Coincidental Overlapping Cystic Pathological Changes: A Case against Marsupialisation.

It is relatively common to observe a solitary well defined periapical cystic change associated with decayed primary tooth displacing the underlying developing permanent tooth bud. Marsupialisation of such cysts is indicated so as to allow for eruption of the underlying tooth bud. A similar solitary well defined periapical cystic lesion involving the mixed dentition in a child was planned for enucleation. Surprisingly, during the surgical intervention two distinct separate cystic pathological changes were observed. Marsupialisation of the cystic defect with extraction of the primary tooth would have left the enlarged follicle with the developing tooth bud unaddressed. The pathological process associated with the dilated follicle would continue to progress further and may require an additional surgical intervention. The distinction between enlarged follicle and dentigerous cyst clinically is also important. Considering the size, extent and presence of the large bony cavity during the surgical intervention enucleation of both the pathological changes was performed.

Acetaminophen-induced exanthem of the breasts.

We describe an unusual case of a maculopapular exanthem secondary to acetaminophen use that presented on the breasts and anterior pelvis in regions of pressure from the patient's undergarments. A review of the literature regarding exanthematous drug eruptions secondary to acetaminophen use also is presented.

Subcutaneous immunoglobulin therapy in an 11-year-old patient with common variable immunodeficiency and von Willebrand disease.

BACKGROUND: Subcutaneous immunoglobulin (SCIG) is an option for replacement therapy in patients with humoral immune deficiencies. OBJECTIVE: To describe a patient with common variable immunodeficiency (CVID) and von Willebrand disease who tolerated immunoglobulin replacement via the subcutaneous route. METHODS: An 11-year-old boy receiving monthly intravenous immunoglobulin (IVIG) since 5 years of age presented to an academic medical center after moving to the area. The patient also had a history of von Willebrand disease. He had started receiving IVIG because of recurrent infections and an absent IgG subclass 3. Further immunologic assessment revealed a normal B-cell count, decreased IgM level, and an abnormal response to bacteriophage phiX174. Given these findings and the lack of another cause, the patient was diagnosed as having CVID. Because of difficult intravenous access, a port was placed for IVIG administration in 1999. The initial port was removed because of infectious complications, and a second port was found to be distally displaced in the right atrium, requiring removal. RESULTS: Continued difficulties with intravenous access and the potential complications with maintaining a long-term indwelling catheter prompted consideration of alternative methods for immunoglobulin administration. After removal of the port, the patient was prescribed weekly SCIG infusions. He tolerated the infusions well without bleeding complications related to the von Willebrand disease and was able to transition to home infusions. CONCLUSIONS: SCIG was well tolerated by a pediatric patient with CVID and von Willebrand disease without any significant bleeding complications.

Systemic reaction rates to field stings among imported fire ant-sensitive patients receiving >3 years of immunotherapy versus <3 years of immunotherapy.

As imported fire ants (IFAs) expand their range, hypersensitivity reactions to their stings are becoming a significant cause of morbidity and mortality in the United States. Currently, IFAs whole body extract (WBE) immunotherapy is the mainstay of treatment for IFA hypersensitivity but the optimal duration of treatment is unknown. A questionnaire was administered to patients diagnosed with IFA venom hypersensitivity based on history and the presence of IFA venom-specific IgE who had been offered immunotherapy. The patients were grouped into those who received > or =3 years of immunotherapy and those who received <3 years of immunotherapy. Forty of the 272 patients initially identified were successfully contacted (14%) with 6 patients being excluded. Of these patients, 19 reported having received <3 years of IFA immunotherapy (reduced course) and 15 stated they had been given >3 years of immunotherapy (complete course). Subsequent field stings were reported by 18 (95%) of the reduced course groups and 14 (93%) of the complete course group with 1 person from each group (6 and 7%, respectively) experiencing a systemic reaction. There were no significant differences between the two groups in the number of patients with subsequent field stings or systemic reactions after subsequent IFA stings. Less than 3 years of IFA immunotherapy may offer long-term protection against IFA hypersensitivity reactions although additional studies with more subjects and controls are necessary before definitive conclusions may be made.

Progressive dyspnea in a 46-year-old woman.

BACKGROUND: Hypersensitivity pneumonitis (HP) is an inflammatory lung disease that requires a high index of suspicion and evaluation for potential causative antigens in the patient's environment. OBJECTIVE: To describe a patient referred for allergic rhinitis who was found to have progressive dyspnea and was ultimately diagnosed as having HP. METHODS: The history of progressive dyspnea with findings of diffuse pulmonary crackles on physical examination and restrictive pulmonary function testing prompted further radiologic, pathologic, laboratory, and home environment evaluations. RESULTS: The constellation of findings from these studies led to the diagnosis of HP secondary to parakeet antigens. Elimination of further antigen exposure and corticosteroid therapy led to resolution of the patient's symptoms. CONCLUSION: Prompt diagnosis and removal of the antigen source are of paramount importance in the management of HP.

Exhaled nitric oxide levels in military recruits with new onset asthma.

Approximately 800 United States Air Force basic military trainees (BMTs) are diagnosed with asthma, annually, resulting in separation from the military. With training costs of approximately 10,000 dollars/person, around 8 million dollarsis lost per year. Improved methods in diagnosing asthma would be beneficial. The aim of this study was to determine the fraction of exhaled nitric oxide (FENO), a marker of airway inflammation, in a military recruit population referred for an asthma evaluation. In BMTs referred for respiratory complaints during basic training, FENO levels were determined before an asthma evaluation consisting of a history, physical, baseline spirometry, and histamine bronchoprovocation. Of 172 BMTs who had symptoms suggestive of asthma and underwent histamine bronchoprovocation, 80% were diagnosed with asthma. FENO levels were significantly higher in asthmatic patients than nonasthmatic patients (mean, 30 parts per billion [ppb] versus 19 ppb, p < 0.001; median, 21 ppb versus 17 ppb, p < 0.02). Various FENO cutoff points provided a range of sensitivity and specificity for the diagnosis of asthma. However, an optimal FENO cutoff level for asthma was not obtained. An FENO value of 10.5 ppb provided a sensitivity of 86% for the diagnosis of asthma, but specificity was only 21%. In contrast, an FENO value of 46 ppb provided 100% specificity but only 17% sensitivity. FENO levels were significantly elevated in BMTs diagnosed with asthma but the lack of an optimal cutoff level limits the test as a diagnostic tool for asthma. Additional studies are necessary to determine the value of FENO for asthma screening in a military population.

Randomized placebo controlled assessment of airway inflammation due to racemic albuterol and levalbuterol via exhaled nitric oxide testing.

STUDY OBJECTIVES: The S-stereoisomer found in racemic albuterol may have associated proinflammatory properties. We tested the hypothesis that airway inflammation as assessed by exhaled nitric oxide is no different in patients with COPD when using racemic albuterol relative to levalbuterol or placebo. MEASUREMENTS: Twelve mild to moderate COPD patients were assigned to five days each of nebulized racemic albuterol, levalbuterol, and saline placebo. Before and after each course of treatment, airway inflammation was assessed via exhaled nitric oxide breath testing. Secondary functional outcomes that were measured included spirometry, a functional assessment utilizing a six-minute walk, and symptoms score using the University of California, San Diego Shortness of Breath Questionnaire. RESULTS: There was no statistically significant difference in pre and post FeNO levels within and between treatment groups (p = 0.121). There were also no significant differences within or between treatment groups for the secondary outcome measurements of FEV1 (p = 0.913), functional assessment utilizing a six-minute walk (p = 0.838) and the symptom scores using Shortness of Breath Questionnaire (p = 0.500). CONCLUSION: We found no difference in mild to moderate COPD patients treated with racemic albuterol, levalbuterol or placebo for measurement of exhaled nitric oxide or the secondary outcomes that were measured.

An unusual case of laryngomalacia presenting as asthma refractory to therapy.

BACKGROUND: Laryngomalacia is the most common cause of stridor in infants, but few reports exist of clinically relevant laryngomalacia in adults. OBJECTIVE: To present and discuss an unusual late presentation of laryngomalacia and its significance in the evaluation and management of asthma. METHODS: An 18-year-old woman presented to an academic medical center with symptoms of "wheezing" on inspiration and exertion, with relatively normal spirometric findings. She was clinically diagnosed as having asthma at the age of 13 years, but her symptoms were poorly controlled by maximal medical therapy. Further evaluation with rhinolaryngoscopy demonstrated laryngomalacia characterized by redundant soft tissue overlying the right arytenoid cartilage and aryepiglottic fold. RESULTS: The patient demonstrated positive bronchoprovocation, with a 33% decrease in forced expiratory volume in 1 second after the administration of histamine, 1 mg/mL. However, with the otolaryngology evaluation, it was determined that her laryngeal findings were clinically significant. She subsequently underwent operative laryngoscopy with carbon dioxide laser excision of the laryngeal abnormality, resulting in improvement in her symptoms and a marked decrease in her need for asthma medication. CONCLUSIONS: We report an unusual case of laryngomalacia presenting as asthma that was successfully treated with laser surgical excision. This case emphasizes the necessity of differentiating classic wheezing from stridor and upper airway obstruction.

The effects of residency on physical fitness among military physicians.

PURPOSE: Demands of medical residency training would be expected to result in physical deconditioning. This study determined the effects of residency on physical fitness. METHODS: A prospective cohort study of the change in physical conditioning during residency using the Army Physical Fitness Test as a standardized measure of fitness was conducted. Ninety-four active duty U.S. Army physicians were followed during their medical residency training from July 1999 to June 2002. Army Physical Fitness Test results from interval tests performed throughout residency were compared to baseline results at matriculation. Changes in total score, number of push-ups and sit-ups completed in 2 minutes, 2-mile run time, and weight were recorded. Correlations between initial and final scores were evaluated. RESULTS: All measured parameters worsened with statistical significance noted in the weight (p < 0.01), push-ups (p < 0.05), and 2-mile run (p < 0.01). Statistically significant negative correlations between initial and subsequent tests were noted in push-ups (p = 0.004), sit-ups (p = 0.0003), and total score (p = 0.0192). CONCLUSIONS: Physical fitness declines during medical residency training. This effect is most notable in residents with higher levels of fitness at the start of medical education. Further studies are necessary to evaluate for a similar decline among civilian residents.