[Perthes syndrome secondary to an asthma attack: A case report in a 15-year-old child]

Perthes syndrome, or traumatic asphyxia syndrome, is a rare clinical entity, associating cyanosis, cervicofacial petechiae and subconjunctival hemorrhage. It is usually secondary to chest trauma, but can occur in any situation of abrupt rise in intrathoracic pressure with closed glottis. In this paper, we present a case of Perthes syndrome that triggered an asthma attack for a child during surgery.

[Unexpected cutaneous purpura in an infant]

A two-month-old boy visited the hospital due to unexpected cutaneous purpura and thrombocytopenia for 2 days. The physical examination revealed a purple mass on the back. The soft tissue color Doppler ultrasound showed rich blood signals in the tissue, and the results of bone marrow puncture indicated an increased number of megakaryocytes. After the treatment with hormone and gamma globulin, the platelet count rapidly increased and maintained at a normal level. Meanwhile, the boy was given oral administration of propranolol. He was followed up for 4 months and the volume of the mass on the back was reduced significantly. He had a definite diagnosis of hemangioma and immune thrombocytopenia. As for the patients with hemangioma complicated by thrombocytopenia, knowledge of Kasabach-Merritt syndrome should be enhanced and there should be a clarification of the association between thrombocytopenia and hemangioma. There should also be an alertness for thrombocytopenia of other causes.

[Uncommon cutaneous presentation of visceral Leishmaniasis associated with HIV]

BACKGROUND

Visceral leishmaniasis is not normally expressed in skin. Herein, we describe the case of an HIV-positive patient who developed two unusual skin manifestations during an episode of visceral leishmaniasis.

PATIENTS AND METHODS

A 48-year-old female patient consulted initially for infiltrated purpura of all four limbs. Skin biopsy revealed leukocytoclastic vasculitis with Leishman-Donovan bodies. Laboratory tests showed medullary, splenic, gastric and colic involvement, suggesting systemic disease, and enabling visceral leishmaniasis to be diagnosed. Two years later, despite prolonged treatment, the patient presented maculopapular exanthema, and histology revealed persistent Leishman-Donovan bodies.

DISCUSSION

We report herein an association of two rare skin manifestations in an HIV-positive patient with visceral leishmaniasis: infiltrated purpura and maculopapular exanthema. However, the underlying mechanisms remain hypothetical. The initial leukocytoclastic exanthema could be secondary to either polyclonal hypergammaglobulinaemia or to IgA deposits, or possibly to mechanical impairment of blood vessels by the actual parasite. The maculopapular exanthema occurring later raised the possibility of post-Kala-Azar leishmaniasis due to blood-borne dissemination in an anergic subject or perhaps even immune reconstitution inflammatory syndrome.

Atypical clinical presentation of meningococcal meningitis: a case report

A young woman was examined in the Emergency Department for fever, pharyngitis and widespread petechial rash. Physical examination, including neurological evaluation, did not show any other abnormalities. Chest X-ray was negative. Blood exams showed leukocytosis and CPR 20 mg/dL (nv<0.5 mg/dL). On the basis of these results and petechial rash evidence, lumbar puncture was performed. CSF was opalescent; physico-chemical examination showed: total proteins 2.8 (nv 0.15-0.45), glucose 5 (nv 59-80), WBC 7600/μL (nv 0-4/ μL). In the hypothesis of meningococcal meningitis, antimicrobial therapy was started. Blood and cerebrospinal fluid cultures were positive for N. meningitidis. During the first hours the patient experienced hallucinations and mild psychomotor agitation, making a spontaneous recovery. A brain MRI showed minimal extra-axial inflammatory exudates. She was discharged after 10 days in good condition. We underline the need to consider meningococcal meningitis diagnosis when any suggestive symptom or sign is present, even in the absence of the classic meningitis triad, to obtain earlier diagnosis and an improved prognosis.

Frequency Dependence of Petechial Hemorrhage and Cardiomyocyte Injury Induced during Myocardial Contrast Echocardiography

Myocardial contrast echocardiography (MCE) for perfusion imaging can induce microscale bio-effects during intermittent high-Mechanical Index scans. The dependence of MCE-induced bio-effects on the ultrasonic frequency was examined in rats at 1.6, 2.5 and 3.5 MHz. Premature complexes were counted in the electrocardiogram, petechial hemorrhages with microvascular leakage on the heart surface were observed at the time of exposure, plasma troponin elevation was measured after 4 h and cardiomyocyte injury was detected at 24 h. Increasing response to exposure above an apparent threshold was observed for all endpoints at each frequency. The effects decreased with increasing ultrasonic frequency, and the thresholds increased. Linear regressions for frequency-dependent thresholds indicated coefficients and exponents of 0.6 and 1.07 for petechial hemorrhages, respectively, and 1.02 and 0.8 for cardiomyocyte death, compared with 1.9 and 0.5 (square root) for the guideline limit of the mechanical index. The results clarify the dependence of cardiac bio-effects on frequency, and should allow development of theoretical descriptions of the phenomena and improved safety guidance for MCE.

A Quick Review of the Cutaneous Findings of the Zika Virus

The current outbreak of Zika virus is a growing public health concern, especially for pregnant women. Zika virus infection may manifest as a maculopapular skin eruption that progresses rostrocaudally, with or without hemorrhagic manifestations such as petechiae and gingival bleeding. Recognizing the cutaneous findings associated with Zika virus may aid in early diagnosis, particularly in individuals at increased risk for the disease.

Multiple myeloma with an unusual oral presentation

Multiple myeloma (MM) is a dyscrasia caused by neoplastic proliferation of somatically mutated plasma cells. Myeloma cells divide and expand within the bone marrow affecting multiple locations in the body where bone marrow is present. Oral manifestations, though common are usually not diagnosed. This report describes rare oral manifestations of multiple myeloma like oral petechiae and gingival swelling presented in a 40-year-old male patient. The diagnosis was established by blood examination & skeletal survey, while oral findings were later correlated with the diagnosis of MM. A brief review on MM is presented along with the demonstration of rare oral manifestations.

Bleeding and Other Presentations in Thai Patients with Dengue Infection

Dengue infection is a major public health problem, affecting the general population in Southeast Asia. Hematologic aberrations in dengue infection include atypical lymphocytosis, coagulopathy, and predominant thrombocytopenia. Bleeding and other presentations in 30 Thai patients with dengue infection during an endemic season (2003) are presented. A review of the clinical presentation of these patients was performed. All had fever as a chief complaint. The three most common complaints were fever (100%), vomiting (90%), and cough (90%), respectively. Concerning bleeding, only eight cases (26.6%) had signs of bleeding. Those manifestations included petechiae (seven cases, 23.3%) and melena (one case, 3.3%). Skin bleeding (petechiae) due to thrombocytopenia is the most common bleeding manifestation in dengue infection. However, physicians should not overlook bleeding from other less common sites such as the gastrointestinal tract and genitourinary tract.

Spontaneous Gingival Bleeding A Surprising and Sinister Etiology: A Case Report

It is rare for a dentist to be confronted with a situation where the immediate well-being of a patient is dependent upon his or her diagnosis. Spontaneous gingival bleeding, as in this case report, may present such a situation. The patient had no remarkable medical history, was not taking medication and had a recent (two weeks) normal CBC. Only by noticing petechiae on the patient's palate and buccal mucosa was the dentist convinced of an underlying clotting problem. A patient visit to his physician confirmed thrombocytopenia due to quinine in the tonic water he was taking.

Case 2-2016. An 84-Year-Old Woman with Chest Pain, Dyspnea, and a Rash

An 84-year-old woman was admitted to the hospital because of chest pain, respiratory distress, and a purpuric rash. Initial chest imaging showed bilateral patchy and confluent opacities, a finding consistent with pulmonary edema. A diagnostic procedure was performed.

Red Rash

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

[Periorbital purpura: a pathognomonic but late sign of AL amyloidosis]

INTRODUCTION

AL amyloidosis is the most common type of systemic amyloidosis and is caused by the deposition of an amyloidogenic protein composed of immunoglobulin light chains produced by a clonal population of plasma cells.

CASE REPORT

We report the case of a 77-year-old woman with arterial hypotension, peripheral edema and renal failure. Electrocardiogram reveals low voltage on peripheral leads. Echocardiogram shows normal values for left ventricle size with increased wall thickness and cardiac wall reflectance with ground glass appearance. Serum immunofixation electrophoresis (IFE) is negative while urine IFE detects type monoclonal light chains. Abdominal Fat Pad biopsy is positive for Congo red with typical apple green birefringence after polarization under optical microscopy (OM) while ultrastructural analysis does not show presence of amyloid deposition. Two months later, the patient undergoes further worsening of general clinical condition and development of purpura in the periorbital area, at the base of the neck and in the anterior chest wall.

DISCUSSION

This clinical case presents classic signs of AL amyloidosis, such as cardiac and renal involvement with the presence of a urine monoclonal component. Periorbital purpura is a pathognomonic sign of AL amyloidosis but it appears late. Final diagnosis is "AL amyloidosis with prevalent cardiac, renal and soft tissue involvement".

Flagellate shiitake mushroom dermatitis

An 84-year-old woman presented with 5 days of a pruritic skin eruption that formed arciform and linear patterns. She was diagnosed with flagellate shiitake mushroom dermatitis related to shiitake mushroom consumption the day prior symptom onset.