A case report of generalized pustulosis with systemic manifestations requiring burn intensive care unit admission

Not infrequently patients are transferred to a burn center with the diagnosis of toxic epidermal necrolysis (TEN). Not all cases of generalized erythema and skin sloughing represent TEN. Acute generalized pustular psoriasis (AGPP) of the von Zumbusch type and acute generalized exanthematic pustulosis (AGEP) are two rare skin diseases that can also present with widespread erythema and skin sloughing. We present the case of a 55 year old morbidly obese woman with a history of severe psoriatic arthritis treated in our burn unit for generalized pustulosis, erythema, and skin sloughing. This was accompanied by respiratory failure, hypotension, acute renal failure, and elevated direct bilirubin. Skin biopsy narrowed the differential diagnosis to AGPP and AGEP. Her skin sloughing was treated as second degree burns with petrolatum gauze and mupirocin ointment. She required intubation, aggressive fluid resuscitation and inotropic support. She recovered with these measures over the course of 1 week. Like TEN, AGPP, and AGEP can involve the skin to an extent requiring burn intensive care admission. Patients can present on rare occasions with multi-system failure. We would like to raise the awareness of burn specialists regarding these rare diseases. They should be distinguished from TEN, as they tend to have better prognosis than TEN and their management can be different.     

Rare presentation of Graves’ disease with myalgia: A case report

A 42‐year‐old woman presented with myalgia, which ameliorated a week after treatment. She was diagnosed with Graves’ disease. The presence of concomitant autoimmune diseases is important considerations for patients with Graves’ disease presenting with myalgia. Thyrotoxicosis should be included as a rare differential diagnosis for myalgia.     

Effectiveness of yoga in eating disorders – A case report

Eating disorders are among the most common psychosomatic diseases and are often associated with negative health consequences. The use of yoga as a treatment method in eating disorders is controversial discussed. The interviewee was a 38 year old female patient suffering on anorexia nervosa and various psychosomatic-psychiatric diagnoses in her medical history. The patient reported that yoga recovered the soul contact which she lost and she had learned to perceive and feel herself again. She stated that yoga helped her to find access to her body and its needs and to cope with her traumatic experiences. She also reported that attitudes have changed in relation to her stomach in the treatment of her anorexia. The case report confirmed the positive effect of yoga on eating disorders. Research should pay particular attention to taking into account the influence of individual’s co-morbidities, as eating disorders usually occur in association with co-morbidities.     

Geriatric problems and their management. The nursing perspective

Geriatric problems and its Nursing care is not like any other speciality which deals with one group of diseases. Older adults suffer from various disabilities and diseases. Geriatric group will lose memory power, bearing, eyesight, etc. The Nurse who deals with geriatric patients is expected to be well versed in all the aspects. She approaches the patients through Nursing process. She plans and directs the day-to-day Nursing care according to the situation that arises. Because of the scientific knowledge and modern techniques acquired by the Nurses and health care workers they are able to give a fairly comfortable life to the elderly people.     

Psychosocial reactions of children with cancer. A program for rehabilitation.

The diagnosis of cancer in children challenges all the skills of the pediatric nurse. She utilizes her basic knowledge of development, family dynamics, and disease process. She explores all the implications of long-term illness. She assesses, plans, implements, and evaluates care for the child and his family. She acts as liaison, teacher, and counselor. She is the advocate for the child and his family. As an active member of the team she is instrumental in the process of rehabilitation for the child, physically and emotionally. She can help the child to live with cancer and assure quality of life in the days granted him.     

Coexistence of thrombotic thrombocytopenic purpura and immune thrombocytopenic purpura in an Asian woman: a case report

A 33-year-old Chinese woman with a history of immune thrombocytopenic purpura presented with heavy menstrual bleeding. She was found to have thrombocytopenia, plasma ADAMTS13 activity of 0%, and positivity for the plasma ADAMTS13 inhibitor. She was diagnosed with the coexistence of thrombotic thrombocytopenic purpura and immune thrombocytopenic purpura. The patient was treated by plasmapheresis, a glucocorticoid, and rituximab. Her platelet level returned to normal, and she was discharged 28 days after admission. The number of plasmapheresis sessions and the timing of rituximab administration may be the key aspects of management of patients with thrombotic thrombocytopenic purpura who have underlying immune dysfunction caused by diseases such as immune thrombocytopenic purpura.     

Living with lung disease

Pauline Adam is a 42-year-old former nurse and mother of one. She has a genetic lung condition called Alpha-1-Antitrypsin Deficiency (A1AD). This condition is rare, affecting about one in 3,000 people in the UK. Ms Adam lives in Edinburgh and is a long-time supporter of the British Lung Foundation (BLF). She is a former organiser of her local BLF Breathe Easy support group, but is currently not well enough to attend group meetings. She is mostly confined to a wheelchair and is reliant on constant oxygen therapy.     

Successful treatment of pyoderma gangrenosum with concomitant immunoglobulin A nephropathy: A case report and review of literature

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition of an unknown etiology and is often associated with immune diseases. However, PG rarely shows visceral involvement, especially in the kidney. A 20-year-old female presented with pedal edema and skin ulceration of both lower limbs. The skin lesion began as an erythematous plaque and then became a blister. She also complained of abdominal distension and a decreasing urine volume. Laboratory data showed high proteinuria, hypoalbuminemia and hyperlipidemia. Her skin and kidney were biopsied. The pathological results indicated PG and immunoglobulin A (IgA) nephropathy. The patient was finally cured with prednisolone in combination with cyclosporine A (CsA).     

Alopecia treatment using minimally manipulated human umbilical cord-derived mesenchymal stem cells: Three case reports and review of literature

BACKGROUNDAlopecia areata (AA) is a common autoimmune disease characterized by hair loss. AA appears in extensive forms, such as progressive and diffusing hair loss (diffuse AA), a total loss of scalp hair (alopecia totalis), and complete loss of hair over the entire body (alopecia universalis). Recently, mesenchymal stem cells (MSCs) have been identified as a therapeutic alternative for autoimmune diseases. For this reason, preclinical and case studies of AA and related diseases using MSCs have been conducted.CASE SUMMARYCase 1: A 55-year-old woman suffered from AA in two areas of the scalp. She was given 15 rounds of minimally manipulated umbilical cord-MSCs (MM-UC-MSCs) over 6 mo. The AA gradually improved 3 mo after the first round. The patient was cured, and AA did not recur. Case 2: A 30-year-old woman, with history of local steroid hormone injections, suffered from AA in one area on the scalp. She was given two rounds of MM-UC-MSCs over 1 mo. The AA immediately improved after the first round. The patient was cured, and AA did not recur. Case 3: A 20-year-old woman, who was diagnosed with alopecia universalis at the age of 12, was given 14 rounds of MM-UC-MSCs over 12 mo. Her hair began to grow about 3 mo after the first round. The patient was cured, and alopecia universalis did not recur.CONCLUSIONMM-UC-MSC transplantation potentially treats patients who suffer from AA and related diseases.     

Collision tumor: invasive ductal carcinoma in association with mucosa-associated lymphoid tissue (MALT) lymphoma in the same breast

Synchronous occurrence of multiple neoplastic processes is uncommon and the relationship between breast cancer with lymphoproliferative diseases is unusual as well. Furthermore, breast involvement by malignant lymphoma is a rare event and primary breast mucosa-associated lymphoid tissue (MALT) lymphoma is even rarer. We report a patient with synchronous occurrence of malignant lymphoma of MALT type and ductal carcinoma of the breast, presenting as "collision tumor," invading each other and occurring as a single mass in the breast. Involvement of the sentinel lymph node by MALT lymphoma was demonstrated with no evidence of metastatic carcinoma. Staging bone marrow biopsy did not show involvement by malignant lymphoma or carcinoma. Our patient was treated with chemotherapy for the lymphoma. She also received radiotherapy and aromatase inhibitor as adjuvant therapy for the breast carcinoma.     

Chronic lymphocytic leukemia/small lymphocytic lymphoma complicated with skin Langerhans cell sarcoma: A case report

BACKGROUNDLangerhans cell sarcoma (LCS) is a rare malignancy with poor prognosis. LCS and chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) can occur in the same diseased tissues, such as lymph nodes or skin. CASE SUMMARYA 48-year-old female Han Chinese patient was admitted for generalized lymph node enlargement for 6 years and abdominal distension for 1 wk. She was diagnosed with small B-cell lymphoma (stage IV)/CLL (Benet stage B) and received chemotherapy. She started oral ibrutinib in February 2019. She was hospitalized on June 11, 2019, and a 1.5 cm × 1.5 cm dark-red nodule with ulceration scalp lesion was found. Biopsy revealed LCS but without CLL/SLL. She was diagnosed with CLL/SLL (Binet stage C, Rai stage IV) accompanied by secondary histiocytic sarcomas and skin LCS and received cyclophosphamide, doxorubicin, vincristine, dexamethasone, and etoposide but developed severe cytopenia. She ultimately refused treatments and discharged spontaneously. She died on September 12, 2019. The literature review showed that in patients with CLL/SLL, skin lesions of LCS are accompanied by CLL/SLL. This patient was different from the previously reported cases of skin LCS in patients with CLL/SLL.CONCLUSIONIn this patient, the skin lesion of LCS showed no concomitant CLL/SLL.     

Case reports: postpartum cerebral angiopathy in a patient with chronic migraine with aura

A 25-year-old woman with a history of chronic severe migraine with aura presented in an apoplectic state 1 week after the delivery of her third child. She developed a severe headache and within hours lapsed into a coma. A CT scan of the brain showed cerebral edema and an occipital hemorrhage. A four-vessel angiogram showed diffuse arterial narrowing of all the intracranial vessels with segmental narrowing of the suprasellar portion of the internal carotid arteries bilaterally. She had no risk factors for stroke or vasculitis. Her pregnancy and delivery were uneventful with no preeclampsia or eclampsia. Apart from ergometrine at the time of the delivery, no vasoconstrictor drugs were used. She recovered spontaneously. Serial CT scans of the brain demonstrated resolution of the edema and hemorrhage with the development of cortical and watershed infarcts. A repeat cerebral angiogram was normal. She was, therefore, diagnosed as having suffered from postpartum cerebral angiopathy, a form of reversible cerebral vasoconstriction, called the Call or Call-Fleming syndrome. The relationship between migraine and postpartum angiopathy in the development of reversible cerebral vasoconstriction is discussed.     

Thrombotic thrombocytopenic purpura in a patient with rheumatoid arthritis treated by plasmapheresis.

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, and neurologic symptoms. TTP is associated with many diseases and several therapeutic drugs. We report the rare case of a patient with rheumatoid arthritis who developed TTP that was not associated with drug therapy, 18 months after the onset of rheumatoid arthritis. She recovered from the TTP following daily sessions of therapeutic plasma exchange (TPE) with fresh frozen plasma replacement and glucocorticoid therapy. Recent pathogenic mechanisms are reviewed as they relate to von Willebrand factor. In this report of the rare association of TTP with rheumatoid arthritis, an immediate relationship is likely because both are of an immune nature. Awareness of the possible development of TTP in rheumatoid arthritis is important for early diagnosis and treatment.     

Polyarteritis nodosa in a patient with type 1 autoimmune hepatitis

Polyarteritis nodosa is a systemic necrotizing vasculitis that affects small- and medium-sized arteries. Liver involvement in patients with polyarteritis nodosa has been described, and ranges from asymptomatic elevation of aminotransferases to hepatic aneurysm rupture. We describe the case of a patient with type 1 autoimmune hepatitis and compensated liver cirrhosis who developed classic polyarteritis nodosa, complicated with cytomegalovirus and repeated urinary tract infections. After a long bedridden hospitalization, the patient's condition was stabilized. She is currently in good health, with well-controlled blood pressure, and stable kidney and liver function. To our knowledge, this is the first case report in the literature with concurrent appearance of both diseases.     

Woman with a hand ulcer

A 20-year-old woman presented to the emergency department for evaluation of a wound to left hand (Fig. 1). She admitted having a history of chronic severe headaches requiring daily use of analgesics. She first noted the ulcer approximately 10 months prior to presentation. Her examination was remarkable for a 10-cm by 8-cm ulceration to the dorsum of her left hand with exposed and necrotic metacarpals. Fibrous exudate was present in the wound-bed, and the ulcer was associated with a foul odor. She was afebrile on presentation with a peripheral white blood cell count of 6.4 x109/L, CRP 1.9 mg/dL, and ESR 15 mm/h.     

Cases from NACCT acute and intensive care symposium: Altered mental status,seizures, and rash in a fumigation company employee

Context. Methyl bromide is a halogenated aliphatic hydrocarbon that exists as a colorless gas or a volatile liquid. Methyl bromide historically had been used in fire extinguishers but is more commonly used as a gas fumigant for soil-borne diseases and pests. Methyl bromide is being phased out due to concerns for ozone depletion but can still be found. It is readily absorbed through the lungs while dermal absorption can also occur. Signs and symptoms of severe exposures include headache, respiratory distress, pulmonary hemorrhage, and seizures. In large pulmonary exposures, death can occur as rapidly as 1 h usually from respiratory failure. Methyl bromide can penetrate clothing and protective equipment presenting challenges to first responders. There is a debate over the mechanism of toxicity of methyl bromide and the role of hemodialysis and chelation in treatment. Case details. A 22-year-old female employee of a fumigation company contacted emergency medical services (EMS) after opening a tank of compressed methyl bromide in her car. She was initially combative and confused. She underwent two water dermal decontaminations and was transported to the nearest tertiary center. She rapidly progressed to obtundation with seizure-like activity and dysrhythmias. Despite the supportive care and resuscitative efforts, she died approximately 1 h after her call to EMS. Discussion. Methyl bromide exposures can be fatal, and this case highlights the difficulty in managing these acutely poisoned patients. Questions for consideration after this case include time spent on decontamination, use of adjunctive anti-epileptic drugs, role of chelation therapy, and the role of hemodialysis in the treatment of methyl bromide poisoning.     

Woman with a hand ulcer

A 20-year-old woman presented to the emergency department for evaluation of a wound to left hand (). She admitted having a history of chronic severe headaches requiring daily use of analgesics. She first noted the ulcer approximately 10 months prior to presentation. Her examination was remarkable for a 10-cm by 8-cm ulceration to the dorsum of her left hand with exposed and necrotic metacarpals. Fibrous exudate was present in the wound-bed, and the ulcer was associated with a foul odor. She was afebrile on presentation with a peripheral white blood cell count of 6.4 x109/L, CRP 1.9 mg/dL, and ESR 15 mm/h.     

Fatal cytomegalovirus infection with CD4+ T-lymphocytopenia during corticosteroid therapy for bronchial asthma

An 80-year-old woman was admitted with dyspnea. She had been treated with oral prednisolone for bronchial asthma. She was intravenously treated with dexamethasone. On the 9th day, she presented oliguria and thrombocytopenia. She was diagnosed as dehydration and disseminated intravascular coagulation, and was treated with hydration and heparin infusion. On the 12th day, she presented macroscopic hematuria and melena. Cystoscopy revealed hemorrhagic cystitis. Bone marrow aspiration showed hemophagocytosis. Serum antigen of cytomegalovirus (CMV) was positive. CD4+ T cell count was very low (40/μL). She was diagnosed as disseminated CMV infection, and was treated with gancyclovir and immunoglobulin infusion. On the 14th day, she died of pneumonia. This is the first report of fatal CMV infection during corticosteroid therapy for bronchial asthma.     

Rituximab as successful therapy in a patient with refractory paroxysmal cold hemoglobinuria

BACKGROUND: Paroxysmal cold hemoglobinuria (PCH) is a rare autoimmune hemolytic anemia (AIHA) attributed to a biphasic hemolysin known as the Donath-Landsteiner (DL) antibody. It is most commonly encountered as an acute transient AIHA after a viral infection in children; the disease resolves after cessation of the infection. The rarest form of PCH is a chronic form in adults that is not (nowadays) associated with infection and is not responsive to conventional therapies. Rituximab has been found to be effective therapy in other forms of AIHA, such as cold agglutinin syndrome, that are refractory to conventional therapies. We describe a case of PCH refractory to steroids that responded to rituximab therapy on two separate occasions. CASE REPORT: A 64-year-old woman with fatigue was found to be profoundly anemic with laboratory findings consistent with AIHA. She was admitted for the workup and management of her disease after she failed to respond to a course of oral steroids. Laboratory evaluation demonstrated a positive DL test suggesting PCH. She was given a course of rituximab that resulted in normalization of her hemoglobin concentration. She presented 9 months later with recurrent hemolysis. She was given another course of rituximab that again resulted in termination of hemolysis. The patient remained in remission since her last dose of rituximab 19 months previously. CONCLUSION: To our knowledge, this is the first report of an adult case of refractory PCH successfully treated with rituximab.     

SUNCT syndrome in association with persistent Horner syndrome in a Chinese patient

This is the first case report of a chinese patient with SUNCT (shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing) presenting with persistent Horner's syndrome. She had episodic, brief, right periorbital pain in association with ipsilateral eye injection, lacrimation and rhinorrhea as well as persistent ipsilateral miosis and ptosis. She had partial response to a combination of indomethacin and carbamazepine therapy.