A Case of Histoplasmosis with Central Nervous System Relapse after Itraconazole Therapy Needs Further Research.

Central nervous system (CNS) histoplasmosis occurs in 5-20% of all cases and is most commonly seen in immunosuppressed patients who have acquired immunodeficiency syndrome (AIDS) or have received organ transplant. The prevalence of histoplasmosis in patients greater than 65 years old between the years of 1999-2008 in the state of Texas was about 2-3 cases per 100,000 patients year. Since 1990 with the discovery of Triazoles, itraconazole (ICZ) has become the standard initial and suppressive therapy in patients with mild-moderate histoplasmosis without CNS involvement. However, poor penetration of ICZ into the brain, in vitro fluconazole resistance and lack of controlled-trials pose challenge in the treatment of cerebral histoplasmosis.

Dahl's Sign: An Indicator of Severe Chronic Obstructive Pulmonary Disease.

Dahl's sign, a clinical sign in which areas of thickened and darkened skin seen on the lower thighs and/or elbows, is seen in patients with severe chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, congestive heart failure (CHF), and chronic moderate to severe persistent asthma. The aim of our present report is to create awareness and encourage providers to lay emphasis on physical examination in every medical examination that can give clues to the severity of the underlying disorder.

Hemichorea Induced by Non-ketotic Hyperglycemia in a Caucasian Woman.

Chorea is a disorder characterized by irregular, involuntary, hyperkinetic movements and has various causes. One unusual cause is hyperglycemia. This case involves a 76-year-old diabetic Caucasian female who developed gait disturbances, hemichorea of the face and limbs, and slurred speech over two to three weeks. She was found to have glucose level of 690 mg/dL with HbA1c of 14.7%. Head CT demonstrated hyperdensity in the left basal ganglia and mild involvement of right basal ganglia. Treatment with insulin alleviated her symptoms. The exact pathophysiology is unknown; however, many theories exist.

Calciphylaxis: A Deceiving Cellulitis.

Calciphylaxis is a rare and serious disorder seen most in end-stage renal disease (ESRD) patients on dialysis. It is associated with the calcium deposits in small and medium blood vessels of the skin and subcutaneous tissues resulting in painful skin lesions, plaques, ulcerations, gangrene, and secondary infections. The aim of our present report is to create awareness and encourage providers to consider calciphylaxis in the differential diagnosis of cellulitis in the appropriate clinical setting.

Low rates of bone mineral density measurement in Medicare beneficiaries with prostate cancer initiating androgen deprivation therapy.

BACKGROUND: Men with prostate cancer who undergo androgen deprivation therapy (ADT) are at risk for bone loss and fractures. Our objective was to determine if Medicare beneficiaries with prostate cancer in the state of Texas underwent DXA scans when initiating ADT. METHODS: We identified men diagnosed with prostate cancer between 2005 and 2007 in the Texas Cancer Registry/Medicare linked database, and who received parenteral ADT or orchiectomy. We identified DXA claims within 1 year before or 6 months after starting ADT. We examined use of bone conservation agents in the subgroup of patients enrolled in Medicare Part D. Multivariate logistic regression models were used to examine determinants of DXA use. RESULTS: The analysis included 2,290 men (2,262 parenteral ADT, 28 orchiectomy); 197 (8.6 %) underwent DXA within 1 year before and 6 months after starting ADT. Men aged 75 years or older were more likely to undergo DXA than men aged 66-74 years (OR 1.5; 95 % CI 1.1-2.1). Those living in small urban areas were less likely to undergo DXA than those in big areas (OR 0.40; 95 % CI 0.19-0.82). Of the 1,060 men enrolled in Medicare part D, 59 (5.6 %) received bone conservation agents when starting ADT; 134 (12.6 %) either received bone conservation agents or underwent DXA. CONCLUSIONS: Fewer than one in ten Medicare beneficiaries with prostate cancer initiating ADT underwent a DXA exam. Variation in utilization was also related to residence area size. Further research is needed to identify whether the use of DXA in patients with prostate cancer receiving ADT will result in fracture prevention.

Denosumab in patients with cancer and skeletal metastases: a systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review of the literature to determine the efficacy and safety of denosumab in reducing skeletal-related events (SRE) in patients with bone metastases. METHODS: A literature search using MEDLINE, EMBASE, Web of Science and The Cochrane Collaboration Library identified relevant controlled clinical trials up-to-March 14, 2012. Two independent reviewers assessed studies for inclusion, according to predetermined criteria, and extracted relevant data. The primary outcomes of interest were SRE, time to first on-study SRE, and overall survival. Secondary outcomes included pain, quality of life, bone turnover markers (BTM), and adverse events. RESULTS: Six controlled trials including 6142 patients were analyzed. Compared to zoledronic acid, denosumab had lower incidence of SRE with a risk ratio (RR) of 0.84 (95% confidence intervals (CI) 0.80-0.88), delayed the onset of first on-study SRE (RR 0.83; 95% CI 0.75-0.90) and time to worsening of pain (RR 0.84; 95% CI 0.77-0.91). No difference was observed in overall survival with pooled hazard ratio of 0.98 (95% CI 0.90-1.0). For total adverse events, denosumab was similar to zoledronic acid (RR 0.97; 95% CI 0.89-1.0). No significant differences were observed in the frequency of osteonecrosis of the jaw (RR 1.4; 95% CI 0.92-2.1). Patients on denosumab had a greater risk of developing hypocalcemia (RR 1.9; 95% CI 1.6-2.3). CONCLUSIONS: Denosumab was more effective than zoledronic acid in reducing the incidence of SRE, and delayed the time to SRE. No differences were found between denosumab and zoledronic acid in reducing overall mortality, or in the frequency of overall adverse events.

Lambl's excrescences: a rare cause of stroke.

Cardiogenic cerebral embolism is believed to be responsible over 25% of all ischemic strokes. Since 1856, Lambl's description of small excrescences on the aortic valves has attracted widespread attention and controversy. With the increasing use of transesophageal echocardiography, ever-increasing valvular strands are being detected. The case is presented of a cardioembolic stroke secondary to Lambl's excrescences in a 59-year-old man. In addition, the current concepts regarding the importance of recognizing these valvular strands are discussed, and a brief review of the topic is provided.

An unusual complication of polyarteritis nodosa with massive retroperitoneal hemorrhage: a case report.

UNLABELLED: BACKGROUND AND CASE REPORT: Polyarteritis Nodosa (PAN) is a systemic necrotizing vasculitis that affects medium-sized and occasionally involves small arteries leading to the disruption of the internal and external elastic lamina and contribute to the development of aneurysms. Aneurysms develop at bifurcation of major blood vessels; they are prone to thrombosis, rupture and haemorrhage. Retroperitoneal haemorrhage around kidneys was previously reported in patients with PAN. We report a case of massive retroperitoneal bleeding from inferior pancreaticoduodenal artery aneurysm rupture in a 70-year-old female with PAN. CONCLUSION: Prognosis of untreated PAN is very poor with 20% 5 year survival rate, therefore early recognition of the disease will prevent catastrophic complications and improves survival.

Acute chest pain: Acute coronary syndrome versus lead perforation: A case report.

BACKGROUND: Diagnosing pacemaker lead perforation in the setting of chest pain and EKG changes is difficult and usually not considered unless we have awareness and high index of suspicion. This kind of clinical scenario represents one of the diagnostic challenges. CASE PRESENTATION: A 77 year-old Caucasian female came to emergency room with left sided non-exertional chest pain radiating to her back for the past two days. A week prior to this presentation, she had a stent supported angioplasty for in-stent re-stenosis and subsequently dual chamber pacemaker implantation for sick sinus syndrome. On physical exam she is very obese, had normal vital signs, peripheral pulses and cardio-respiratory exam. Electrocardiogram revealed new T- wave inversions in inferior and anterior leads. Initial chest X-ray, 2D-Echocardiogram and cardiac enzymes were normal. Acute coronary syndrome was considered as an initial probable diagnosis. She was anticoagulated with heparin and eptifibatide. Patient continued to have chest pain with negative cardiac biomarkers. She developed hypotension, oliguria, elevated white count, pyuria and renal failure. Because of a normal 2D-echocardiogram, cardiac etiology for shock was not suspected. After initial fluid challenge, empiric treatment for septic shock was initiated with antibiotics and vasopressors. Work up for pulmonary embolism and intra-abdominal hemorrhage was negative. Because of persistent chest pain, shock with cold & clammy extremities and elevated central venous pressure cardiogenic shock was considered and a repeat 2D-echocardiogram was done on third day of hospitalization which revealed pericardial effusion. Non-contrast CT-scan chest done to look for lead position confirmed that she had hemorrhagic pericardial effusion along with lead perforation. Patient underwent pericardial window placement along with over-sewing of atrial wall to seal the leakage point. The patient improved and was then discharged from the hospital. CONCLUSION: Lead perforation presenting with chest pain and EKG changes is often not appreciated resulting in significant delay in diagnosis and inappropriate treatment.