When Occipital Artery Biopsy is Preferred to Temporal Biopsy for Giant Cell Arteritis: A Step-By-Step Description of the Surgical Technique.

Giant cell arteritis is an autoimmune disease that affects large and medium blood vessels of the head and neck. Its prompt treatment is mandatory to avoid severe and permanent complications, such as blindness. Temporal artery biopsy is an important part of the diagnostic work-up, especially in those patients with cranial symptoms or in the elderly with a fever of unknown origin. Most patients have signs and symptoms matching the distribution of their arterial involvement. In the case scenario of occipital headache or nuchal pain, a biopsy of the occipital artery may be preferred to a temporal artery biopsy. This article provides important anatomical details of the course of the occipital artery and explains, in a stepwise fashion, how to perform an occipital artery biopsy.

Granulomatosis with Polyangiitis Manifesting as Refractory Otitis Media and Mastoiditis.

Granulomatosis with polyangiitis (GPA) is a rare rheumatologic disease characterized by small to medium vessel vasculitis and inflammation within multiple organ systems. Majority of cases involve both upper and lower respiratory tracts but other organs including brain, kidneys, joints and skin can also be involved. Patients who have recurrent otitis media and sinusitis often initially present to internists and then to ear nose and throat (ENT) physicians and may be treated with multiple courses of antibiotics without having proper workup for GPA. We present a middle-aged white male who exemplifies this unique presentation with new onset recurrent otitis media and mastoiditis, which did not respond to repeated courses of antibiotics requiring mastoidectomy and myringotomy tube placement. On chest x-ray, he was found to have multiple lung nodules that was followed by a computed tomography (CT) scan of his chest and CT guided biopsy which revealed granulomatous inflammation and necrosis, consistent with GPA. Autoimmune laboratory work-up was also suggestive of GPA. The patient had complete resolution of symptoms with steroid therapy. This case reinforces the concept of high index of suspicion of GPA for patients with recurrent and resistant otitis media or mastoiditis not responding to optimal duration and doses of antibiotics. Appropriate work-up for GPA may allow for earlier diagnosis of this devastating vasculitic disease which can help prevent multi-organ dysfunction.

Acute kidney injury secondary to thrombotic microangiopathy associated with idiopathic hypereosinophilic syndrome: a case report and review of the literature.

BACKGROUND: Renal involvement in idiopathic hypereosinophilic syndrome is uncommon. The mechanism of kidney damage can be explained as occurring via two distinct pathways: (1) thromboembolic ischemic changes secondary to endocardial disruption mediated by eosinophilic cytotoxicity to the myocardium and (2) direct eosinophilic cytotoxic effect to the kidney. CASE PRESENTATION: We present a case of a 63-year-old Caucasian man who presented to our hospital with 2 weeks of progressively generalized weakness. He was diagnosed with idiopathic hypereosinophilic syndrome with multiorgan involvement and acute kidney injury with biopsy-proven thrombotic microangiopathy. Full remission was achieved after 8 weeks of corticosteroid therapy. CONCLUSION: Further studies are needed to investigate if age and absence of frank thrombocytopenia can serve as a prognostic feature of idiopathic hypereosinophilic syndrome, as seen in this case.

Methimazole-Induced Pauci-Immune Glomerulonephritis and Anti-Phospholipid Syndrome: An Important Association to Be Aware of.

While methimazole (MMI) is the first line treatment for hyperthyroidism, this medication is not devoid of adverse effects. In this article, we present a 70-year-old male who admitted the hospital with right lower extremity pain and rash. The patient was recently treated with MMI for hyperthyroidism. Imaging studies revealed bilateral renal and splenic infarcts along with thrombosis of popliteal artery. Laboratory data revealed hematuria and proteinuria with positive (MPO), anti-proteinase-3 (PR3) and anti-cardiolipin IgG antibodies. Renal biopsy revealed pauci-immune glomerulonephritis and features with anti-phospholipid antibody syndrome (APS). MMI was discontinued and the patient was treated successfully with steroid therapy and anti-coagulation with resolution of proteinuria, hematuria and normalization of laboratory parameters. While MMI-induced pauci-immune glomerulonephritis has been previously reported, its association with APS has never been described before. Our case demonstrates that this rare diagnosis can be treated by early withdrawal of MMI and initiation of steroids along with anticoagulation.

Recognizing Obesity in Adult Hospitalized Patients: A Retrospective Cohort Study Assessing Rates of Documentation and Prevalence of Obesity.

BACKGROUND: While obesity is a chronic condition that predisposes patients to other more serious disorders, the prevalence and the documentation of obesity as diagnosis has not been extensively studied in hospitalized patients. We conducted a retrospective chart review to investigate the prevalence and documentation of obesity as a diagnosis among patients admitted to our medical center. METHOD: IRB approval was obtained for this retrospective study. Body mass index (BMI) as per CDC, admission and discharge diagnosis of obesity and common comorbidities (hypertension, diabetes, hyperlipidemia, coronary artery disease, congestive heart disease, chronic kidney disease and chronic obstructive pulmonary disease) were recorded. The length of stay in the hospital was also calculated. We also investigated whether counselling was provided to the obese patients for weight loss. RESULTS: A total of 540 consecutive patients were reviewed with a mean age was 66 ± 6 years. Out of 540 patients only 182 (34%) had normal weight, 188 (35%) of the patients were overweight and 170 (31%) patients were obese. Of the obese group, 55% were female and 45% were male.100 (59%) had class I obesity, 43 (25%) had class II obesity and 27 (16%) class III obesity. Of the obese patients 40/170 (23.5%) patients had obesity documented on the admission problem list and only 21 (12%) had obesity documented as a discharge diagnosis. Only 3 (2%) patients were given appropriate counseling and referral for obesity management during the hospitalization. Comorbidities and their prevalence included, hypertension (68%), diabetes mellitus (35%), hyperlipidemia (36%), coronary artery disease (18%), chronic kidney disease (17%), congestive heart failure (18%) and COPD (24%). The average length of stay in normal weight, overweight and obese patients was similar for all three groups (4.5 ± 0.5 days). CONCLUSION: A significant number of hospitalized patients were overweight and obese. An overwhelming percentage never had weight status documented. Hospitalization offers health care providers a window of opportunity to identify obesity, communicate risks, and initiate weight management interventions.

Contrast-induced nephropathy: Pathophysiology, risk factors, and prevention.

Contrast-induced acute kidney injury is a common iatrogenic complication associated with increased health resource utilization and adverse outcomes, including short- and long-term mortality and accelerated progression of preexisting renal insufficiency. The incidence of contrast-induced nephropathy (CIN) has been reported to range from 0% to 24%. This wide range reported by the studies is due to differences in definition, background risk factors, type and dose of contrast medium used, and the frequency of other coexisting potential causes of acute renal failure. CIN is usually transient, with serum creatinine levels peaking at 2-3 days after administration of contrast medium and returning to baseline within 7-10 days after administration. Multiple studies have been conducted using variety of therapeutic interventions in an attempt to prevent CIN. Of these, careful selection of patients, using newer radiocontrast agents, maintenance of hydration status, and avoiding nephrotoxic agents pre- and post-procedure are the most effective interventions to protect against CIN. This review focuses on the basic concepts of CIN and summarizes our recent understanding of its pathophysiology. In addition, this article provides practical recommendations with respect to CIN prevention and management.

Ischemic monomelic neuropathy: a long-term follow-up of two cases.

INTRODUCTION: Ischemic monomelic neuropathy (IMN) is the most dreaded complication of an arteriovenous access creation. While uncommon, it can lead to pain, paresthesia or/and hand weakness. Creation of an arteriovenous connection causing a sudden diversion of blood away from the nerves can lead to ischemic injury to the neural tissue and cause IMN. Immediate surgical ligation has been traditionally recommended to limit ongoing neural tissue injury. CASE DESCRIPTION: We present two diabetic patients who developed IMN after the creation of a left upper extremity brachial-cephalic fistula and refused to undergo surgical ligation. The clinical examination revealed paresthesia localized to the volar aspect of the left forearm with mild weakness of the thumb, index and middle finger. Rehabilitation therapy was initiated in both and revealed a significant improvement in weakness but paresthesia persisted. Fistula maturation was achieved in both patients with an access flow of 1100-1200 cc/min. At 4 months, fistula was used successfully for dialysis in both patients. At a follow-up of 11 months, hand weakness did not progress and paresthesia disappeared. CONCLUSIONS: These cases demonstrate sensory-motor improvement with time and rehabilitation therapy and challenge the traditional approach of fistula ligation. The approach presented in this paper also results in the preservation of the lifeline of a patient. Future investigations should focus on identifying candidates who could benefit from physical therapy and rehabilitation.