Cryoglobulinemia: Images of the Patient

Cryoglobulinemia refers to a clinical syndrome of systemic inflammation due to the presence of cryglobulin-containing immune complexes. Most commonly affected organs are skin and kidneys. Cryoglobulinemia is closely associated with hepatitis C.
Here is presented a 30-year old married male who presented with blackened tip of nose, tips of fingers and toes (images). The patient is also positive for hepatitis C virus. Vasculitic lesions are shown in images.

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Keywords: Cryoglobulinemia, Cryoglobulins, Immune complexes, Hepatitis C

Butterfly Fracture

What is butterfly fracture?

Butterfly fracture is a type of comminuted fracture. So, it refers to a comminuted fracture with a wedge-shaped or triangular-shaped piece of bone involving one cortex of the bone, between the proximal and distal portions of the fractured bone. It is also called as comminuted fracture with butterfly fragment or wedge fracture.

A butterfly fracture of right tibia

What is the cause of butterfly fracture?

Butterfly fractures are caused by angulation or bending movements and butterfly fragment is produced due to compression.

What is the treatment of butterfly fracture?

Butterfly fractures are managed with inter-fragmentary compression screw fixation at each fracture interface of the fractured bone.

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Keywords: Butterfly fracture, Comminuted fracture, Butterfly fragment, Types of fracture, Wedge fracture

Spot Diagnosis # 5

A 70 years old male presented with earache deep inside the left ear radiating to pinna. On examination, his left external canal and pinna showed vesicular rashes with drooping left side of the mouth.  What is your spot diagnosis?

Answer:
The diagnosis is Ramsay Hunt Syndrome (RHS). It is a reactivation syndrome of herpes zoster virus in an L-shaped ganglion of facial nerve named  as geniculate ganglion, present in facial canal. RHS occurs when herpes zoster virus infects facial nerve and presents with painful shingle rash with fluid filled vesicles seen on, in or around the single ear. It may present with ear pain, hearing loss, ringing of ear, difficulty in closing the eye on the affected side as well as vertigo, change in taste and facial paralysis. All the signs and symptom described in the scenario above support the diagnosis of Ramsay Hunt Syndrome or herpes zoster oticus.

Spot Diagnosis # 4

Keywords: Earache, Vesicular rash, Drooping mouth, Ramsay Hunt Syndrome or herpes zoster oticus

Spot Diagnosis # 4

A 25 years old boy, a treated case of tuberculosis presents with shortness of breath and painful tense, distended abdomen (image of the abdomen is shown below). Echocardiography shows a thin pericadial effusion around the heart. Ultrasound shows splenomegaly. What is your spot diagnosis?

Tense distended abdomen

Please write your spot diagnosis below in the "comments section". The answer will be given after a week!

Spot Diagnosis # 3

Keywords: Tuberculosis, Thin pericardial effucion, Distended abdomen

Spot Diagnosis # 2

A 65 years old male patient presents with red, hot and painful right leg with some pus-filled blisters (as shown in the image below). The patient is known case of liver cirrhosis. What is your spot diagnosis?

A 60 years old male with red, hot and painful leg

Answer:

Diagnosis: Cellulitis

What is cellulitis?

Cellulitis is a serious and spreading infection of skin and underlying tissue. This infection can occur anywhere in the body; however, skin of the lower limbs is affected most of the times.

What causes cellulitis?

Cellulitis is a bacterial infection. Most often staphylococcus and streptococcus are the culprits. Other bacteria include methicillin-resistant Staph aureus, Hemophilus influenzae, Pneumococcus, and Clostridium.

What are the risk factors of cellulitis?

Cuts and cracks, insect bites, surgical incisions, weakened immune system, eczema and athlete’s foot, IV drug use and abuse, previous history of cellulitis, and chronic or debilitating disease, especially diabetes, liver cirrhosis and renal failure.

What are the sign and symptoms of cellulitis?

The patient with cellulitis presents with pain, redness and swelling of the affected area. On examination, the affected area is observed swollen, red, hot, tender and with tight glossy appearance. The patient is febrile and the skin may have sores.

What is the treatment of cellulitis? 
Depending upon the severity of the infection, oral or intravenous antibiotics are given. Penicillin is the drug of choice for cellulitis. Analgesics are used to relieve from pain. Elevation and compression dressing of the affected area are mandatory to reduce edema. Amclav 1g (Amoxicillin 875mg, Clavulanic acid 125mg) orally, twice a day, is used as adult dose in cellulitis. Amclav 1.2g IV twice a day is also used in severe cellulitis.

What to do to prevent cellulitis? 
You can prevent cellulitis by keeping the skin moist (to avoid skin cracks), treating the skin infections promptly, wearing protective covering while working and inspecting the skin on daily basis.

Spot Diagnosis# 1

Keywords: Cellulitis, Cellulits treatment, Signs and Symptoms, Red hot leg, Painful, Pus-filled blisters

Spot Diagnosis # 1

A 4-5 years old male child presented with the black spots on his both legs along with bleeding from oral mucosa (as shown in the images below). His hemoglobin level was found to be 12 gm/dl, total leukocyte count 7400/cumm and platelets 51000/cumm. What is your spot diagnosis?

Answer:

Diagnosis: Idiopathic thrombocytic purpura (ITP)

What is ITP?
ITP is a blood disorder where platelets (a kind of blood cells) are destroyed autoimmunically by the spleen.
What causes ITP?
ITP is caused by antiplatelet autoantibodies, leading to destruction of platelets through the process of phagocytosis.
What are the risk factors of ITP?
Usually it is seen that viral infections precipitate the development of ITP. In its acute form, ITP occurs after two weeks of infection with self-limiting bruises, petechiae and purpura. In its chronic form, it runs an indefinite course of signs and symptoms like bleeding, purpura, bleeding from nose or heavy menstruation.
What are signs and symptoms of ITP?
ITP may present as bleeding from mucus membranes like oral mucosa and tiny hemorrhages or black spots on the body.
Does ITP cause splenomegaly?
Bear in mind, in ITP, there is no splenomegaly.
What tests are carried out in ITP?
Bone marrow examination shows increased number of megakaryocytes in marrow. Antiplatelet autoantibodies may also be seen in the blood. Mild disease may not need any treatment.
How to treat ITP?
If the condition is symptomatic or platelets are below 20000/L, prednisolone 1mg/kg/day should be started (and reduce the dose after remission). The target of the therapy is to keep platelets above 30000/L.
If ITP relapses?
If ITP relapses, splenectomy results in 80% cure. Immunosupression (azathioprine or cyclophosphamide) may be started if the management still fails.
Should we transfuse platelets?
Do not transfuse platelets.
What to do during pregnancy?
Intravenous immunoglobulins may raise platelet count temporarily in conditions such as surgery and pregnancy.

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Keywords: ITP, Diagnosis, Splenomegaly, Haematology, Platelet disorder, Low platelets

What is Hairball or Trichobezoar?

Trichobezoar

“Recently, in Kyrgyzstan, an 18 years old healthy girl suffered from stomach pain. The doctors from Bishkek operated on her stomach and removed 9lb of hairball. On medical history, she had a nasty habit of eating hairs of her own or picked-up from the floor carpet.”

What is this hairball? Where from it got stuck into her stomach? Did her stomach produce hair on its own? Isn’t strange? 

Relax! It is not the only case. There have been reported many. Bezoars are known from 12^th century B.C.

Medically, this hairball is called trichobezoar. Usually and exclusively, teenage girls use to eat their hair that is called trichophagia. They love to pull-out their hair to eat which is called trichotillomania. It is almost always associated with some kind of psychiatric illness. Teenage girls with psychiatric illnesses like mental disorders, abuse, obsessive compulsive disorder, pica, depression and anorexia nervosa usually are the sufferers.

Trichobezoar is usually found in stomach; however, it may be found in other parts of gastrointestinal tract (GIT) such as duodenum, jejunum and ileum. The cases where trichobezoar extend into the intestine, the condition is called Rapunzel syndrome.

It is difficult to diagnose trichobezoar at initial stages. The ingested hair are trapped in the folds of GIT. Our stomach could not digest the hair and these continue to add up in-addition to food and mucus, leading to the development of hairball or trichobezoar. Trichobezoar presents with pain abdomen and epigastric mass or abdominal mass and may be taken for a kind of tumor. Trichobezoars lead to intestinal obstruction.

The best technique to diagnose trichobezoar is endoscopy and the treatment of choice is conventional laparotomy. Psychiatric consultation is also the part of the trichobezoar management.
Other types of bezoars include lactobezoar, pharmacobezoar, phytobezoar and diospyrobezoar.

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Keywords: Trichobezoar, Hairball, Bezoar, Trichophagia, Trichotillomania, Teen age girls, Epigastric mass, Stomach pain, Intestinal obstruction

Murphy's Sign in Cholecystitis

Murphy's sign is elicited as a part of physical examination of abdomen in order to differentiate the causes of pain originating in the right hypochondrium.

In order to elicit Murphy's sign "lay two fingers over right upper quadrant and ask the patient to breath in. The patient will experience pain and stop to breath in as the inflamed gall bladder impinges on the examiner's fingers. Murphy's sign is positive if the same procedure does not cause pain in left upper quadrant." 

Cholecystitis gives positive Murphy's sign.

Murphy's sign was named after American physician and surgeon John Benjamin Murphy.

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Keywords: Murphy's sign, Cholecystitis, Gallbladder disease.

Horner's Syndrome: Causes and Manifestations

What is Horner's syndrome?

Horner's Syndrome

Have you ever heard about the combination of ptosis, miosis and anhydrosis? This is what called Horner's syndrome. In Horner's syndrome, your eyelid droops, your pupil gets small in size and you cannot sweat on the affected side of your face! 

How does Horner's syndrome occur?

Horner’ syndrome occurs due to interruption or damage to the sympathetic fibers [1,3]. The postganglionic sympathetic fibers for the eye originate in the superior cervical ganglion and travel along the carotid and ophthalmic arteries and supply dilator papillae, tarsal muscle of upper eyelid and orbital muscle which tends to hold the eyeball forward. Some fibers also supply the face’s sweat glands.The interruption of sympathetic fibers may take place at many levels: at brain stem (demyelination, vascular disease), cord (syringomyelia), and thoracic outlet (Pancoast’s tumor) or on the sympathetic nerve’s trip on the carotid artery into the skull (carotid artery aneurysm) and thence to the orbit.

What are the manifestations of Horner's syndrome?

Manifestations of Horner’s syndrome develop when damage to the sympathetic fibers take place. The following manifestations are seen on the side of the lesion:

• Drooping of eyelid (Ptosis) [2,3]
• Small pupil (Miosis)
• Sunken eye (Endophthalmos)
• Loss of sweating of the face on the side of lesion (Anhidrosis) [3]

The patient’s with Horner’s syndrome may experience flushing on the affected side of the face because of dilated vessels under the skin. In children, the interruption to the sympathetic ganglion may cause difference in the colors of the two eyes [1]. 

Horner’s syndrome is known with many other names like Horner syndrome, Bernard-Horner syndrome or as oculosympathetic palsy. 

Reference

1. Lonmore M, Wilkinson I, Turmezei T, Cheung CK. Lumps in the neck: Oxford handbook of clinical medicine 7^th Ed. New York: Oxford university press 2007; 620.
2.  Ropper AH, Brown RH (2005). "14: disorders of ocular movement and pupillary function". In Ropper AH, Brown RH. Adams and Victor's Principles of Neurology (8th Ed.). New York: McGraw-Hill Professional. pp. 222–45. 
3. Nasir SA, Inayatullah M. Methods of Clinical Examination: Bedside Techniques 3^rd Ed. Multan: Saira Publishing 2006; 203

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Keywords: Horner syndrome, Bernard-Horner syndrome, Oculosympathetic palsy, Causes, Treatment

Emergency Triage: What is Triage?

Triage refers to the assessment and management of the patients on priority basis or clinical urgency or level of severity. Triage is a necessary element of emergency department (ED). In other words, it is a time-critical intervention which allows emergency room (ER) services providers to assess and allocate proper treatment areas to the patients.

Triage helps determining the urgency of life support and the key problems of the patient, depending upon the appearance, work of breathing and circulation of skin. It categorizes the patients in different levels:

Category 1

Immediate management! The patient needs treatment in 2-5 minutes of arrival, e.g. cardiac and respiratory arrest, immediate risk to airway, extreme respiratory distress, blood pressure below 80 mmHg, Glassgow coma scale (GCS) less than 9, unresponsive to painful stimulus, hypoventilation, intravenous drug overdose, severe behavioral problems where immediate violence is expected.

Category 2

Imminently life-threatening! The patient needs treatment in 10 minutes of arrival, e.g. airway risk (severe stridor or drooling with distress), severe respiratory distress, circulatory compromise, blood sugar level (BSL) less than 55 mg/dl, drowsy (GCS <13), very severe pain, fever with signs of lethargy, high-risk history, major multi-trauma or severe local injury and acute dysphagia.

Category 3

Potentially life threatening! The patient can be managed in 30 minutes of arrival, e.g. moderately severe blood loss, moderate shortness of breath, persistent vomiting, moderate shortness of breath, oxygen saturation 90-95%, BSL more than 180 mg/dl, seizures, head injury with short loss of consciousness and dehydration.

Category 4

Potentially serious! The patient can be treated in 60 minutes of arrival, e.g. mild hemorrhage, moderate pain, foreign body aspiration without respiratory distress, vomiting or diarrhea without dehydration, difficulty in swallowing, moderate pain, foreign body eye or eye inflammation and minor limb trauma.

Category 5

Less urgent! The patient can be treated in 2 hours of arrival, e.g. minimal pain, minor injuries, immunization only and other low risk conditions.

Remember, note date, time, triage officer's name, chief complaint, short history, relevant findings, area and treatment allocation and reassessment.

Note: ER service providers are at potential risk of aggressive behavior of the injured or sick patients or their relatives. Therefore, they must have non-threatening environment with as maximum privacy as possible.

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Keywords: Triage, Emergency room triage, Emergency triage, Emergency room, ER services and triage, Triage field