An Eye Popping Case of Orbital Necrotizing Fasciitis Treated with Antibiotics, Surgery, and Hyperbaric Oxygen Therapy.

BACKGROUND Necrotizing fasciitis (NF) of the orbit is a rare and deadly condition that requires prompt surgical and medical management to decrease morbidity and mortality.  CASE REPORT Here we present an interesting case of an individual who developed fulminant NF of the left orbit requiring emergent surgical intervention, antibiotics, and subsequent hyperbaric oxygen therapy in an attempt to save the eye.  CONCLUSIONS With an early and aggressive multifaceted approach using antibiotics, surgery, and hyperbaric oxygen it may be possible to preserve eye structure and function. Without treatment NF is a rapidly progressive condition and can result in significant morbidity.

Tuberculous Meningitis in an Immunocompetent Host: A Case Report.

BACKGROUND Tuberculous meningitis is very rare in the United States in immunocompetent hosts. Risk factors are similar to those of pulmonary tuberculosis, including poverty, malnutrition, overcrowding, a compromised immune system, and coming from an endemic area. Meningeal tuberculosis mortality and other outcomes have changed little over time despite effective therapies due to delay in diagnosis because of its rarity, variable presentation, and often indolent course. CASE REPORT We describe a case of a 57-year-old male immigrant from Senegal with no significant past medical history and no previous history of tuberculosis or evidence of immune compromise. He presented to the hospital with headache and altered mental status and was subsequently diagnosed with tuberculous meningitis. CONCLUSIONS This is a rare case of tuberculous meningitis in an immunocompetent host, questioning the conventional view that tuberculous meningitis is a disease of immunocompromised individuals. It emphasizes the importance of maintaining a strong clinical suspicion of tuberculous meningitis even in an immunocompetent patient in a geographical area with low prevalence if the patient has risk factors. Missed or delayed diagnosis is commonly fatal.

Hepatic epithelioid hemangioendothelioma in a patient with hemochromatosis.

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare hepatic vascular tumor that represents a diagnostic challenge. The rarity of this neoplasm precludes establishment of a standard-of-care treatment. Risk factors for HEHE are not well-known. Liver transplant remains the most common therapeutic modality for nonmetastatic disease. This article describes a patient who presented with abdominal pain, fatigue, poor appetite, and weight loss. Genetic testing showed that the patient was homozygous for C282Y consistent with hereditary hemochromatosis, and liver biopsy was consistent with malignant epithelioid hemangioendothelioma. The patient was referred for a liver transplant but was deemed inappropriate for transplant secondary to peritoneal studding, with frozen-section analysis showing metastatic disease at the time of surgery.

Integrating real-time clinical information to provide estimates of net clinical benefit of antithrombotic therapy for patients with atrial fibrillation.

BACKGROUND: Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. METHODS AND RESULTS: This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. CONCLUSIONS: Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.

Trace elements content in the selected medicinal plants traditionally used for curing skin diseases by the natives of Mizoram, India

Objective: To determine the trace elements content in the selected medicinal plants, namely, Eryngium foetidum L., Mimosa pudica L., Polygonum plebeium, and Prunus cerasoides D. Don traditionally used by the natives of the Mizoram, one of the north eastern states in India as their folklore medicines for curing skin diseases like eczema, leg and fingers infection, swelling and wound. Methods: A 3 MeV proton beam of proton induced X-ray emission technique, one of the most powerful techniques for its quick multi elemental trace analysis capability and high sensitivity was used to detect and characterized for trace elements. Results: The studies revealed that six trace elements, namely, Fe, Zn, Cu, Mn, V, and Co detected in mg/L unit were present in varying concentrations in the selected medicinal plants with high and notable concentration of Fe, Zn, Mn and appreciable amount of the Cu, Co and V in all the plants. Conclusions: The results of the present study support the therapeutic usage of these medicinal plants in the traditional practices for curing skin diseases since they are found to contain appreciable amount of the Fe, Zn, Cu, Mn, V and Co.

Trace elements content in the selected medicinal plants traditionally used for curing skin diseases by the natives of Mizoram, India

OBJECTIVE@#To determine the trace elements content in the selected medicinal plants, namely, Eryngium foetidum L., Mimosa pudica L., Polygonum plebeium, and Prunus cerasoides D. Don traditionally used by the natives of the Mizoram, one of the north eastern states in India as their folklore medicines for curing skin diseases like eczema, leg and fingers infection, swelling and wound.@*METHODS@#A 3 MeV proton beam of proton induced X-ray emission technique, one of the most powerful techniques for its quick multi elemental trace analysis capability and high sensitivity was used to detect and characterized for trace elements.@*RESULTS@#The studies revealed that six trace elements, namely, Fe, Zn, Cu, Mn, V, and Co detected in mg/L unit were present in varying concentrations in the selected medicinal plants with high and notable concentration of Fe, Zn, Mn and appreciable amount of the Cu, Co and V in all the plants.@*CONCLUSIONS@#The results of the present study support the therapeutic usage of these medicinal plants in the traditional practices for curing skin diseases since they are found to contain appreciable amount of the Fe, Zn, Cu, Mn, V and Co.

Diagnosis of pheochromocytoma in the setting of Parkinson disease.

BACKGROUND: A 59-year-old man with a 7-year history of Parkinson disease (PD) presented with episodes of sudden, severe headaches with neck pain, tachycardia, sweating and pallor. During these episodes, the patient showed marked elevations in blood pressure, regardless of posture. This was unusual, given that he had no prior history of hypertension. The array of symptoms raised suspicions of pheochromocytoma, but diagnosis was challenging, as the standard diagnostic biochemical tests were confounded by dopaminergic medications. Further work-up revealed left adrenal medullary hyperplasia. Several reports exist of pseudopheochromocytoma in patients on dopaminergic therapy, but this is the first documented case of pheochromocytoma syndrome due to adrenal medullary hyperplasia in a patient with PD. This case highlights the challenges of performing a diagnostic work-up in a PD patient with symptoms suggestive of pheochromocytoma, and illustrates the utility of (123)I-metaiodobenzylguanidine ((123)I-MIBG) single-photon emission CT in making a diagnosis.Investigations. Physical examination, laboratory tests, abdominal MRI scan, abdominal (123)I-MIBG scan, abdominal (18)F-fluorodeoxyglucose PET scan. DIAGNOSIS: Pheochromocytoma syndrome due to adrenal medullary hyperplasia.Management. Surgical excision of the left adrenal gland.

A case of levodopa-responsive camptocormia associated with advanced Parkinson's disease.

BACKGROUND: A 48-year-old man with a 9-year history of Parkinson's disease who had previously shown a good response to levodopa presented for evaluation of increasingly disabling motor fluctuations and marked camptocormia. INVESTIGATIONS: Video-recorded neurological examinations when in 'off' and 'on' states, brain MRI scan. DIAGNOSIS: Advanced Parkinson's disease complicated by levodopa-responsive camptocormia. MANAGEMENT: Adjustment of dopaminergic therapy (carbidopa-levodopa and entacapone) to minimize motor fluctuations and camptocormia.

Impact of obesity on coronary microvascular function in the Zucker rat.

OBJECTIVE: To test the hypothesis that vasomotor control is impaired in the coronary circulation of prediabetic obese (OZR) relative to lean Zucker rats (LZR). METHODS: Cardiac function was assessed with in vivo measures of cardiac output and microvascular structure and function was assessed in vitro using videomicroscopic techniques. RESULTS: OZR showed a marked hyperdynamic circulation with an increased cardiac output and elevated stroke volume. Contrary to the stated hypothesis, the authors found no diminution of vasodilator function and no augmentation of vasoconstriction. Indeed, dilation to acetylcholine was potentiated and vasoconstriction to endothelin was reduced in OZR compared to LZR. Structural characteristics of small coronary arteries were similar between LZR and OZR. CONCLUSIONS: Taken together, these results indicate that obesity, as manifested in the prediabetic OZR, does not impair coronary vasomotor control. This lack of dysfunction in the presence of the same risk factors that affect other beds may reflect a reversal of vascular injury by the increased metabolism and coronary blood flow caused by hyperdynamic cardiac function early in obesity.