A Rare Presentation of Undiagnosed Systemic Syphilis: A Case Report and Review of Literature.

Within the specialties of infectious diseases and dermatology, few rashes involve the palms and soles. The syphilitic rash has a pathognomonic association with these body surfaces and signals physicians to investigate this disease. However, the distinct presentations and symptoms associated with syphilis and the various stages of the disease make it diagnostically challenging. We herein report a rather intricate and unusual case of a patient who presented with a new-onset headache and blurred vision and a two-month history of diffuse pruritic maculopapular rash sparing the palms and soles. Several physicians had not established a diagnosis in the outpatient setting. Inpatient workup eventually revealed that the patient was suffering from secondary syphilis with neurological and ocular involvement. Management included a prolonged course of intravenous penicillin G leading to a complete recovery. We share images of the skin findings and the details of the intricate workup and hospital course, as well as a review of the literature.

Serotonin Toxicity Precipitated by Tramadol in the Setting of Polypharmacy: A Case of Serotonin Syndrome.

Serotonin syndrome (SS), a potentially life-threatening condition, typically occurs due to polypharmacy and interaction with multiple serotonergic agents. The case presented here is based on a serotonin syndrome (SS) diagnosis, precipitated by newly prescribed tramadol in conjunction with previously prescribed serotonergic medications. A 79-year-old woman receiving combined citalopram and trazodone for major depressive disorder alongside oxycodone for chronic pain developed generalized weakness, tremors, altered mentation, episodic auditory and visual hallucinations, fever, tachypnea, tachycardia, and diaphoresis a few days after tramadol was prescribed for pain. On clinical examination to medication reconciliation, and ruling out other causes of altered mental status, it became evident that the addition of tramadol had resulted in acute serotonin toxicity. SS is important to recognize because many healthcare providers encounter it during their careers. This diagnosis is essential to include in the differential diagnosis, especially when a medication not often associated with serotonin, like opiates, is the culprit.

Single Institution Review of Patients With Prior Breast Augmentation Undergoing Breast Conservation Therapy for Breast Cancer.

BACKGROUND: Increasing number of patients with preexisting breast implants desire breast conservation therapy for breast cancer. There is paucity of comparative data on tumor margins and re-excisions in these patients. High re-excision rates up to 25% have been reported in breast conservation therapy patients; efforts to obtain cosmesis and avoid implant rupture might increase this further. We analyzed tumor margins, re-excision rates, and recurrence in previously augmented versus non-augmented patients undergoing lumpectomy for breast cancer. We preserved preexisting implants if feasible with oncologic clearance and cosmesis. METHODS: Institutional review board-approved retrospective analysis was performed on patients undergoing lumpectomy with history of prior breast augmentation (N = 52) and consecutively selected non-augmented patients (N = 51). Based on tumor distance to inked margin, we grouped margins as negative (≥2 mm), close (<2 mm), and positive. Patients were followed up clinically and with imaging in the outpatient clinic, and recurrences were documented. RESULTS: Patients in the non-augmented group were significantly more likely to have larger tumors (T2 and above; P = 0.05) compared with the augmented group. Although more patients in the augmented group had positive margins, this was not statistically significant (6 vs 3, P = 0.86). No difference was noted between re-excision rates among the augmented versus non-augmented groups (21.1% vs 19.6%, respectively; odds ratio, 0.91; 95% confidence interval, 0.35-2.37; P = 0.85); these remained unchanged even when adjusting for tumor stage (P = .75) and margins (P = 0.73). Although more patients in the augmented group recurred (4 vs 0), this was not statistically significant (P = 0.1). CONCLUSIONS: Our results indicate that, from the oncological standpoint, patients with prior augmentation can undergo lumpectomy with equivalent tumor margins and re-excision rates. To the best of our knowledge, this is the first reported comparative study between these 2 groups.

Complications and Recurrence in Implant-Sparing Oncologic Breast Surgery.

BACKGROUND: Patients with a history of prior breast augmentation and newly diagnosed breast cancer represent a rapidly expanding and unique subset of patients. Prior studies have described changes in breast parenchyma and characteristic body habitus of previously augmented patients, as well as increased rates of capsular contracture associated with breast conservation therapy. In our current study, we aimed to study the risk factors contributing to morbidity and whether recurrence rates are higher in patients with prior breast augmentation undergoing lumpectomy or mastectomy for breast cancer and identify differences in complications between these 2 groups. METHODS: Retrospective analysis approved by institutional review board was performed on patients with prior breast augmentation undergoing lumpectomy (N = 52) and mastectomy (N = 64) for breast cancer. RESULTS: Patients with prior breast augmentation undergoing mastectomy had a higher rate of complications compared with those undergoing lumpectomy (20.3% vs 5.9% respectively, P = 0.031), after adjusting for patient-specific factors including body mass index [odds ratio (OR), 0.242; 95% confidence interval (CI), 0.063-0.922; P = 0.0376], tumor stage (OR, 0.257; 95% CI, 0.064-1.036; P = 0.0562), smoking status (OR, 0.244; 95% CI, 0.065-0.918; P = 0.0370), and chemotherapy (OR, 0.242; 95% CI, 0.064-0.914; P = 0.0364). Four patients (7.7%) developed late complications in the lumpectomy group with 2 developing capsular contractures, 1 had fat necrosis and 1 needed complex reconstruction because of flattening of the nipple-areolar complex. There was no difference in recurrence or tumor margins between lumpectomy and mastectomy groups. CONCLUSIONS: Patients with prior breast augmentation undergoing mastectomy have higher complication rates compared with lumpectomy even after adjusting for tumor stage. There appears to be no increased oncologic risk associated with either procedure given our current follow-up. Understanding these operative risks may help in patients' decision-making process with regards to type of oncologic surgery.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

BACKGROUND: Women who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. METHODS: Institutional review board-approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. RESULTS: Fifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). CONCLUSIONS: Implant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

BACKGROUND: Women who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. METHODS: Institutional review board-approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. RESULTS: Fifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). CONCLUSIONS: Implant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.