Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat

BACKGROUND

The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future.

METHODS

Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3).

RESULTS

Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery.

CONCLUSIONS

When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.

Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat

BACKGROUND

The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future.

METHODS

Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3).

RESULTS

Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery.

CONCLUSIONS

When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.

Progression to macula-off tractional retinal detachment after a contralateral intraoperative intravitreal bevacizumab injection for proliferative diabetic retinopathy

We report a patient with progression to a macula-off tractional retinal detachment in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection. A 32-year-old diabetic man noted decreased vision in his left eye 1 week following 25 gauge pars plana vitrectomy, gas tamponade, and intraoperative injection of bevacizumab in his right eye. Left eye visual acuity decreased from 20/80 to 20/200, and macula-off tractional retinal detachment was seen on clinical exam and imaging. Progression of tractional retinal detachment associated with proliferative diabetic retinopathy in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection may occur.

Bilateral papillopathy as a presenting sign of pheochromocytoma associated with von Hippel-Lindau disease

A 7-year-old girl presented with decreased vision in both eyes for 1 month. Examination showed visual acuity of 20/50 and 20/60, no afferent pupillary defect, cecocentral scotomas, and bilateral optic disc edema with extensive peripapillary and macular exudates. Magnetic resonance imaging showed multiple cortical and subcortical white matter lesions. Both the laboratory workup and the systemic examination were unrevealing. However, on follow-up, the patient showed episodic elevations of blood pressure as high as 240/160. Further workup revealed elevated urine catecholamines and a right supra-adrenal mass proven to be a pheochromocytoma by histopathologic analysis. The paroxysmal hypertension resolved, and the visual acuity, visual fields, fundus exam, and neuroimaging improved. The patient was lost to follow-up until age 18 when she developed shortness of breath and was found to have multiple pulmonary metastases identified as pheochromocytoma by biopsy. Genetic testing identified a 3p25-26 (c.482 G>A) VHL gene chromosomal mutation consistent with von Hippel–Lindau disease genotype. Multiple peripheral retinal vascular dilations and small retinal capillary hemangioblastomas were also found. This case highlights the importance of recognizing the lability of blood pressure often seen with pheochromocytomas, which may mask the underlying cause of hypertensive papillopathy and retinopathy, a diagnosis of low clinical suspicion in the pediatric population. The case also underscores the importance of thorough systemic workup, including genotyping to detect conditions where pheochromocytoma may be the presenting sign of the disease, such as multiple endocrine neoplasia 2A and 2B, von Hippel–Lindau disease, von Recklinghausen disease, tuberous sclerosis, and Sturge–Weber syndrome.

Ocular surface symptoms in veterans returning from operation Iraqi freedom and operation enduring freedom

PURPOSE

To correlate situational exposures and psychiatric disease with self-reported ocular surface symptoms in a younger veteran population involved in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF).

METHODS

Cross-sectional study of all veterans evaluated in the OIF/OEF clinic between December 2012 and April 2013 who completed the dry eye questionnaire and screening evaluations for environmental exposures, posttraumatic stress disorder (PTSD), and depression. The main outcome measures were the influence of environmental exposure and psychiatric disease on ocular surface symptoms.

RESULTS

Of 115 participants, the average age was 33 years. While overseas, exposure to incinerated waste (odds ratio [OR] 2.67, 95% confidence interval [CI] 1.23-5.81, P = 0.02) and PTSD (OR 2.68, 95% CI 1.23-5.85, P = 0.02) were associated with self-reported ocular surface symptoms. On return to the United States, older age (OR per decade 2.66, 95% CI 1.65-4.31, P = 0.04) was associated with persistent symptoms and incinerated waste was associated with resolution of symptoms (OR 0.25, 95% CI 0.07-0.90, P = 0.04). When evaluating symptom severity, 26% of the responders complained of severe ocular surface symptoms, with PTSD (OR 3.10, 95% CI 1.22-7.88, P = 0.02) and depression (OR 4.28, 95% CI 1.71-10.68, P = 0.002) being significant risk factors for their presence.

CONCLUSIONS

PTSD was significantly associated with ocular surface symptoms both abroad and on return to the United States, whereas air pollution in the form of incinerated waste, was correlated with reversible symptoms.