Introduction MCC is a rare, aggressive, malignant solid tumor known bymany other names, including trabecular cell carcinoma, neuroendocrine or primary small cell carcinoma of the skin, and anaplastic cancer of the skin. Classic clinical presentation ofMCC is identical to that of numerous other benign and malignant neoplasms. Establishing a high index of suspicion is difficult because MCC is uncommon and lacks unique clinical features. Its aggressive nature makes prompt diagnosis and adequate treatment essential. The etiology of MCC is unknown, but it is thought to be derived from the Merkel cell, a specialized, nonkeratizing epithelial cell found in the basal cell layer of the epidermis and dermis and around hair follicles. MCC has a predilection for sun-exposed areas (e.g., head, neck, extremities), suggesting that chronic UVR exposure plays a role in etiology.MCChas been described in patients treated with PUVA andUVB phototherapy.MCC can present in unexposed areas (e.g., penis, vulva), indicating that other etiologic factors are involved. No predisposing conditions have been consistently identified; however, the incidence is higher among immunosuppressed patients. Numerous cases of spontaneous remission have been reported, presumably immune-mediated, illustrating the importance of the immune system in the development, prognosis, and treatment of MCC. MCC tumors can be solitary or multiple and have high rates of local recurrence (25%) and regional lymph node metastases (25%Y50%) (Wolff et al., 2005). MCC tumors frequently disseminate to the viscera and central nervous system, and distant metastasis occurs in 33% of cases (Wolff et al.). MCC mortality rates exceed those of melanoma (Wolff et al.).
Heparin-induced thrombocytopenia is an uncommon manifestation of a very commonly used drug. It can lead to catastrophic complications, especially if appropriate therapy is not initiated. This article reviews the pathophysiology, diagnosis, and management of this important topic.
A 36-year-old HIV-infected man admitted with a possible pyelonephritis of the left kidney and a 3.5 cm thrombus of the left renal vein developed sudden onset of dyspnea. Multiple cavitating nodules revealed under CT were aspirated yielding purulent fluid. MRSA isolates, from both the lung and blood had identical susceptibility patterns. The patient failed to respond to antibiotics until intravenous heparin was begun.
1) Myocardial infarction (MI): Aspirin (160-300 mg/day) therapy started immediately after the onset, with or without simultaneous coronary arterial thrombolytic therapy, reduces the mortality rate in vascular diseases, including MI, and prevents reinfarction. Maintenance therapy with the same dosage is also recommended. 2) Angina pectoris: In unstable angina, aspirin in a dose of 300 mg/day for 2 years reduces the mortality and the incidence of MI. Ticlopidine decreases anginal attacks in a few cases of angina at rest. 3) Coronary artery bypass grafting (CABG): Long-term administration of 325 mg aspirin/day should be started on the day of surgery and combined with 200-400 mg dipyridamole/day administered from 2 days before to 1 week after the surgery. 4) Percutaneous transluminal coronary angioplasty (PTCA): Current antiplatelet drugs prevent post-procedural acute coronary occlusion but not late restenosis.
Hyperuricemia is an elevated uric acid level in blood. Gout is a common systemic metabolic disease characterized by deposition of monosodium urate monohydrate crystals with resultant acute intense inflammation of the involved joint. The clinical spectrum ranges from asymptomatic hyperuricemia to intermittent acute episodes of gouty arthritis to chronic tophaceous gout and chronic gouty arthropathy.
It is often assumed that cardiovascular disease is due to issues related to lifestyle. While lifestyle does contribute to the expression of cardiovascular issues, a genetic etiology to Marfan's syndrome, hypertrophic cardiomyopathy and long QT syndrome have been shown. It is unclear as to what role genetics plays in hypertension and hyperlipidemia, although it is felt that genetics contributes to these pathologies as well.
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus characterized by abnormal infiltration of eosinophils. The incidence of the disease that occurs in children and adults has been rapidly increasing in the last decade. Diagnosis and management of EoE warrants consultation with an allergist and a gastroenterologist.
Venous thrombo-embolic disease carries a high mortality rate and sometimes difficulties in diagnosis. Conventional pulmonary angiography remains the gold standard diagnostic test for pulmonary embolism. While contrast venography remains the gold standard modality to diagnose deep venous thrombi, the highly sensitive and specific venous ultrasonography makes it the most common initial test. The management of below-the-knee deep vein thrombosis and the indications for thrombolysis in pulmonary embolism are among the controversies explored.
Thymic lymphoepithelioma-like carcinoma is a rare subtype of thymic cancer with a poor prognosis; a few cases have been reported in the English literature. Strong clinical suspicion should be pursued in patient management decision making despite initial diagnostic studies, which sometimes mcould islead clinicians, as in our case.
Renin-angiotensin inhibitors are effective in slowing the progression of chronic proteinuric kidney disease. These medicines should be used in preference to anti-hypertensives that do not provide renoprotection.
Direct-current cardioversion has a higher success rate than does medical therapy in converting supraventricular tachyarrhythmias to sinus rhythm and should be performed immediately in patients with hemodynamic instability. Hemodynamically stable patients with atrial fibrillation or atrial flutter, a rapid ventricular rate and without preexcitation syndrome should be treated with intravenous beta-adrenergic blocking drugs, amiodarone, verapamil, or diltiazem. In hemodynamically unstable patients with supraventricular tachycardia, intravenous adenosine is the drug of choice.
The most common craniofacial malformation in the newborn is the orofacial cleft, consisting of cleft lip with or without cleft palate and isolated cleft palate. Given its prevalence it is important to understand the etiology of the deformity, medical management prior to surgical correction, surgical techniques and timing.
Numerous double-blind, randomized, placebo-controlled studies have shown that antihypertensive drug therapy reduces cardiovascular events in elderly persons. In the Hypertension in the Very Elderly Trial, patients aged 80 years and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30 percent reduction in fatal or nonfatal stroke, a 39 percent reduction in fatal stroke, a 21 percent reduction in all-cause mortality, a 23 percent reduction in death from cardiovascular causes, and a 64 percent reduction in heart failure. The goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mmHg and to less than 130/80 mmHg in older persons with diabetes or chronic renal insufficiency. All antihypertensive drugs may predispose the elderly person to develop symptomatic orthostatic hypotension and postprandial hypotension and syncope or falls. Adverse effects depend upon the antihypertensive drugs used, the doses of these drugs, the comorbidities in the elderly patients taking these drugs, and drug-drug interactions.
Hypersensitivity pneumonitis consists of a group of diseases resulting from inhalation of organic particles causing an immunopathological reaction of the lungs in susceptible individuals. The diagnosis requires a detailed and careful history that would include social, environmental, and occupational status, pulmonary function tests, serum precipitins, bronchoalveolar lavage, imaging, and lung biopsy. Early recognition and avoidance of the causative agent is important although the use of corticosteroids hastens improvement of symptoms.
AASV is an autoimmune disease with multiple-system involvement, which if untreated, carries a poor prognosis. The kidneys are the most common involved organ in these vasculitides. We present a case of AASV who presented with severe anemia and acute renal failure that was treated with steroids and cyclophosphamide.
Enhanced external counterpulsation (EECP) is a Food and Drug Administration approved non-pharmacological treatment for angina pectoris refractory to medical management and for use in the treatment of congestive heart failure. EECP improves quality of life, symptoms and exercise duration in these patients.
Lung cancer is the leading cause of cancer death in the United States. Fifteen percent of patients are asymptomatic at diagnosis. Symptoms usually indicate advanced disease. Signs include chronic cough, hemoptysis, wheezing, dyspnea, vague chest pain, hoarseness, pleural effusion, cardiac arrhythmias and bone pain. Significant surgical advances have reduced operational mortality rate. Early detection and surgery can increase survival rates for some patients.
Given its short therapeutic time window, successful ischemic stroke therapy requires a multi-disciplinary and streamlined approach. Intravenous recombinant tissue plasminogen activator remains the most efficacious treatment available. New therapies and advances in the understanding comorbidities associated with stroke have reshaped and expanded traditional treatment.
