Cognitive decline among older adults who developed acute coronary syndrome during hospitalization for non-cardiac illness

Background: Atypical presentations of acute coronary syndrome (ACS) delay its recognition and treatment in the elderly patients. Functional decline and delirium which are common to the elderly during hospitalization, leads to cognitive impairment and poor health outcomes. Steps taken for its prevention is usually not considered the top priority by the cardiologist. The present study was conducted to identify cognitive decline among elderly patients who developed ACS during hospitalization for noncardiac illness and their outcome. Materials and Methods: Three hundred and ten elderly patients above 60 years of age with ACS were included from June 26, 2020 to October 13, 2020. Subjects were divided into those admitted primarily due to an ACS (Group I, n = 94) and those developing ACS following admission for noncardiac illness (Group II, n = 216). Co-morbidities, medications, investigations, management, clinical outcome, and Montreal Cognitive Assessment scale were compared between the two groups at the time of admission, after 30 days and after 6 months. Results: Majority of the subjects were admitted due to acute kidney injury (27.1%) in Group II and had a non-ST elevation ACS (90.2%). Optimum management was given to a lesser extent due to the clinical condition of these patients. Poor clinical outcome, cognitive impairment during hospitalization and cognitive decline during follow-up was more in Group II. Conclusion: Clinicians must be vigilant for the development of cognitive impairment and cognitive decline when an elderly patient is admitted to the hospital, as early detection and optimum management provides better clinical and cognitive outcome.

Síndrome compartimental: una presentación atípica como causa de la púrpura de Henoch-Schönlein / Compartment syndrome: an atypical presentation as a cause of Henoch-Schönlein purpura

Resumen: Introducción: en la literatura existen escasos reportes de caso del desarrollo de síndrome compartimental como una potencial complicación de la púrpura de Henoch-Schönlein. Caso clínico: se presenta el caso clínico de una paciente de 17 años con un cuadro de síndrome compartimental bilateral en pies como presentación atípica de la púrpura de Henoch-Schönlein, nunca antes descrita en la literatura. Conclusión: con una rápida sospecha diagnóstica y un tratamiento quirúrgico con fasciotomías, se consiguió preservar la viabilidad de las extremidades y su funcionalidad a los seis meses de seguimiento, a pesar de tratarse de una presentación sumamente atípica de la patología en cuestión.

Abstract: Introduction: there are few case reports available that describe compartment syndrome as a complication of Henoch-Schönlein purpura. Case report: we report the case of a 17-year-old patient with bilateral compartment syndrome of the foot as an atypical presentation of Henoch-Schönlein purpura. A case like this has not been reported before. Conclusion: although the patient had an extremely rare clinical presentation, the viability and functionality of the limbs was preserved even after six months of follow-up thanks to an early diagnosis and surgical treatment.

Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey

BACKGROUND: Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays. OBJECTIVES: To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults. DESIGN AND SETTING: Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey. METHODS: Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether. RESULTS: Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality. CONCLUSION: One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities

A Cautionary Tale of an Atypical Presentation of COVID-19 in the Geriatric Population

@#Geriatric patients may present with atypical symptoms for COVID-19. This case aims to highlight how an elderly patient with two to three weeks of low-grade fever of unknown origin was managed. The family medicine resident was able to assess the patient holistically and admit her to the right discipline with the proper contact precaution.

An Unusual Presentation Of Systemic Lupus Erythematosus With Vasculitic Polyneuropathy

We report a case of systemic lupus erythematosus (SLE), in a 48-year-old woman, a known hypertensive and recently diagnoseddiabetic, with a predominant complain of acute onset bilateral lower limb weakness and loss of sensation of the bilateral palmand soles with bowel incontinence and excessive hair loss. On evaluation, her vitals were stable, cardiovascular, respiratory,and abdominal systemic examination revealed no significant abnormality. Neurological examination revealed a normal tone withdistal muscle weakness more in the lower limb than in the upper limb. She was thoroughly evaluated for the above-mentionedcomplaints and examination findings. Nerve conduction study was done - which revealed upper limb - severe asymmetric motorsensory neuropathy - axonal type and lower limb - axonal symmetrical severe polyradiculoneuropathy. Nerve biopsy revealed avasculitic neuropathy. Autoimmune workup was positive for antinuclear antibodies, and low C3 levels, with direct Coombs testpositive, increased UPCR ratio. According to the Systemic Lupus International Collaborating Clinic criteria, she was diagnosedwith SLE. Hence, this is a case of SLE, with a primary presentation of a vasculitic neuropathy, an unusual occurrence.

Diagnostic dilemmas in fulminating sub-acute sclerosing pan-encephalitis (SSPE) with atypical presentation

@#Subacute sclerosing panencephalitis (SSPE) is a progressive, fatal disease of the central nervous system caused by a persistent measles virus in the brain. It is clinically characterized by insidious onset of intellectual deterioration and behavioral changes followed by myoclonic jerks and eventually complete neurologic deterioration. In about 10% of patients, the clinical manifestations of SSPE are not typical and that may cause a delay in the diagnosis. We report here 3 cases of SSPE with atypical presentations. Bilateral vision loss, hemiparesis, ataxia and acute encephalopathy with focal seizures were respectively the presenting symptoms at the onset of disease. The typical periodic EEG complexes in two patients and positive CSF measles IgG antibody led to the diagnosis of SSPE.

Vesícula biliar gigante / Giant gallbladder

Se registra el caso de una paciente femenina de 73 años con antecedente de colecistitis crónica, quien al examen físico presentaba una tumoración palpable en hipocondrio derecho que se extendía a fosa ilíaca derecha. La ecografía abdominal mostró aumento del tamaño vesicular que alcanzaba fosa ilíaca derecha con contenido multilitiásico; se confirmó dicho hallazgo con estudio tomográfico. Se realizó laparotomía exploradora con hallazgo operatorio de vesícula gigante de paredes engrosadas, tensa, adherida a órganos circundantes, de dificultosa disección, que requirió punción para drenaje de su contenido. Se efectuó, además, colecistectomía convencional según técnica de Pribram, y se obtuvo una pieza quirúrgica de aproximadamente 15 × 10 cm, con informe de anatomía patológica de colecistitis crónica. En contraste con la presentación habitual de la colecistitis crónica, el caso de referencia obedece a una presentación atípica con una vesícula gigante.

We report the case of a 73-year old female patient with a history of chronic cholecystitis with a palpable mass extending from the right hipochondrium to the right iliac region. An abdominal ultrasound showed an enlarged gallbladder extending to the right iliac region with multiple gallstones confirmed by computed tomography scan. An exploratory laparotmy was performed. A giant gallbladder with thickened walls and presence of adhesions to the neighbor organs that were difficult to remove were found and required drainage. A conventional cholecystectomy was performed using the Pribram's technique. A surgical specimen measuring 15 x 10 cm was sent to the pathologist who made a diagnosis of chronic cholecystitis. This case is an atypical presentation of chronic cholecystitis due to a giant gallbladder.

Incidence of mortality due to malaria with typical and atypical presentation

Background: Malaria, despite intensive efforts to control, remains a leading cause of morbidity and mortality in humans. India contributes to 61 per cent of malaria cases and 41 per cent of malaria deaths in SEAR countries. The objective of the present study was to find out an incidence of mortality due to malaria with typical and atypical presentation.Methods: The present was conducted over a period of three years. During the study period 630 patients with clinical suspicion of malaria were tested for malaria using peripheral smear, QBC and RDT.Results: The mortality rate in this study group 161 (25.55%) out of which maximum mortality observed in patients with falciparum malaria either singly or with mixed infestation. There is no significant correlation between the typical and atypical presentations in the different age groups with mortality.Conclusions: For timely diagnosis and treatment a high index of suspicion for the disease should be maintained by treating physicians, especially in endemic areas. They should be aware of the varied manifestations to minimize the mortality due to malaria.

Changing clinical profile of malaria at a tertiary care hospital

Background: There is a widespread range of diverse typical and atypical manifestations of malaria. The diagnosis of malaria may escape the attention of treating physician due to its unusual and vague presentations.The morbidity and mortality due to malaria is increased due to lack of early diagnosis and right treatment. The Aim of the present study was to examine the changing clinical pattern of malaria with special attention to atypical presentations.Methods: The present study comprised of 630 cases of definitively diagnosed malaria.Diagnostic methods used were conventional thick and thin peripheral smear stained with Leishman stain and rapid malarial antigen test.Results: This study revealed atypical symptoms like lack of taste (1.3%), throat discomfort (13.33%) and cough (24.0%) and vomiting (52.4%) as presenting complaints. These were significantly more in patients with P. vivax infestations.Conclusions: A high degree of suspicion is necessary for early detection and treatment of malaria, especially of unusual presentations.

American cutaneous leishmaniasis triggered by electrocoagulation

Abstract Cutaneous leishmaniasis is usually transmitted by infected phlebotomine sand fly bites that initiate local cutaneous lesions. Few reports in the literature describe other modes of transmission. We report a case of a previously healthy 59-year-old woman who underwent electrocoagulation to remove seborrheic keratosis confirmed by dermatoscopy. Three months later, a skin fragment tested positive for Leishmania culture; the parasite was identified as L. (V.) braziliensis. Trauma may generate inflammatory cascades that favor Leishmania growth and lesion formation in previously infected patients. American cutaneous leishmaniasis is a dynamic disease with unclear pathophysiology because of continually changing environments, demographics, and human behaviors.

Mieloma múltiplo em cão com apresentação clínica atípica de paralisia facial bilateral: relato de caso / Multiple Myeloma in dog with atypical clinical presentation of bilateral facial paralysis: case report

Objetivou-se com o presente trabalho relatar um caso de mieloma múltiplo (MM) em uma cadela com apresentação clínica atípica de rigidez da musculatura facial. Foram realizados hemogramas seriados, exames bioquímicos, sumário de urina, sorologia para leishmaniose, radiografias de crânio, citologia de medula óssea e eletroforese de proteínas séricas. O infiltrado plasmocitário em medula óssea >20%, a gamopatia monoclonal e as lesões compatíveis com lise óssea, observados no mielograma, eletroforese de proteínas e exame radiográfico, respectivamente, foram determinantes para conclusão diagnóstica de MM. A doença pode ter uma apresentação clínica variável em cães e representar um desafio ao diagnóstico na clínica de animais de companhia, principalmente em áreas endêmicas de doenças infecciosas que se manifestam com apresentações clínicas e laboratoriais semelhantes.(AU)

This paper reports a case of multiple myeloma (MM) in a bitch with atypical clinical presentation of rigidity of the facial muscles. Hemogram, biochemical tests, urinalysis, serology for leishmaniasis, skull radiography, bone marrow cytology and serum protein electrophoresis were performed. The plasma cell infiltration in bone marrow was >20 %, the monoclonal gammopathy and lesions compatible with bone lysis observed in the myelogram, protein electrophoresis and radiographic examination respectively, were decisive for diagnostic conclusion of MM. The disease may have a variable clinical presentation in dogs and pose a challenge for diagnosis in the pet clinic, especially in endemic areas of infectious diseases that present with similar clinical and laboratory presentations.(AU)

Actinomicose atípica em bovinos / Atypical actinomycosis in cattle

Casos de actinomicose com apresentação atípica são descritos em dois bovinos. Em ambos os casos notou-se uma aumento de volume extenso e duro na maxila. A maxila dos dois bovinos tomou um aspecto de favo de mel como resultado da rarefação destrutiva e da proliferação óssea regenerativa. Na superfície de corte as lesões consistiam de tecido fibroso branco e brilhante em meio ao qual numerosos grânulos amarelos podiam ser vistos. Tratos fistulosos podiam ser demonstrados em meio às lesões. Em cortes corados pela hematoxilina e eosina as lesões consistiam de ilhas de inflamação piogranulomatosa em meio a extenso estroma fibroso. No centro do granuloma havia uma massa basofílica de forma irregular cercada por uma zona com projeções eosinofílicas radiadas (reação de Splendore-Hoeppli). Ao redor da massa radiada havia uma zona de neutrófilos cercada por uma camada de macrófagos epitelioides e ocasionais células gigantes multinucleadas. Uma camada externa de linfócitos e plasmócitos limitava o granuloma do extenso estroma conjuntivo que o cercava. Na coloração de Gram, a parte central da colônia revelava um aglomerado de micro-organismos em forma de bastonetes, com morfologia compatível com Actinomyces bovis. Uma vez que a apresentação pouco usual das lesões levou a má interpretação diagnóstica inicial nestes casos, a descrição detalhada das lesões é feita aqui com o objetivo de ajudar no diagnóstico diferencial feito por veterinários clínicos e inspetores de carne.

Cases of actinomycosis with atypical presentation are described in two oxen. In both cases there was a hard irregular and extensive lesions in the maxilla. The maxilla of both cattle became enlarged and honeycombed as a result of destructive rarefaction and regenerative bone proliferation. The cut surface of the lesions consisted of white glistening fibrous tissue within which numerous yellow caseous granules could be seen. Sinus tracts could be demonstrated within the lesions. In hematoxylin-eosin stained sections the lesions consisted of island of pyogranulomatous inflammation within an extensive fibrous stroma. In the center of the granuloma there was a basophilic irregular shaped mass surrounded by a zone radially arranged eosinophilic projections (Splendore-Hoeppli material). Around the radiating mass there was a zone of neutrophils, surrounded by a layer of epithelioid macrophages and occasional multinucleated giant cells. An outer layer of lymphocytes and plasma cells was present that limit the granuloma from the abundant fibrous tissue surrounding it. Up on Gram stain the central part of the colony revealed a tangled mass of rod shaped organisms morphologically consistent with Actinomyces bovis. Since the unusual presentation of this lesions misled the initial diagnosis the detailed description of these cases are reported here in the hopes it can help in the differential diagnosis by veterinary practitioners and met inspectors.

Enfermedad celiaca con presentación atípica / Atipical celiac disease

Presentamos tres casos clínicos de pacientes que fueron internados en el Hospital del Niño "Dr. Ovidio Aliaga Uría" por enfermedad celiaca con manifestaciones clínicas de presentación infrecuentes.

We describe three cases of atypical clinical presentation of celiac disease who were admitted to the Hospital del Niño "Dr. Ovidio Aliaga Uría".