Medicine
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Case Reports
Paracoccidioidomycosis of bones and joints. A clinical, radiologic, and pathologic study of 9 cases.
Paracoccidioidomycosis is a systemic fungal infection endemic to Central and South America. It is associated with a broad spectrum of clinical manifestations and has been classified into acute and chronic forms. The latter is the most common type and usually affects male agricultural workers in rural communities. ⋯ Our patients exhibited features of skeletal infection that have not been emphasized previously, however, including 1) frequent involvement of large joints or long bones of the extremities, 2) presentation with relatively rapidly developing musculoskeletal symptoms, and 3) manifestation as a solitary joint or bone lesion with or without concurrent clinically detectable pulmonary disease. Bone and joint paracoccidioidomycosis should be considered in the differential diagnosis in patients who have skeletal lesions with or without pulmonary involvement and have either lived in or traveled through endemic areas. Early diagnosis and treatment with antifungal medications can achieve an excellent outcome with limited local sequelae.
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Review Comparative Study
In-hospital cardiopulmonary resuscitation. Survival in 1 hospital and literature review.
Cardiopulmonary resuscitation (CPR) has been used extensively in the hospital setting since its introduction over 3 decades ago. We reviewed the CPR records at 1 hospital during a 2-year period and the results from 113 published reports of inpatient CPR with a total patient population of 26,095. We compared the survival rates of patients following CPR and the pre-arrest and intra-arrest factors related to survival. ⋯ Patient's location was related to outcome, with emergency room and coronary care unit patients more likely to survive than intensive care unit and general ward patients. Other factors related to better survival rates were respiratory arrest, witnessed arrest, absence of comorbidity, and short duration of CPR. Knowledge of the likelihood of survival following CPR for subgroups of the hospital population based on pre-arrest and intra-arrest factors can help patients, their families, and their physicians decide, with compassion and conviction, in what situations CPR should be administered.
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Milk-alkali syndrome can be caused by ingesting large amounts of calcium carbonate. Coincident with the promotion of calcium carbonate as treatment for both dyspepsia and osteoporosis, milk-alkali syndrome is now a common cause of hypercalcemia severe enough to require admission to the hospital. The syndrome accounted for less than 2% of such admissions before 1990, but from 1990 through 1993, it was the cause of hypercalcemia for over 12% of these patients. ⋯ Modern assays for PTH demonstrate the expected suppression of PTH by hypercalcemia. Nonetheless, measurement of PTH must be performed in a timely manner as treatment with intravenous saline may result in hypocalcemia and elevated PTH soon after admission. Given the pathophysiology of milk-alkali syndrome compared to other causes of hypercalcemia, hypocalcemia with rebound hyperparathyroidism is probably unique to milk-alkali syndrome.
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We identify and describe clinical findings in hypocomplementemic urticarial vasculitis syndrome (HUVS), an uncommon to rare illness related to systemic lupus erythematosus (SLE). A patient with recurrent, idiopathic urticaria-like lesions was diagnosed as having HUVS if a lesional biopsy showed leukocytoclastic vasculitis, the serum C1q was markedly decreased, and antibody to C1q was detected in the patient's serum. The clinical characteristics, serologic findings, and outcome of patients who met these criteria were determined from prospective and retrospective data, including hospital and office records, patient interviews, previously banked serum samples, and freshly drawn sera. ⋯ The pathogenesis of HUVS may involve humoral autoimmunity, although it is not clear how autoimmunity would participate in development of obstructive lung disease. Cigarette smoking appears to be a risk factor for fatal lung disease in HUVS. All patients with HUVS should be made aware of this possibility and should be advised, encouraged, and helped to avoid tobacco smoke.
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Bronchiectasis as a feature of rheumatoid arthritis is considered rare and, in most series, has preceded rheumatoid arthritis. We identified 23 patients with rheumatoid arthritis and bronchiectasis at the Brigham and Women's Hospital followed between 1984 and 1991, 18 of whom had arthritis preceding lung disease. The 18 patients with rheumatoid arthritis and subsequent bronchiectasis had a mean age of 63.8 years. ⋯ They also had received fewer disease-modifying agents for the treatment of their rheumatoid arthritis. Bronchiectasis can be a feature of rheumatoid arthritis and is often found in patients with severe, long-standing nodular disease. Recurrent pulmonary infections and respiratory failure occur and may be fatal.