Anal melanoma: an aggressive malignancy masquerading as hemorrhoids.

Anal melanoma is a devastating malignancy easily confused with benign hemorrhoids. Physician unfamiliarity with this bleeding rectal lesion can lead to delays in diagnosis and therapy. Four cases of anal melanoma, all initially mistaken for hemorrhoids, have been documented in the past 4 years at our institution. Despite surgical intervention and chemoimmunotherapy, each patient succumbed to widely metastatic disease. Average survival was 15.2 months. The clinical, pathologic, surgical, and oncologic features of anal melanoma are reviewed to enhance physician recognition of this unusual anorectal disorder.

Eosinophilic pleural effusion due to dantrolene: resolution with steroid therapy.

A quadriplegic patient with severe spasticity, treated with dantrolene (400 mg daily) for 5 years, had dyspnea, orthopnea, hypoxia, and right-sided opacity of the chest on radiograph. At thoracentesis, an exudative effusion containing 64% eosinophils was documented, with simultaneous peripheral eosinophilia of 11%. An allergic reaction to dantrolene was postulated. Despite withdrawal of the offending medication and repeated thoracenteses, symptomatic recurrence of effusion persisted for 4 days. After institution of prednisone therapy, rapid resolution of symptoms, signs, hypoxia, and radiologic abnormalities was observed. In contrast to five previously reported cases of dantrolene-associated eosinophilic pleural effusion (EPE), ours represents the first in which the patient was treated with steroids and suggests that steroid therapy may be of benefit in drug-related EPE.

Late postpartum eclampsia 16 days after delivery: case report with clinical, radiologic, and pathophysiologic correlations.

BACKGROUND: Postpartum eclampsia is a rare, frightening, and potentially tragic complication of hypertensive pregnancies, usually developing within 48 hours of delivery. Seizures occurring days to weeks after parturition are exceedingly uncommon and require rapid, precise clinical evaluation by multiple specialists. METHODS: A case presentation of delayed postpartum eclampsia illustrates unique features of the syndrome. Extensive review of the literature highlights pathogenesis, controversies, and dilemmas surrounding this enigmatic hypertensive disorder. RESULTS AND CONCLUSIONS: A 39-year-old hypertensive patient had an uneventful full-term delivery by her family physician only to develop headache, double vision, and recurrent tonic-clonic seizures 16 days later. Initial evaluation showed severe hypertension, diplopia, hyperreflexia, proteinuria, and hyperuricemia. She was given a magnesium sulfate infusion. Magnetic resonance imaging (MRI) documented asymmetric ischemic foci within gray matter in the distribution of the posterior cerebral arteries. All symptoms, signs, and abnormal laboratory values resolved within 4 days. A follow-up MRI showed complete resolution of all cytotoxic cortical lesions. Based on human autopsy data, radiologic investigations, and animal studies, eclampsia is believed to result from explosive vasospasm, endothelial dysfunction, and cytotoxic edema of cerebral cortex. This central nervous system vasculopathy is most prominent in the posterior cerebral vasculature and is often rapidly reversible. Difficulties in differential diagnosis, typical findings on neuroimaging, and urgent management strategies are discussed. The time limit for postpartum eclampsia probably should be lengthened to 4 weeks, as indicated by our case and other clinical series.

Solitary erythema migrans in Georgia and South Carolina.

OBJECTIVE: To evaluate the incidence of Borrelia burgdorferi infection in humans with erythema migrans (EM) in 2 southeastern states. DESIGN: Prospective case series. SETTING: Family medicine practice at academic center. PATIENTS: Twenty-three patients with solitary EM lesions meeting Centers for Disease Control and Prevention (CDC) criteria for Lyme disease. INTERVENTIONS: Patients underwent clinical and serologic evaluation for evidence of B burgdorferi infection. All lesions underwent photography, biopsy, culture and histopathologic and polymerase chain reaction analysis for B burgdorferi infection. Patients were treated with doxycycline hyclate and followed up clinically and serologically. MAIN OUTCOME MEASURES: Disappearance of EM lesions and associated clinical symptoms in response to antibiotic therapy; short-term and follow-up serologic assays for diagnostic antibody; growth of spirochetes from tissue biopsy specimens in Barbour-Stoenner-Kelly II media; special histopathologic stains of tissue for spirochetes; and polymerase chain reaction assays of tissue biopsy specimens for established DNA sequences of B burgdorferi. RESULTS: The EM lesions ranged from 5 to 20 cm (average, 9.6 cm). Five patients (22%) had mild systemic symptoms. All lesions and associated symptoms resolved with antibiotic therapy. Overall, 7 patients (30%) had some evidence of B burgdorferi infection. Cultures from 1 patient (4%) yielded spirochetes, characterized as Borrelia garinii, a European strain not known to occur in the United States; 3 patients (13%) demonstrated spirochetallike forms on special histologic stains; 5 patients (22%) had positive polymerase chain reaction findings with primers for flagellin DNA sequences; and 2 patients (9%) were seropositive for B burgdorferi infection using recommended 2-step CDC methods. No late clinical sequelae were observed after treatment. CONCLUSIONS: The EM lesions we observed are consistent with early Lyme disease occurring elsewhere, but laboratory confirmation of B burgdorferi infection is lacking in at least 16 cases (70%) analyzed using available methods. Genetically variable strains of B burgdorferi, alternative Borrelia species, or novel, uncharacterized infectious agents may account for most of the observed EM lesions.

The many 'faces' of Graves' disease. Part 2. Practical diagnostic testing and management options.

Recognition of the many "faces" of Graves' disease can lead to earlier detection and management. Diagnosis is not always obvious, and this common multisystem syndrome requires attentive clinical evaluation. New laboratory and nuclear medicine diagnostic procedures now allow precise biochemical and pathophysiologic confirmation of the disease. Beta blockers promptly alleviate symptoms, allowing time for thoughtful consideration by patient and physician as to optimal definitive therapy with antithyroid drugs, RAI, or surgery.

The many 'faces' of Graves' disease. Part 1. Eyes, pulse, skin, and neck provide important clues to diagnosis.

The variety in clinical appearance of patients with Graves' disease suggests that predominant symptoms affecting one body system may be either compelling or misleading to clinicians during the initial assessment. However, each patient in these case presentations had additional bedside evidence of many of the recognized multisystem manifestations of hyperthyroidism, as detected on more extensive evaluation. Laboratory tests confirmed the diagnosis in each instance. While these cases are not meant to represent all reported manifestations of Graves' disease, grouping of symptoms into memorable "faces" is helpful for definitive clinical recognition and precise diagnosis of this complex and challenging syndrome.

Orbital myositis due to Kawasaki's disease.

Kawasaki's disease is an inflammatory syndrome of young children that affects multiple organ systems. The most common ophthalmologic manifestations of Kawasaki's disease are bilateral conjunctival injection and nongranulomatous iridocyclitis. To our knowledge, this patient is the first with Kawasaki's disease to demonstrate extraocular muscle palsy and orbital myositis.

Attachment sites of four tick species (Acari: Ixodidae) parasitizing humans in Georgia and South Carolina.

From June 1995 through January 1998, 677 tick specimens were submitted by 521 humans from 14 states. Analysis was limited to specimens originating in Georgia and South Carolina, representing 87.3% of total submissions. Attachment sites were specified in 367 specimens (62.3%). The American dog tick, Dermacentor variabilis (Say), a vector of the agent of Rocky Mountain spotted fever, favored the head and neck in 59% of attached specimens. The lone star tick, Amblyomma americanum (L.), a strongly implicated vector of the agent of human monocytic ehrlichiosis, favored the lower extremities, buttocks, and groin in 54% of specimens. The blacklegged tick, Ixodes scapularis Say, the main eastern vector of the Lyme disease spirochete, had widely distributed attachment sites with no apparent site preference. The Gulf Coast tick, A. maculatum Koch, parasitized humans in too few instances for analysis. In the southeastern United States, prevention of tick bites and tickborne illnesses such as Rocky Mountain spotted fever, ehrlichiosis, and Lyme disease may be enhanced by personal practices and public health measures based on knowledge of preferred attachment sites of potentially infectious tick species.

Periorbital vasculitis complicating Kawasaki syndrome in an infant.

Periorbital vasculitis is a previously unreported complication of Kawasaki syndrome (KS). We describe an infant with severe KS refractory to initial management with salicylate and intravenous immunoglobulin (IVIG). Retreatment with IVIG and high-dose pulsed steroids was required for persistent fever and inflammatory manifestations. Despite aggressive medical therapy, a large left coronary artery aneurysm developed. After apparent complete KS remission, acute periorbital vasculitis developed in the left upper eyelid and orbit, requiring operative intervention for diagnosis and high-dose pulsed steroids for therapy. The significance of this previously unreported ophthalmic complication of KS is reviewed, along with a discussion of the role of steroids in KS manifestations refractory to IVIG.

Lyme disease update. Current approach to early, disseminated, and late disease.

A rational approach to diagnosis and treatment of Lyme disease requires an understanding of the endemic range of the tick vectors for B burgdorferi, the epidemiologic risk factors, and the spectrum of clinical manifestations. A two-step approach to serologic testing (ELISA followed by Western blot analysis of positive or equivocal results) can be useful if the pretest likelihood of Lyme disease is higher than 20%. Consideration should be given to the possibility of (1) a noninfectious disease with clinical features similar to those of Lyme disease or (2) coinfection with a second tick-transmitted organism. Late Lyme disease must be distinguished by clinical characteristics from fibromyalgia (the commonest source of misdiagnosis in several studies). Antibiotic therapy should be tailored to the extent of disease and limited to 4 weeks in most cases. Human vaccines based on an outer-surface protein from B burgdorferi have been tested in large-scale US clinical trials and may soon be approved for use in persons whose occupational or recreational activities place them at risk for B burgdorferi exposure.

Breath test diagnosis of Helicobacter pylori in peptic ulcer disease: a noninvasive primary care option.

BACKGROUND: Helicobacter pylori is implicated as the causative agent for most duodenal and gastric ulcers. Invasive (endoscopy and biopsy) and noninvasive (serology, breath test) methods are currently available for definitive diagnosis of infectious peptic ulcer disease. METHODS: Twenty-six patients with chronic gastritis symptoms underwent upper endoscopy, biopsy, rapid urease test, and [14C]urea breath test for the detection of H pylori. RESULTS: Twenty of 26 patients (77 percent) had biopsy-proved H pylori infection. All 20 (100 percent) with definite H pylori proved by invasive diagnosis had strongly positive results on urea breath test. Six patients with absence of H pylori on biopsy had negative urea breath test results. The urea breath test displayed 100 percent sensitivity, specificity, and predictive value compared with endoscopy and biopsy. CONCLUSIONS: [14C]Urea breath testing is comparable to endoscopy and biopsy in the diagnosis of H pylori infection and could become useful in primary care settings for noninvasive evaluation of peptic ulcer disease.

Beware the left-sided effusion.

A left-sided pleural effusion is an infrequent clinical occurrence compared with bilateral or right-sided effusions. After coronary bypass surgery, a patient presented with dyspnea and an enlarging left pleural effusion erroneously attributed to congestive heart failure and refractory to medical management. Thoracentesis generated a clinical surprise, allowed specific therapy, and produced evidence for a rarely reported complication of coronary artery bypass grafting. The management of chylothorax and the differential diagnosis of left-sided pleural effusions are reviewed.

Ticks parasitizing humans in Georgia and South Carolina.

From 1990 through 1995, 913 ticks removed from 460 human patients in Georgia or South Carolina were identified and recorded. The majority of these specimens (758, 83.0%) were lone star ticks, Amblyomma americanum. One hundred and four (11.4%) American dog ticks Dermacentor variabilis, 36 (3.9%) blacklegged ticks Ixodes scapularis, 9 (1.0%) Gulf coast ticks Amblyomma maculatum, and 6 (0.7%) brown dog ticks Rhipicephalus sanguineus were also recovered. All active stages (larvae, nymphs, and adults) of A. americanum were represented, whereas nymphs and adults of D. variabilis and I. scapularis and only adults of A. maculatum and R. sanguineus were recorded. Compared with data published for other regions in the U.S.A., A. americanum was a much more prevalent parasite of humans in the current survey. Only 1 (3%) of the I. scapularis collected was a nymph. Because these tick species are vectors of zoonotic pathogens or cause tick paralysis in humans, the data have epidemiological significance.

Detection of Borrelia burgdorferi in human blood and urine using the polymerase chain reaction.

We investigated the use of the polymerase chain reaction (PCR) to detect Borrelia burgdorferi strain B-31 in human blood and urine experimentally inoculated with 5 and 1 borreliae/cm3, respectively, and to biotinylate a DNA probe specific for B. burgdorferi in the dot blot and Southern blot assays. When the blood and urine samples were subjected to PCR, a 370-bp amplified product was consistently visible on agarose gel electrophoresis after 30 and 45 cycles, respectively. The total human genomic DNA extracted from a 1-cm3 sample of inoculated blood was approximately 6.25 micrograms, and the total amount of B. burgdorferi DNA was estimated to be 0.01 pg/6.25 micrograms of the human DNA. For PCR, 2.5 micrograms of human DNA which contained the equivalent of 0.004 pg of borrelia DNA (approximately two borreliae) were used for enzymatic amplification. When 1/20 or 1/10 of the PCR-amplified products were used either for dot blot or Southern blot hybridization, the accessible copies of amplified B. burgdorferi DNA were sufficient for detectable hybridization to occur. PCR amplification of B. burgdorferi DNA in clinical specimens followed by dot blot hybridization may be a valuable adjunct or alternative to current but inadequate laboratory methods for the diagnosis of Lyme disease.