fluid in the abdominal and pelvic cavity. Angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema was suspected, and anti-hypertensive medications were discontinued. Her symptoms improved within the next 24 hours, and repeat CT after 72 hours revealed marked improvement in stomach and small bowel thickening and resolution of ascites. The recognition of angiotensin-converting enzyme (ACE) and angiotensin receptor blocker (ARB) intestinal angioedema constitutes a challenge to primary care physicians, internists, emergency room personal and surgeons.     

临床药师培训病例考核模式改革的问卷调查

目的：在启用新模式进行病例考核示范中,了解带教药师对该模式的评价,以完善该考核模式。方法：采用问卷调查的方法,发放问卷47份,收回33份,回收率为70.2%。通过该方法对改革后病例考核新模式的评价等进行调查和分析。结果：28名被调查者（84.8%）对新考核模式给予积极评价,大多数认为该模式提高了考核的规范性和评价的标准化,少数提出该模式可能会限制学员能力的充分发挥。24名被调查者（72.7%）认为考核病例的命题应由临床医师和药学带教老师或与考核专家三者一起提供,并应补充现场考核专家的即兴提问。25名被调查者认为不同培训阶段考核病例命题难度与侧重点应有层次。结论：新模式病例考核是目前适合我国临床药师培训、考核的较好模式,但尚需进一步探索和实践。     

Implementation and faculty assessment of an oral examination in a therapeutics course in a distance synchronous education pharmacy programme

Objectives To describe the process and implementation of an oral exam in a large class with distance synchronous education technology and to evaluate the faculty's perspective of the development, administration, and assessment of the oral exam. Methods The Department of Pharmacy Practice at Nova Southeastern University, USA, created two patient cases for the oral exam per course over two semesters within the Therapeutics and Pathophysiology course sequence to be distributed across three campus sites. The faculty's perspective was evaluated utilizing a questionnaire distributed via an online survey. Key findings The oral exam was administered simultaneously across three campuses to a total of 464 students over two semesters. A total of 42 faculty members assisted in the exam process. Four cases were developed for the two exams, with detailed answer keys to minimize subjectivity in grading. Twenty‐eight faculty members (66%) completed the assessment questionnaire. Most faculty were in support of continuing to administer the oral exam in subsequent therapeutic courses. Conclusions Implementation of an oral exam in a large class with synchronous education via distance campuses is feasible. However, exam coordinators must take into account logistics such as time commitment from faculty, adequate facilities and detailed case and key development.     

Zosteriform Darier's disease versus acantholytic dyskeratotic epidermal nevus

Patients with keratotic lesions distributed in a unilateral, linear, zosteriform or localized pattern and revealing histologic features of dyskeratotic acantholysis have been reported. There is still some controversy regarding the appropriate nosologic placement of this entity. Some believe it represents a localized form of Darier s disease, while others argue it is a variant of epidermal nevus. We report a case of a 42-year-old physician who presented with a 15-year history of an asymptomatic eruption that had been diagnosed as "chronic zoster." Physical exam revealed hyperkeratotic papules and plaques in a dermatomal distribution. The controversy regarding the correct nosologic placement of such a patient is discussed.     

某县免费孕前优生健康检查结果的分析

目的探讨孕前优生健康检查对发现导致不良妊娠结局的风险因素的积极作用。方法采用国家免费孕前优生健康检查项目技术服务要求,对3887份孕前优生健康检查《家庭档案》进行分析。结果 7774例接受孕前优生检查的夫妇,690例异常病史以男性吸烟、饮酒等不良生活习惯和女性不良妊娠史居多;高风险人群668例,女性占64.22%,其中不良妊娠史占34.46%,男、女乙型肝炎病毒感染占高风险人群的27.84%。861例获得妊娠结局,不良妊娠结局15例。不良妊娠结局中自然流产9例、治疗性引产5例,早产1例。结论孕前优生健康检查可以筛选高风险人群,发现可能发生出生缺陷的风险因素,降低不良妊娠结局的发生风险,计划怀孕夫妇参加检查和接受优生优育指导是非常必要的。     

肾盂旁囊肿的诊断与治疗(附16例报道)

目的 探讨肾盂旁囊肿的诊断与治疗方法.方法 回顾性分析16例肾盂旁囊肿患者的临床资料,比较B超、IVP、CT及MRI等检查方法与手术方式在诊治肾盂旁囊肿中的应用意义.结果 5例行开放手术治疗,术后随访6个月～3年,无1例复发.5例行B超定位下经皮肾穿刺硬化术患者,复发2例.6例后腹腔镜下肾囊肿去顶减压术患者,均无肾血管及肾盂损伤并发症,1例因不能理想暴露而改行开放手术,术后随访1年时复发1例.结论 B超、IVP及CT是诊断肾盂旁囊肿常用的有效方法,B超与IVP结合可作为常规检查,CT对诊断该病准确率高,诊断困难时可行MRI检查.开放手术疗效确切,但微创手术是治疗肾盂旁囊肿的趋势.     

Quadriplegia due to pachymeningitis, vasculitis and sepsis in a patient with rheumatoid arthritis: a case report

We report the case of a 84-year-old man, with history of rheumatoid arthritis, admitted the Hospital for a fall and complaining of dysaesthesia and pain located to the cervical spine and arms. Within a few hours after admission, fever and acute, progressive, ascendant quadriplegia became evident. Magnetic resonance imaging (MRI) of cervical spine showed spinal canal stenosis between C4-C6 with spinal cord compression. Hemocultures resulted positive for Staphylococcus aureus. The clinical picture rapidly evolved to sepsis with a fatal multi-organ failure. An autopsy found a osteosclerosis narrowing the neurocanal at the level of C3-C6, and recent cervical medulla infarction. A histological exam revealed the presence of a suppurative pachymeningitis with local phenomenas of periradiculitis, vasculitis and thrombosis of the anterior medullar artery, associated with coagulative necrosis of the neural tissue.     

Multiple basal cell carcinomas in a young adult treated with imiquimod 5%: a case report and literature review

We present a case of basal cell carcinoma that is unique in the literature with regard to the rare combination of age of onset and number of BCCs at initial presentation that was successfully treated with imiquimod 5%. The patient is a 28-year-old Caucasian man with no past medical or dermatological history. Physical exam was remarkable for seven pink translucent skin lesions on the forehead, alar ridge, zygoma, and upper back. There were no signs or symptoms of a syndrome or disease entity known to cause BCC. Shave biopsies revealed basal cell carcinoma in all 7 lesions. The patient was successfully treated with topical imiquimod 5% 6 days per week for 6 weeks. The presentation of this number of de novo BCCs in a patient this young in absence of a known BCC syndrome has, to the best of our knowledge, not previously been reported in the literature and was successfully treated with imiquimod 5%.     

Not everything acid-fast is Mycobacterium tuberculosis--a case of Nocardia

We report a case of a 47 year old woman who presented with a history of motor convulsions and a three month history of an increasingly painful and progressively enlarging mass on the right side of her back. Neurological examination revealed generalised wasting and a right sided hemiplegia. A biopsy of the mass was taken for microbiology which reported growing branching gram positive rods after three days of incubation. A mycological diagnosis of Nocardia asteroides was made. An MRI scan revealed extensive infiltration of the fungal mass into extending from the base of the skull to fifth cervical vertebra.     

Progressive course of isolated splenic myeloid sarcoma

A previously healthy 40-year-old male presented with a 2-week history of fever and abdominal discomfort that was resistant to empirical broad-spectrum antibiotic treatment. The patient’s blood cell count and complete biochemical panel was normal, except for an increased lactate dehydrogenase level. Ultrasonography and computed tomography of the abdomen showed a large, soft tissue mass had infiltrated superior part of the spleen. Splenectomy with total tumor mass removal were performed. The pathological examination of the tumor tissue confirmed diagnosis of isolated myeloid sarcoma with monoblastic differentiation. Despite intensive antileukemic therapy, patient died four months after diagnosis was established.     

A case of levetiracetam induced bullous pemphigoid

Bullous pemphigoid is a chronic, acquired autoimmune skin disease. Certain drugs such as furosemide, penicillins, sulfonamides, ciprofloxacins, penicillamines, angiotensin converting enzyme inhibitors, chloroquine, and phenacetin were reported to cause bullous pemphigoid. This is a case report of a 70-year-old female, who presented with the formation of diffuse cutaneous blister in month after starting to use levetiracetam. Dermatological exam and histopathological findings were consistent with bullous pemphigoid. To the best of our knowledge this is the first case of bullous pemphigoid in the literature associated with levetiracetam use.     

Methamphetamine toxicity secondary to intravaginal body stuffing

BACKGROUND: People who ingest packets of illicit drugs or insert them into body cavities in an attempt to smuggle them are termed body packers. People who do this in an attempt to hide the drugs when encountered by law enforcement are called body stuffers. Severe toxicity and death occurs in body packers and body stuffers, and this is usually secondary to leaking of drug from packets in the gastrointestinal tract. This is well reported with cocaine and heroin and occurs less commonly with methamphetamine. We report an unusual case of intravaginal body stuffing that lead to severe methamphetamine toxicity in a young woman. CASE REPORT: A 20-year old female, who was in police custody, developed multiple seizures, altered mental status, tachycardia and hypertension shortly after admitting to having drugs enclosed in plastic bags in her vagina. She was hospitalized for 4 days with gradual improvement in her symptoms with the exception of a resting tachycardia. Gas chromatography and mass spectrometry of the urine at this time confirmed the presence of methamphetamine and the amphetamine metabolite, co-intoxicants were excluded based on comprehensive urine drug screening using GCMS. Quantitative serum levels of methamphetamine and amphetamine were 3100 ng/ml and 110 ng/ml, repectively. CONCLUSION: We report an unusual case of intravaginal body stuffing that lead to severe methamphetamine toxicity in a young woman. This case highlights the potential for severe methamphetamine poisoning secondary to intravaginal stuffing. If either body packing or stuffing is suspected, a vaginal exam may be warranted.     

Nasopharyngeal Necrosis After Chronic Opioid (Oxycodone/Acetaminophen) Insufflation

Nasopharyngeal necrosis resulting from narcotic insufflation is a recognized phenomenon, but cocaine use is more commonly associated with this pathology than opioid abuse. Physical exam findings associated with severe tissue destruction are not routinely seen on physical examination or available in the medical literature. We present a case of chronic oxycodone/acetaminophen insufflation and images of a defect in the soft palate.     

Primary cutaneous B-cell lymphoma in a 74-year-old Caucasian male

Primary cutaneous B-cell lymphoma is an uncommon neoplasm with classification schemes that may be confusing, but with clinical presentations that are relatively consistent. Clinical exam and history can raise the index of suspicion for this condition, although the diagnosis is confirmed only by pathological evaluation. We report such a scenario in the case of a 74-year old male with a slowly expanding oval plaque on his right upper arm.     

美国肿瘤专科临床药师认证考试分析及其思考与启示

目的：分析美国肿瘤专科临床药师（BCOP）认证考试,为我国临床药师培养与考核提供建议。方法：基于对美国专科药师委员会（BPS）考试项目分析,以BCOP认证为例,详细阐述和分析其认证机构和所设项目,申报资格、考试安排、考试大纲,认证复审及费用等内容,并列举BCOP考试知识点及模拟试题。结果：BCOP认证对药师工作经验和教育背景要求较严,认证考试涉及药物治疗和管理、科研与教学、管理实践、公众健康和宣传4大领域,包含能力要求20项,知识点42处,考试形式为以案例为基础的单选题,采取全国统考。结论：笔者认为,BCOP全面综合考查肿瘤药师,注重考核药师药物治疗能力,其对药师能力要求、考试内容和考试形式值得我们借鉴,可结合我国实际情况,不断改进现有临床药师培训与考试。     

以创新思维培养为导向的药剂学教学模式

精选基于药物制剂新技术、新剂型上市的创新型药物制剂作为案例,教学过程以案例引出问题,通过层层深入解决问题,使学生在掌握理论知识的基础上,激发其创新思维、提高学习兴趣,并通过期末考试引入案例分析及"药物制剂创新设计",评价教学效果。     

Isolated sixth nerve palsy after intravitreal ranibizumab injection

After intravitreal ranibizumab injection for diabetic macular edema (DME) in a 55-year-old man, the patient was admitted to our ophthalmology clinic with the complaint of diplopia. Given the results of the patient's history, physical exam, and negative magnetic resonance imaging (MRI), we believed that the patient had a sixth nerve palsy related to ranibizumab injection. To the best of our knowledge, this is the first case with isolated abducens palsy after ranibizumab injection.     

A case of a testosterone-secreting oncocytic adrenocortical carcinoma

Oncocytic neoplasms are most rarely found in the adrenal gland. They are usually benign and non-functioning. We present a case of a testosterone-secreting oncocytic adrenocortical carcinoma in a 19-year-old female who presented with acne, hirsutism and irregular menses. Clinical investigations revealed an elevated testosterone and DHEA-S and a 4×5 cm left adrenal mass. The tumour was successfully excised. The histology showed the tumour to be comprised of oncocytic cells with granular, eosinophilic cytoplasm, features consistent with an oncocytic carcinoma. This is the first case presented of a testosterone-secreting oncocytic adrenocortical carcinoma.     

Diagnostic pitfalls in childhood acute obstructive dyspnea

Diagnosis of an acute obstructive dyspnea is very difficult because there are many possible causes. The authors reported the case of a 3.5-year-old boy with an atopic status who presented iterative asthma attacks which evolute to severity in spite of an appropriate therapy. Then suffocation occurred with a serious infectious context. The cause of the disease was diagnosed by respiratory tract endoscopic exam which allowed to detect a laryngeal papillomatis. The surgical extraction of this tumour cured the patient. Physiopathology of acute obstructive dyspnea in child was discussed. Upper airway obstructions are separated from lower pulmonary diseases. Two syndromes are very difficult to separate among upper airway obstructions: spasmodic laryngitis and subglottal laryngitis. They are considered in fact as different outward signs of the same disease: subglottal laryngitis is the infectious evolutive form of a spasmodic laryngitis in which atopic status exists. Laryngeal papillomatosis would be a favourising factor of infection. The authors conclude that respiratory tract endoscopic exam is very important to diagnose childhood acute obstructive dyspnea.     

Phosgene Exposure: A Case of Accidental Industrial Exposure

Introduction

Phosgene is a rare exposure with strong clinical implications. We report a phosgene exposure that resulted in the patient's death.

Case Report

A 58 year-old man arrived to the emergency department 1 hour after exposure to phosgene with complaints of a sore throat. Initial vital signs were blood pressure 175/118 mmHg, heart rate 98/min, respirations 12/min, and oxygen saturation of 93% on room air. Physical exam revealed few scattered rhonchi, without signs of distress. Initial arterial blood gases (ABG's) revealed pH 7.42, pCO2 43 mmHg, pO2 68 mmHg, HCO3 27 meq/L, and oxygen saturation of 93% on room air. Initial chest x-ray 2 hours after the exposure demonstrated clear lung fields. Approximately 2.5 hours after the exposure, he began complaining of dyspnea, restlessness and his oxygen saturation dropped below 90%. He received nebulized albuterol, 1 gram intravenous methylprednisolone, and 100 % oxygen via face mask. Minimal improvement was noted and he was intubated. The post intubation chest x-ray, 3.5 hours after the exposure, revealed diffuse alveolar infiltrates. Acetylcysteine, terbutaline, and IV steroids were administered without improvement. The patient died 30 hours after exposure.

Discussion

There are many misunderstandings concerning phosgene due to its rare presentation. Traditional treatment modalities are often unproven in human trials and were unsuccessful in this case.

Conclusion

This case highlights the significant toxicity that results from phosgene exposure and the challenges of the limited treatment modalities. There is concern for the use of this agent in chemical terrorism.