Large Congenital Hydrocephalus:Extended Survival without Neurosurgery.

PROFESSIONAL PRESENTATION: This work was presented at the 57th Quarterly Grand Rounds at Fairview Developmental Center, Costa Mesa, California on October 17, 2012. ACKNOWLEDGMENT: Authors are grateful to Stephan Reynolds CRT, and Indira Makwana for records. CONFLICT OF INTEREST: None of the authors has any conflict of interest with the information provided in this article. ABSTRACT: We report the case of a 45-year-old patient with large congenital hydrocephalus. Patient was born prematurely at 26-weeks' gestation with a weight of 1.14Kg. His head-circumferences have been: Birth, 27.9 cms; age 3-months, 40.6 cms; 18-months, 74 cms; 36-months, 80 cms; current, 88.4 cms (normal adult: 52-58 cms). During infancy, his prognosis was considered "terminal" due to rapid progression of severe hydrocephalus; therefore no neurosurgical intervention was undertaken. At 18-months' age, he was admitted to our developmental center where he is presently comfortable and clinically stable. Due to habitual unilateral decubitus, his head is now markedly flattened on the right (deformational plagiocephaly), and disproportionately long and narrow (scaphocephaly: occipitofrontal length 36.8 cms, biparietal width 12.5; ratio 2.9). We credit patient's extended survival to diligent professional care. INDICES USED: PubMed.

Errors in Patient History in Hospital Records.

CONFLICT OF INTEREST: Ghan-Shyam Lohiya MD provided medico-legal opinions as a Qualified Medical Evaluator (Occupational Medicine & Toxicology) supporting a related workers' compensation death claim. Dr G. Lohiya received partial payments for his services from Gallagher Bassett Services Company (workers' compensation insurance adjuster for the patient's employer). Sonia Krishna MD, Sapna Lohiya and Sunita Lohiya MD: No actual or potential, real or perceived conflict of interest in the drugs, devices or procedures described in the enclosed manuscript. ABSTRACT: A patient died of renal failure related to treatment of a hand contusion with ibuprofen and valdecoxib. Her hospital records revealed several incorrect and mutually conflicting statements about seven historical items in the Initial Evaluation Reports authored by five treating physicians. There were errors of commission (relying on imperfect memory, acquiescing erroneous information), and errors of omission (failure to proofread transcribed reports, question and resolve contradictory statements in sister reports, obtain correct history, and review prior medical records). Such errors wrongly implied that patient had preexisting conditions (advanced renal failure, diabetes mellitus, hypertension, asthma and alcoholism) which caused her death, and negatively impacted her workers' compensation claim. Incorrect allergy history was also noted. Preventive measures are suggested. PROFESSIONAL PRESENTATION: At the 53rd Quarterly Grand Rounds in Costa Mesa, California.

Human bites: bloodborne pathogen risk and postexposure follow-up algorithm.

Human bites may transmit bloodborne pathogens (BPs) by exposing the biter's oral mucosa to the bitee's blood and the bite wound to biter's saliva. Consequently, bites may require postexposure follow-up per the Occupational Safety and Health Administration (OSHA) BP standard. Literature reveals that BP transmission via bites is rare. Review of available records in our developmental center identified no bite-related BP transmission between 1993 and 2011. To avoid unnecessary testing while remaining OSHA-compliant, we propose an algorithm for selective follow-up of bites. Since hepatitis B virus can be transmitted by mucosal exposure to blood and, rarely, also by nonintact skin exposure to blood-free saliva, all biters and bitees require hepatitis B follow-up. Since hepatitis C virus and human immunodeficiency virus (HIV) transmissions require "visible blood" exposure, and since saliva is usually bloodfree, risk of HCV-HIV transmission from biter to bitee is negligible. Therefore biters need HCV-HIV testing only after bloody saliva bites. Since biter's oral mucosa invariably gets exposed to bitee's blood (reverse exposure), all bitees should be tested for HCV-HIV infectivity. Our proposed algorithm may prevent harm and waste from unnecessary biter testing and venipuncture.

Serious pH1N1 influenza illness and pneumonia despite inactivated vaccine: success of prompt diagnosis and treatment.

A 42-year-old bedridden patient suddenly became seriously ill with an unexplained fever (39 degrees C) and hypoxemia (pulse oximetry oxygen saturation: patient, 90%; normal, >98%). He had received the inactivated vaccine for pandemic 2009 H1N1-influenza (pH1N1) 41 days earlier. He had no cough, sore throat, or pharyngitis. Therefore, he did not satisfy the Centers for Disease Control criteria for an "influenza-like illness." Nevertheless, his nasopharyngeal swab was tested by rapid enzyme-linked immunosorbent assay for influenza A and found positive. He was promptly treated with supplemental oxygen and oseltamivir (75 mg twice daily) for 5 days. On day 6, reverse transcriptase-polymerase chain reaction test confirmed the virus to be pH1N1. A chest radiograph was normal on day 1 but revealed bilobar pneumonia on day 2. This was considered bacterial superinfection and empirically treated for 10 days with 3 g of piperacillin and 375 mg of tazobactam. The patient fully recovered. This case of pH1N1 vaccine failure occurred because no vaccine is 100% protective, and immune response may be poorer in patients with chronic medical problems. Vaccine failure was not due to immunodeficiency or improper vaccine handling. We credit this patient's recovery to our facility's heightened surveillance for influenza even among the vaccinated individuals, and also in those without classic influenza-like illness.

Bloodborne pathogens exposure from occupational fingernail scratches.

Following occupational fingernail scratches (OFSs) in a developmental center, the source resident and the injured employee were tested for bloodborne pathogens (BPs). The pros and cons of this practice were scrutinized since fingernails usually contain no blood. Available records revealed no OFS-related BP transmission in 14 years. PubMed displayed no article linking OFS with BP. The facility's practice was discontinued as it was deemed unnecessary, wasteful, an impediment to the event's expeditious closure, an ineffective workers' compensation safeguard, and a potential source of venipuncture-related complications and false-positive laboratory results. Even long-standing practices require periodic scientific review.

The wheelchair thrombosis syndrome.

OBJECTIVE: To report a case of deep vein thrombosis (DVT) related to prolonged wheelchair use. CASE REPORT: A 48-year-old patient with spastic quadriplegia usually spent 10-12 hours daily in a wheelchair. He suddenly developed marked swelling of his right foot, leg and thigh. His plasma D-dimer level was 1,030 (normal <500) ng/ml. A duplex ultrasound revealed common femoral vein thrombosis. He was hospitalized and anticoagulated; his extremity swelling decreased considerably by day 45. Hypercoagulability work-up disclosed previously subclinical mild elevation of serum cardiolipin immunoglobulin G (antiphospholipid syndrome). This patient will receive longterm anticoagulation. CONCLUSION: Prolonged sitting in wheelchair may cause DVT. To enhance public recognition of this avoidable risk, we propose the term "wheelchair thrombosis syndrome."

The futility of universal pre-employment chest radiographs.

In a developmental center, a preemployment chest x-ray was required for all job applicants. We scrutinized the pros and cons of this practice through a review of the medical literature and our experience, and discussion with our colleagues. We concluded that such chest x-ray caused unwarranted radiation exposure, did not produce compliance with the tuberculosis laws, gave a false sense of security regarding workers' compensation risk management, was contrary to established occupational medicine practice guidelines, and was unnecessary and wasteful. We discontinued such chest x-rays. The purpose of the pre-employment examination should remain narrowly job related. Even long-established procedures require periodic utilization review.

Scombrotoxinism: Protracted Illness following Misdiagnosis in the Emergency Department.

Background. Scombrotoxinism is an acute toxin-induced illness caused primarily by bacterial synthesis of histamine in decomposed fish. Case Report. Immediately after taking 2-3 bites of cooked salmon, a clerical worker developed oral burning, urticaria, and asthma. In the emergency department, she was diagnosed with "allergies"; scombrotoxinism was never considered. She then developed wide-ranging symptoms (e.g., chronic fatigue, asthma, anxiety, multiple chemical sensitivity, and paresthesiae) and saw many specialists (in pulmonology, otorhinolaryngology, allergy, toxicology, neurology, psychology, and immunology). During the next 500+ days, she had extensive testing (allergy screens, brain MRI, electroencephalogram, electromyogram, nerve conduction velocity, heavy metal screen, and blood chemistry) with essentially normal results. She filed a workers' compensation claim since this injury occurred following a business meal. She was evaluated by a Qualified Medical Evaluator (GL) on day 504, who diagnosed scombrotoxinism. Comment. Scombrotoxinism should be considered in all patients presenting to the emergency department with "oral burning" or allergy symptoms following "fish consumption." Initial attention to such history would have led to a correct diagnosis and averted this patient's extended illness. Specialist referrals and tests should be ordered only if clinically indicated and not for diagnostic fishing expedition. Meticulous history is crucial in resolving clinical dilemmas.

Identification of low bone mass in a developmental center: finger bone mineral density measurement in 562 residents.

OBJECTIVES: The objective of this study was to measure finger bone mineral density (BMD) in residents of a developmental center. DESIGN: A cross-sectional descriptive study performed during the residents' annual physical examination. SETTING: This study was conducted at a long-term care facility for people with severe developmental disabilities (mental retardation, cerebral palsy, epilepsy, and autism). PARTICIPANTS: Study participants included 562 (67%) of the 833 residents aged 30 years or more on whom we could measure BMD. MEASUREMENTS: We measured BMD by peripheral dual-energy x-ray absorptiometry (DXA) on the residents' middle fingers by Accudexa. The instrument converted the BMD values into T-scores relative to the manufacturer's reference young healthy population. We retrieved the residents' clinical variables from a centralized database. RESULTS: T-scores for the 562 residents were: <-2.5 standard deviation (SD) (osteoporotic): 98 (17%), -2.5 SD>t <-1 SD (osteopenic): 156 (28%), and >-1 SD (normal): 308 (55%). Multivariate regression analysis revealed that BMD was significantly lower in residents (compared with their counterparts) with inability to ambulate, male gender, white race, quadriplegia, profound mental retardation, and older age. CONCLUSION: There is a need for heightened osteoporosis surveillance and preventive effort in this population in which almost half of the residents had previously undiagnosed subnormal BMD, including one sixth who had osteoporosis.

Necrotizing fasciitis: diagnostic challenges in a mute bedridden patient with atypical laboratory parameters.

A 27-year-old mute bedridden patient required parenteral corticosteroids and antibiotics, and hospitalization for an acute respiratory illness. After 2 days, staff noted a ~0.3 cm blister on the patient's right heel. Within 19 hours, blistering increased and the foot became partly gangrenous. The patient developed high fever (40.3°C), and leukocytosis (count: 13 × 10(9)/L; was 6.5 × 10(9)/L ten days earlier). Necrotizing fasciitis (NF) was diagnosed and treated with emergency leg amputation. Histopathology revealed necrosis of fascia, muscle, subcutaneous tissue, and skin. In bedridden patients, corticosteroids may particularly facilitate serious infections, and initial NF blistering may be mistaken for pressure ulcers. Vigilant and frequent whole body monitoring is necessary for all patients incapable of verbalizing their symptoms.

Piperacillin-induced immune hemolysis presenting with tachycardia and cardiac arrest.

A 20-year-old nonverbal patient with profound developmental disabilities was treated with intravenous piperacillin-tazobactam for respiratory infection. After 8 days, he became afebrile with normal pulmonary status, but his pulse remained inexplicably rapid (114/minute). Investigations revealed severe normochromic normocytic hemolytic anemia (hemoglobin: 40 g/L, reticulocytes: 9.4%, nucleated erythrocytes: 5%). While being hospitalized, patient experienced sudden cardiac arrest from which he was successfully resuscitated. He had no blood loss or intrinsic heart disease to explain the acute anemia or cardiac arrest. He had uneventfully received piperacillin-tazobactam on 7 occasions during the preceding 5 years for >50 days. Patient was treated with intravenous crystalloids, methylprednisolone and transfusion of 3 units of packed erythrocytes. Piperacillin-tazobactam was discontinued. A direct antiglobulin test was positive for immunoglobulin G and complement. Antibody to piperacillin was detected in patient's serum by the "immune-complex" method confirming "piperacillin-induced immune hemolytic anemia (PIHA)". On discharge (day 15), patient's hemoglobin improved to 115 g/L (baseline: 131 g/L). Vigilant clinical and hematological monitoring for anemia is indicated in piperacillin-treated patients, particularly in those unable to verbalize their discomfort. Repeated piperacillin exposure may sensitize and predispose patients to PIHA.

Intermittent diarrhea as a delayed presentation of percutaneous endoscopic gastrostomy (PEG)-associated fistula.

A 60-year-old patient with severe dysphagia, weight loss, and recurrent aspiration pneumonia required a percutaneous endoscopic gastrostomy (PEG) for long-term feeding. After 24 uneventful days, she developed an enigmatic recurring but intermittent diarrhea. On day 62, staff noted a feculent odor from her gastrostoma, along with undigested formula in her stools. This prompted her hospitalization. A plain abdominal radiograph demonstrated the PEG tube in the upper abdomen, but could not differentiate if its tip was misplaced. Next, an abdominal barium-contrast computed tomography scan was performed but was inadvertently misinterpreted as normal. Finally, a colonoscopy demonstrated that the tip of the PEG tube was malpositioned in the transverse colon, resulting in a colocutaneous fistula (CCF). The PEG tube was withdrawn uneventfully through the gastrostoma. A laparotomy was performed. Strong adhesions were found between the stomach and the colon; these were lysed and the CCF tract was excised. The patient recovered. CCF should be considered in the differential diagnosis of PEG patients with unexplained diarrhea even if the diarrhea is delayed or intermittent; the diagnosis should be confirmed by a tubogram.