Purpura and leukopenia in a cocaine user

A previously healthy 42-year-old woman presented to the emergency department (ED) for arthralgias and painful lesions on her ears, feet, and knee (Figures 1 and 2) that had developed over the last month. She had no significant past medical history and was not taking any prescribed medications. The rash was purpuric with violaceous borders and hemorrhagic bullae. While she had mild pain with movement, her joint examination was otherwise normal and without signs of infection. ED laboratory testing revealed leukopenia (2500/mm³) and cocaine metabolites in her urine.     

Drug-facilitated sexual assault: educating women about the risks

"Andrea," an 18-year-old college freshman, walked into her first fraternity party with a few of her sorority sisters. As she walked through the crowded house, one of the fraternity boys handed the girls large plastic cups. Another boy circulated through the crowd, filling up the cups of all guests from two pitchers of beer. When he filled Andrea's cup, he smiled and was polite and charming. She thought his act of filling her cup was kind and gentlemanly, and was flattered by his attention. She didn't notice he used a different pitcher for her than he had for her friends. She and her friends continued to mill through the crowd, sipping their beer. About 20 minutes later, Andrea suddenly had trouble focusing her vision. She felt disoriented and "drunk" even though she had only consumed a third of her beer. She started feeling nauseated, and tried to find her friends. The polite boy who had poured her beer asked her if she was all right, and offered to take her up to his room so she could rest. She followed him, grateful to be able to lie down. Forty-five minutes later, her concerned friends searched the house for Andrea. They found her upstairs passed out in a bedroom, lying on her side; she had vomited and her clothes were disheveled. Suspecting only alcohol intoxication; they picked her up, and walked her out of the party. After Andrea slept for about two hours, she woke up and told her friends something wasn't right. She had only drunk a small amount of her beer, and had no recollection after she walked up the stairs with the boy. She burst into tears, stating she feels some vaginal discomfort, and is afraid she may have been raped. Her friends looked at each other, thinking, "How did this happen and what are we supposed to do?"     

Use of power mobility for a young child with spinal muscular atrophy

BACKGROUND AND PURPOSE: Young children with severe motor impairments, such as spinal muscular atrophy, are often unable to move around their environment independently; therefore, they may be at risk for delays in areas of development not directly related to their motor limitations. Power mobility is an intervention that provides young children a means of independent movement and enables them to independently explore their environment. CASE DESCRIPTION: The participant was a 20-month-old girl with type II spinal muscular atrophy. INTERVENTION: The authors provided the child with a power wheelchair and gave her mother and physical therapist general guidelines to encourage her use of the power wheelchair. OUTCOMES: Within 6 weeks after receiving the power wheelchair, the child operated the wheelchair independently. She showed developmental gains in all domains of the Battelle Developmental Inventory and the Pediatric Evaluation of Disability Inventory over 6 months. The authors conducted an interview with the child's mother before and after intervention. She reported that the child was more independent after receiving the power wheelchair. DISCUSSION: The power wheelchair may have been associated with the changes in the child's mobility and her developmental changes over 6 months.     

Side-locked headache as the chief complaint of inflammatory orbital pseudotumor (myositic form): a case report

The case of a 38-year-old woman with continuous unilateral side-locked headache is reported. She had continuous right-sided periorbital pain of mild to moderate intensity for the past 5 months. She also reported a few episodes of pain exacerbations every day. She had no autonomic features. Based on a normal CT scan ordered by her general physician, we started indomethacin (150 mg/day) as well as celecoxib (400 mg/day) for 2 weeks, without relief. Oral prednisone for 6 days provided important relief, and she stayed on daily use of steroids, refusing other forms of therapy. After 5 months she developed orbital and eyelid edema, with painful restrictions to eye movement. Orbital MRI and pathological exam demonstrated inflammatory orbital pseudotumor (myositic form).     

Orbital pseudotumour presenting as orbital cellulitis

A 33-year-old woman presented to a community emergency department with a 4-day history of monocular orbital pain, photophobia and pain on extraocular movement. Findings included chemosis, conjunctival injection and restricted extraocular movements causing strabismus. She was diagnosed with orbital cellulitis during her initial emergency department visit and treated with intravenous antibiotics. On her second ED visit later the same day, a diagnosis of orbital pseudotumour was made after computed tomography revealed inflammation of the sclera, optic nerve, muscle and adipose tissue within the orbit. Antibiotics were discontinued and tapering steroids were initiated, with prompt resolution of symptoms.     

Snapping wrist due to bony prominence and tenosynovitis of the first extensor compartment: A case report

BACKGROUNDA snapping wrist is a rare symptom that results from the sudden impingement of one anatomic structure against another, subsequently causing a sudden movement only during wrist movement.CASE SUMMARYA 30-year-old woman with a history of right wrist contusion reported right wrist snapping after overuse. The snapping became symptomatic after moving heavy objects. The pain persisted even when she received 1 mo of conservative treatment. Physical examination showed painful wrist snapping during wrist radioulnar motion and thumb abduction-adduction. Radiography demonstrated bone overgrowth over the radial styloid process. Sonography disclosed a tendon jumping over a bony prominence in the first compartment during wrist motion. Magnetic resonance imaging revealed no anomalous tendon nor tumorlike lesion. Under the wide-awake local anesthesia no tourniquet (WALANT) technique, the lesion was identified in the first extensor compartment. The patient received stepwise extensor retinaculum release, synovectomy, and bone spur removal. By 6^th week, the patient was completely free of pain and unable to snap her wrist. She started working 7 wk after the surgery. One year after the surgery, the wrist snap was not recurrent.CONCLUSIONCareful physical examination and dynamic sonography may confirm the diagnosis of a snapping wrist. With the WALANT technique, the lesion could be identified under direct vision, and we could take stepwise interventions according to intraoperative presentations.     

Atypical fatigue

CASE STUDY: Mrs. S is a 63-year-old retired teacher who returns to the office for breast cancer follow-up. She was diagnosed with intraductal carcinoma, and her treatment included a modified radial mastectomy followed by four cycles of doxorubicin and cyclophosphamide. Her tumor was estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor 2-negative by fluorescence in-situ hybridization. Chemotherapy was completed nine months ago, and she is taking adjuvant tamoxifen. She has recovered quite well; her only complaint is fatigue. She states, "I expected to be tired during and immediately after chemotherapy, but I thought I would have all my energy back by now. I still feel the need to take a nap in the afternoon. In fact, I feel sleepy all the time!" Mrs. S's medical history is significant for moderate obesity and hypertension for 10 years, which is controlled with the angiotensin converting enzyme inhibitor lisinopril. She has not exercised since her breast cancer diagnosis but has been trying to lose weight with dietary changes. She believes that tamoxifen is hampering her weight-loss efforts. She takes no other medications.     

Patient as Teacher

ABSTRACT

The author provides some reflections based on her experiences as a member of Becky's treatment team (see Werth, this issue). She briefly highlights some of the areas that were most important in her work with Becky and others with life-limiting illnesses, including information-seeking, social support, maintaining normalcy, depression and decision-making, nausea and vomiting, post-traumatic stress disorder, and the role of psychotherapy. She ends with her reactions to working with Becky and how Becky touched her personally and professionally.     

Gabapentin for chronic pain in spinal cord injury: a case report

A 30-year-old white woman with an L1 complete spinal cord injury (SCI) secondary to a gunshot wound in 1985, presented to a chronic pain service for evaluation. She had a 13-year history of chronic lower extremity pain. She described her discomfort as "throbbing, aching, and stabbing." She had tried many different medications, including opioids, Tegretol, and tricyclic antidepressants, without success. During the evaluation process, she admitted to being "angry, frustrated, and anxious." She was diagnosed with central pain after SCI. She was placed on gabapentin 300 mg 3 times daily; within 1 week, her visual analog pain scale fell from 95 mm to 27 mm, and her McGill Short Form pain score fell from 13 to 3. Her mood also vastly improved. This case report suggests that gabapentin should be studied as a therapeutic option for treating central pain post-SCI and should be considered as a viable, well-tolerated, low-toxicity tool.     

Epstein-Barr virus-related encephalitis in a young woman: A case report

Although infectious mononucleosis due to Epstein-Barr virus (EBV) is a common disease among young individuals, central nervous system (CNS) complications are rare. In this report, we describe a case of CNS complications caused by EBV in a previously healthy young woman. She presented to our hospital with a 9-day history of headache and sore throat, followed by the development of fever and facial edema 6 days prior to admission. On Day 2 of admission, she was confused (Glasgow Coma Scale score: 10 points) and had fever, muscle weakness in her right arm and leg, stiff neck, and roving eye movement. We detected EBV in a cerebrospinal fluid (CSF) sample using a polymerase chain reaction (PCR) test. The magnetic resonance imaging of her brain revealed dural enhancement and right parietal and temporal lobe lesions. She was treated with acyclovir and high-dose steroid therapy. She responded well to treatment, recovered without neurologic sequelae, and was discharged home on Day 12.Our experience suggests that PCR detection of EBV DNA in CSF may be useful in diagnosing EBV encephalitis and that prognosis may be associated with an area of the brain that is affected and the time from symptom onset to starting treatment.     

Rehabilitation of an adult with disabilities due to congenital sensory neuropathy

A 37-year-old woman presented with congenital loss of all peripheral sensory modalities, sparing only her face, paraspinal area and proximal limbs. She was otherwise neurologically normal. Her sensory neuropathy was complicated by autoamputation of phalanges, pathologic fractures, failed total hip replacement, burns, pressure ulcers, and a painless peptic ulcer. An unusual cluster of functional deficits occurred when she was unable to substitute vision for peripheral sensibility. In the sudden darkness of a power failure she would fall to the floor; we advised the installation of battery-operated safety lights activated by a drop in line voltage. Voice-activated lights overcame difficulty in finding light switches in darkened rooms. She was unable to drive at night until she had a light placed under the dashboard of her car so she could see the foot pedals. She was unable to wash her hair, as shampoo irritation made her close her eyes and lose balance; swimming goggles and a nonfogging mirror permitted independence in her hair care. The solution of these functional difficulties provides a fresh perspective on the rehabilitation of patients with severe sensory impairments, especially with a cooperative family.     

Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report

Case: A 57-year-old woman was found at home by paramedics to be hypoglycemic with altered mental status. She had multiple attempts at IV access and eventually a 22G IV was established and D50 was infused into her right forearm. Extravasation of the dextrose was noted after approximately 12 g of the medication was infused. She was given a dose of glucagon intramuscularly and her mental status improved. Shortly after her arrival to the emergency department, she was noted to have findings of compartment syndrome of her forearm at the site of the dextrose extravasation. She was evaluated by plastic surgery and taken to the operating room for emergent fasciotomy. She recovered well from the operation. Discussion: D50 is well known to cause phlebitis and local skin necrosis as a complication. This case illustrates the danger of compartment syndrome after D50 extravasation. It is the first documented case of prehospital dextrose extravasation leading to compartment syndrome. There may be safer alternatives to D50 administration and providers must be acutely aware to monitor for D50 infusion complications.     

Legal aspects of consent 18: issues relating to euthanasia

Case Scenario: Norah was in the terminal stages of cancer. She lived with her single daughter, Jane, and was being cared for by Macmillan nurses who came to see her daily. She was on a high level of morphine but still suffered considerable pain. A consultant in palliative care visited her to reassess her medication levels, but Norah found that the new medication still left her with considerable discomfort and pain. Norah asked her daughter to help her end her life. What is the law?     

Caring from the inside out strategies to enhance nurse retention and patient satisfaction

In her book, Leading With Love, hospital administrator/nurse executive Kathleen Sanford, RN, DBA, says, “When theoretical management techniques are applied to a real-life work setting, the thing that will determine their success is a deep, fundamental concern for customers, employees, and the company, similar to the caring of a loving parent.”¹ She believes that nonclinical and clinical caring represent vital keys to patient satisfaction, nurse retention and, ultimately, the financial health of an organization.     

Posttransfusion purpura following bone marrow transplantation

BACKGROUND : Thrombocytopenia is a major cause of morbidity and hospital expense following bone marrow transplantation. Platelet transfusions in these patients are frequently complicated by the recipient's development of antibodies to HLA class I antigens. When these patients become refractory to the transfusion of HLA-matched platelets, the recipient's platelet antigen phenotype must be determined, to ensure that donor platelets will be phenotypically compatible. Cases of alloimmunization to HPA-1a and HPA-1b resulting in refractoriness to transfused platelets and the subsequent development of a posttransfusion purpura-like syndrome are reported. CASE REPORTS: In the first case, a 43-year-old woman with Stage IV infiltrating ductal breast cancer presented to the hospital for a transplant of autologous peripheral blood stem cells. After the transplant, her platelet count remained less than 10 × 10⁹ per L, despite daily platelet transfusions, including HLA-matched platelets. Fourteen days following the transplant, her serum was found to contain anti-HPA-1a. Initially, the patient was refractory to the transfusion of HPA-1a-negative platelets, but after treatment with intravenous immunoglobulin, she had transient increases in posttransfusion platelet counts. She was also treated with a staphylococcal protein A immunoadsorption column and has not had any such subsequent refractoriness. Her genotype has been found, by use of allele-specific oligonucleotide hybridization with white cell DNA, to be HPA-1b/1b. The second case involved a 32-year-old woman with chronic myelogenous leukemia who received an unrelated-donor marrow transplant. Three years later, her CML recurred, and she was treated with interferon-alpha. Four months afterward, she experienced interferon-alpha-induced thrombocytopenia and the interferon therapy was discontinued. She received 12 platelet transfusions in 20 days, but none was effective. Antibodies specific for HLA antigens and HPA-1b were detected, and three HLA-matched, HPA-1b-negative apheresis platelet components were given, but without effect. Two days after treatment with methylprednisolone (1 g intravenously) and prednisone (2 mg/kg/day orally), her platelet count was 26 × 10⁹ per L, and after 8 more days, it was 102 × 10⁹ per L, without further transfusions. She was found to be homozygous for HPA-1a (HPA-1a/1a). CONCLUSION : Anti-HPA- 1a and anti-HPA-1b can cause refractoriness to platelet transfusions in bone marrow transplant patients. Testing for platelet-specific antibodies should be considered in all patients who are refractory to HLA-matched platelets.     

Not for resuscitation instructions: the law for adult patients in the UK

Case Scenario: Marion, aged 55 years, has suffered from multiple sclerosis for 10 years and had reached the stage where she was wheelchair bound and had become extremely depressed. She was admitted to hospital for review of her medication and treatment plan. She discussed with a nurse what should happen in the event of her suffering a cardiac arrest and stated that she would not wish to be resuscitated. She had not discussed this with her relatives, nor had she put the instructions in writing. Two days later, when her daughter was visiting her, she had a cardiac arrest. Her daughter was anxious every effort should be made to resuscitate her and asked the nurse to call the arrest team. However, the nurse said that Marion had told her that she did not want to be resuscitated and that was therefore binding upon her. The daughter disagreed. What is the law?     

Physiological measurements corroborate symptomatic improvement after therapeutic leukapheresis in a pregnant woman with chronic myelogenous leukemia

Therapeutic leukapheresis can control the white blood cell count (WBC) of pregnant women with chronic myelogenous leukemia (CML) who have hyperleukocytosis without leukostasis. The medical justification for this treatment has not been objectively documented. We report a 27‐year‐old woman, diagnosed with CML at 10‐week gestation, who developed severe dyspnea on exertion. A workup that included chest CT and echocardiography with a bubble study detected no cardiopulmonary pathology to explain her symptoms, and thus she was referred for leukapheresis. Prior to her first leukapheresis, which lowered her WBC from 154 × 10³/μL to 133 × 10³/μL, her oxygen saturation (SpO₂) on room air decreased from 98 to 93% during 100 feet of slow ambulation and she was dyspneic. Just after the leukapheresis, her dyspnea on exertion was much improved and her SpO₂ remained at 98% with repeat ambulation. Spirometry and lung volume studies obtained before and after her first leukapheresis demonstrated 32 and 31% improvements in forced vital capacity and forced expiratory volume in 1 s respectively, a 25% increase in functional residual capacity, and a 142% improvement in expiratory reserve volume. Residual volume decreased by almost 20%. Three times in a week, leukapheresis was continued until her WBC was controlled with interferon α‐2b approximately 4 weeks later. Her dyspnea had completely resolved. She gave birth by elective caesarean section to a healthy boy at 32 weeks. Corroboration of symptom relief by leukapheresis with physiological data may justify such treatment in pregnant patients with CML. J. Clin. Apheresis 31:393–397, 2016. © 2015 Wiley Periodicals, Inc.     

The Peer Specialist Movement: An Interview with Gayle Bluebird,RN

In this interview, Gayle Bluebird, RN, Director of the Office of Technical Assistance (OTA) Center for Peer Networking, discusses the history and progress of the peer specialist movement. For the past 40 years, Gayle Bluebird has advocated for persons with psychiatric disabilities in service sectors, policy arenas, and with federal/state agencies. She has helped produce several important films and monographs on reducing seclusion and restraint. Currently her focus is on building a broader understanding of peer support services. This interview focuses on the peer specialist and the strides of peer support specialists in improving mental health services.     

Relapse of idiopathic thrombocytopenic purpura caused by influenza A virus infection: a case report

We report a patient with idiopathic thrombocytopenic purpura (ITP) in remission, who relapsed as a result of an influenza A virus infection. A 41-year-old woman presented with fever elevation, coughing, and generalized petechiae. Her platelet count had decreased to 1 × 10⁹/l. She had been diagnosed with ITP at age 23, and continuous complete remission had followed steroid therapy and splenectomy. Influenza A antigen was positive in her pharyngeal aspirate, and oseltamivir was effective for her symptoms. Findings of a bone marrow smear were typical for ITP. Steroid therapy resulted in a second complete remission. Although the development of ITP caused by influenza infection and a relapse caused by an influenza vaccination have been previously described, a relapse caused by a sporadic infection has never been documented to our knowledge. Physicians should carefully monitor the hematological data of influenza patients, especially those with ITP, even in remission.