Four-Year Follow-Up of a Case of Yellow Nail Syndrome With IgM Deficiency.

Yellow nail syndrome is a rare condition occurring sporadically, with an extremely low prevalence rate. This syndrome classically presents with a triad of lower extremity edema, yellow nails, and mucosal issues such as pleural effusion and/or chronic sinusitis. Two out of the three features are deemed sufficient to diagnose a person with yellow nail syndrome. We present a rare case of yellow nail syndrome that began with chronic leg swelling and later progressed to the development of an asymptomatic pleural effusion and finally discoloration of nails. In our case, the patient did have a significant recent history of a total knee replacement with a titanium implant. Of note was the chronology of events including leg edema and asymptomatic pleural effusion which were present even before the titanium knee implant. The third feature of the hardening and yellow discoloration of the nails was found to have developed following the knee replacement. Interestingly, on further evaluation, he was found to have IgM deficiency.

A Rare Case of Incidentally Diagnosed Pulmonary Inflammatory Myofibroblastic Tumour with Dramatic Response to Crizotinib in a Postpartum Woman.

Introduction: Inflammatory myofibroblastic tumours are rare neoplasms which most commonly affect children and young adults. With an intermediate malignant potential, they are typically detected in the abdomen, lung, mediastinum, head and neck, gastrointestinal tract, and genitourinary tract. Case description: We describe the case of a 33-year-old postpartum woman incidentally diagnosed with a pulmonary inflammatory myofibroblastic tumour following complaints of poorly controlled hypertension a week after caesarean section. She was ALK-negative and received an ALK inhibitor with complete resolution of the lesion. A ROS1-TFG fusion confirmed the diagnosis of an inflammatory myofibroblastic tumour after CT-guided fine needle aspiration. Discussion: This case highlights an uncommon presentation posing a diagnostic and therapeutic challenge and the potential treatment option of crizotinib. LEARNING POINTS: Inflammatory myofibroblastic tumour (IMT) is a rarely reported neoplasm arising in the abdominal soft tissues, the lung, mediastinum, head, neck, gastrointestinal tract, and genitourinary tract, with intermediate malignant potential.IMT is definitively diagnosed only after histological examination following surgical biopsy, based on immunohistochemical markers and the molecular characteristics of the tumour, but small biopsies may have a role in a large lesion.IMT did not cause any complications during gestation.Therapeutic approaches include surgical resection and chemotherapy, including with crizotinib, an ALK tyrosine kinase inhibitor.

Idiopathic Subglottic Tracheal Stenosis Misdiagnosed As Vocal Cord Dysfunction and Successfully Treated with Laser and Controlled Radial Expansion Balloon Dilation.

Idiopathic tracheal stenosis (ITS) is a rare condition, and diagnosis of exclusion should be suspected in patients with exercise intolerance, wheezing, and dyspnea on exertion with a flow-volume loop suggestive of fixed airway obstruction. We report a case of a 32-year-old asthmatic woman with an existing diagnosis of vocal cord dysfunction and previous normal CT scan of the neck. She continued to have fixed upper airway obstruction on repeated flow-volume loops with persistent wheezing and cough along with occasional stridor and hoarseness of voice despite appropriate management of her asthma. She was finally diagnosed with ITS on a repeat CT scan of the neck for which she underwent laser surgery, steroid injection, and controlled radial expansion balloon dilation with a successful reduction of stenosis. This case illustrates the importance of clinical suspicion for early diagnosis of ITS in poorly controlled asthmatic patients and the relevance of non-surgical management of this condition.

Doctor YouTube's opinion on seasonal influenza: A critical appraisal of the information available to patients.

BACKGROUND: Seasonal influenza is a respiratory illness caused by the influenza virus. During the 2017-2018 flu season, the Centers for Disease Control and Prevention noted approximately 959,000 hospitalizations and 79,400 deaths from influenza. We sought to evaluate the educational quality of informational videos pertaining to seasonal influenza on the popular social media forum, YouTube. METHODS: Using the keywords "seasonal influenza," all videos from 28 January to 5 February 2017 were included and analyzed for characteristics, source, and content. The source was further classified as healthcare provider, alternative-medicine provider, the patient and/or their parents, company, media, or professional society. Videos about other categories of influenza (e.g. swine or Spanish) or in foreign languages were excluded. A total of 10 blinded reviewers scored each video independently. RESULTS: Overall, 300 videos were analyzed, with a median of 341.50 views, 1.00 likes, 0 dislikes, and 0 comments. Based on the average scores of videos by source, there was statistically significant difference in the average score among videos by video source (p < 0.01). Healthcare provider videos had the highest mean scores whereas alternative medicine provider videos had the lowest. CONCLUSIONS: Although the aforementioned video sources scored higher than others, these videos did not fulfill our criteria as far as educating patients thoroughly. Our data also suggest alternative medicine and patient source videos were misleading for patients.Clinical implications: Although videos by healthcare providers were a better source of information, videos on seasonal influenza were shown to be poor sources of valid healthcare information. This study reiterates the need for higher-quality educational videos on seasonal influenza by the medical community.

Pulmonary infection with caseating mediastinal lymphadenitis caused by Mycobacterium gordonae.

It is often difficult to discern true mycobacterial infection from colonization due to Mycobacterium gordonae (M. gordonae) since this organism is ubiquitous and is commonly an innocuous saprophyte. This study reports a rare case of caseating hilar adenopathy and pulmonary disease caused by M. gordonae in a patient with chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) on maintenance steroids and methotrexate. Pathologic exam and cultures of lymph node excision biopsy and bronchoalveolar lavage (BAL) confirmed the diagnosis. Triple antimycobacterial therapy with azithromycin, ethambutol and rifabutin was administered. The patient had significant clinical and radiologic improvement and follow-up cultures confirmed microbiologic cure. Mycobacterium gordonae can be a rare cause of significant pulmonary infection, and positive sputum or BAL cultures for M. gordonae should not be automatically discarded and considered as nonpathogenic contaminants or colonizing organisms, especially in immunocompromised hosts with comorbidities. A detailed review of the case and relevant literature is provided.

Pulmonary blastomycosis during pregnancy: case report and review of the literature.

Blastomycosis rarely presents in pregnancy. Pregnancy is a state of partial immunodeficiency that predisposes to blastomyces infection, especially in endemic areas. Blastomycosis in pregnancy has been reported in a few female patients and their offspring. We are reporting a 32-year-old pregnant patient at 34 weeks of gestation who presented with a lung mass. The cytopathological exam of the biopsy taken by fine needle aspiration showed evidence of Blastomyces organisms. She received Liposomal Amphotericin B and was followed closely until delivery. The placenta was examined and did not show evidence of infection in the fetus. Healthcare professionals in endemic areas such as Tennessee should be aware of blastomycosis in pregnancy.

Differences in outcomes between cholecalciferol and ergocalciferol supplementation in veterans with inflammatory bowel disease.

AIM: Vitamin D deficiency is a global health issue associated with increased health-care costs, and could play a role in the pathogenesis and management of inflammatory bowel disease. Prior studies show a high prevalence of vitamin D deficiency in veterans with inflammatory bowel disease. We aimed to examine the outcome differences in patients with inflammatory bowel disease, comparing treatment with ergocalciferol to cholecalciferol. METHODS: A retrospective review of electronic medical records of patients with inflammatory bowel disease at a Veterans Affairs Medical Facility in the Southeastern United States was carried out. Those with at least one serum 25(OH) vitamin D level were included. Initial and follow-up vitamin D values were recorded. The type of vitamin D supplementation, whether cholecalciferol or ergocalciferol, was documented. Costs in the year after measurement of vitamin D were divided into separate inpatient and outpatient categories. RESULTS: Veterans (n = 108) with ulcerative colitis or Crohn's disease and an available 25(OH) vitamin D level were studied. There were differences in follow-up vitamin D levels; those who received weekly ergocalciferol had higher subsequent levels than those who received cholecalciferol, especially at a second follow up, although differences did not achieve statistical significance. However, those who received vitamin D3 were less likely to use laboratory, pharmacy, radiology and fee-based services, and had lower laboratory and pharmacy costs. CONCLUSIONS: Our data suggest that cholecalciferol replacement might improve outcomes to a greater extent than ergocalciferol, and might be better in limiting health-care costs and expenses in patients with inflammatory bowel disease.

Vitamin D deficiency: implications for acute care in the elderly and in patients with chronic illness.

There is evidence that the vast majority of hospitalized patients have vitamin D deficiency. Vitamin D deficiency is a poorly recognized pandemic with evidence to indicate inadequate testing and monitoring of response to treatment in high-risk populations. Vitamin D receptors are ubiquitous in the human body and while the endocrine effects of vitamin D are well recognized, the autocrine and paracrine effects of this steroid hormone are less well appreciated. These functions include antimicrobial and immunomodulation effects as well benefits on cardiovascular health, autoimmune disease, cancer and metabolism. Vitamin D deficiency increases mortality and even a modest amount of vitamin D may enhance longevity. Emerging evidence suggests that a vitamin D replete state carries significant health benefits in acute illness. In this review, we discuss the role of vitamin D deficiency and potential benefits in treating this deficiency focusing on the implications for managing acute illness in elderly patients and those with an underlying chronic illness.

Combining cytomorphology and serology for the diagnosis of cat scratch disease.

Cat scratch disease (CSD) is a self limited zoonotic disease that presents most commonly as a regional lymphadenopathy. We are reporting a case of a 25-year-old male patient who presented with fever and large right inguinal lymphadenopathy. The diagnosis of cat scratch disease was confirmed based on the characteristic cytopathological features on aspirate smears from the lymph node and the serological titers for Bartonella henselae. This case report emphasizes the importance of combining Bartonella serology, and cytopathology in the diagnostic work-up of febrile lymphadenopathy and suspected CSD since the culture of this organism is arduous.

Antimicrobial implications of vitamin D.

Evidence exists that vitamin D has a potential antimicrobial activity and its deficiency has deleterious effects on general well-being and longevity. Vitamin D may reduce the risk of infection through multiple mechanisms. Vitamin D boosts innate immunity by modulating production of anti-microbial peptides (AMPs) and cytokine response. Vitamin D and its analogues via these mechanisms are playing an increasing role in the management of atopic dermatitis, psoriasis, vitiligo, acne and rosacea. Vitamin D may reduce susceptibility to infection in patients with atopic dermatitis and the ability to regulate local immune and inflammatory responses offers exciting potential for understanding and treating chronic inflammatory dermatitides. Moreover, B and T cell activation as well as boosting the activity of monocytes and macrophages also contribute to a potent systemic anti-microbial effect. The direct invasion by pathogenic organisms may be minimized at sites such as the respiratory tract by enhancing clearance of invading organisms. A vitamin D replete state appears to benefit most infections, with the possible noteworthy exception of Leishmaniasis. Antibiotics remain an expensive option and misuse of these agents results in significant antibiotic resistance and contributes to escalating health care costs. Vitamin D constitutes an inexpensive prophylactic option and possibly therapeutic product either by itself or as a synergistic agent to traditional antimicrobial agents. This review outlines the specific antimicrobial properties of vitamin D in combating a wide range of organisms. We discuss the possible mechanisms by which vitamin D may have a therapeutic role in managing a variety of infections.

The potential to improve diabetes control with vitamin D replacement in African American patients: case report and literature review.

African Americans have a higher prevalence of Diabetes mellitus and associated complications. The prevalence of Vitamin D deficiency is also higher in African Americans. We report an African American veteran who was followed for a period of 10 years in the Endocrine clinic for insulin-requiring diabetes. Despite intensive, medical, nutritional and educational efforts during that period, no discernible progress was made in achieving any improvement in glycemic control. The patient appeared to be noncompliant with recommended strategies to improve glycemia. The patient was seen recently and was found to be profoundly Vitamin D deficient with a 25 (OH) Vitamin D level of 11.6 ng/ml [30-100 ng/ml]. While patient did not wish to change his insulin regimen or diabetic management, he was willing to accept Vitamin D therapy. Replacement with Vitamin D was associated with significant improvement in glycosylated hemoglobin to previously unmatched levels of glycemic control. We discuss the multiple potential mechanisms by which improved Vitamin D status may result in improved diabetes control. Given the current pandemic of Vitamin D deficiency and the plethora of potential benefits, we recommend maintaining adequate Vitamin D reserves in diabetic patients with a special emphasis on minority populations.

Benefits of twice-daily injection with insulin glargine: a case report and review of the literature.

Insulin Glargine is recommended as a once-daily basal insulin. We report a patient in whom nocturnal administration of Glargine was associated with significant morning hypoglycemia despite titration of insulin dose. Changing the Glargine regimen to morning administration did not result in improvement. However, changing to a twice-daily regimen of Glargine resulted in the resolution of the hypoglycemia. Few studies have addressed the role of multiple daily injections of Glargine and this remains a valuable option in the management of diabetic patients. Prior studies using multiple daily injections with NPH insulin and Ultralente have demonstrated success. We propose that patients with hypoglycemia despite titration of once daily Glargine should be considered for a twice-daily regimen. Despite a slight increase in cost and inconvenience for the patient, the increases frequency of administration may result in a greater success in achieving glycemic targets.

Fructosamine--an underutilized tool in diabetes management: case report and literature review.

Glucose binds irreversibly to a variety of structures, including hemoglobin and proteins, by non-enzymatic glycosylation. Glycosylated Hemoglobin A1c (HbA1c) measures the blood glucose control over the lifespan of the RBCs. The importance of routinely assessing HbA1c in diabetic patients is well established. Both individual and institutional performance in the diabetes arena may be judged by the number of patients reaching target HbA1c values. In some patients, however, the HbA1c does not accurately portray glycemic control and may delay treatment for poorly-controlled diabetes. We report on a patient in whom the HbA1c values were falsely low as a result of hemolytic anemia associated with Myelodysplastic syndrome. The patient had consistent elevation of glucose values. Fructosamine measurement was able to confirm poorly-controlled diabetes and assist in improving diabetes control. Fructosamine is unaffected by disorders of red blood cells, which have a profound potential influence on HbA1c. Fructosamine also has the advantage of accurately reflecting shorter-term changes in glycemia that correspond to the half-life of albumin. In diabetic patients with HbA1c values below the lower limit of normal, a routine Fructosamine level should be performed. We recommend a Fructosamine level should be considered in all patients with red blood cell disorders or with discrepancies between glucose measurements and HbAlc values. Fructosamine, an inexpensive assay, is currently underused in the clinical practice. A guideline for using Fructosamine levels is included and some of the pitfalls in relying solely on the HbAlc are discussed.