Congestive heart failure: a review and case report from a chiropractic teaching clinic.

OBJECTIVE: To discuss the case of a 62-year-old woman with congestive heart failure (CHF), precipitated by a previous arteriovenous malformation, and to review the clinical presentation, pathophysiology, and treatment options for patients with CHF. CLINICAL FEATURES: The patient complained of pain, rapid weight gain, and shortness of breath. The index event for this patient was known to be an arteriovenous malformation. Biventricular cardiomegaly with pulmonary venous hypertension was evident on chest radiographs. INTERVENTION AND OUTCOME: The patient received both medical care (drug therapy) and chiropractic care (manipulation and soft tissue techniques to alleviate symptoms and discomfort). CONCLUSION: Patients with known and undiagnosed CHF may visit the chiropractic physician; thus, knowledge of comprehensive care, differential diagnosis, and continuity of care are important. Chiropractic management may be helpful in alleviating patient discomfort. Further clinical investigations may help to clarify the role of complementary and alternative care in the diagnosis and treatment of CHF.

Delayed posttraumatic vertebral collapse with intravertebral vacuum cleft.

OBJECTIVE: To discuss the case of a 79-year-old man who had a delayed posttraumatic vertebral collapse and an intravertebral vacuum cleft. The patient had been on long-term corticosteroid therapy. A discussion of Kummell's disease and the controversy surrounding the etiology of the condition is also presented. CLINICAL FEATURES: Six weeks before coming to the clinic, the patient remembered twisting, hearing a pop, and having severe low back pain. Two weeks after the incident, while hospitalized for bacterial cellulitis, he underwent lumbar spine radiography. The radiographs showed degenerative changes and remote (healed) compression fractures but did not demonstrate any deformity of L2. Four weeks later, he sought care for persistent low back pain. Radiographs revealed marked compression of the L2 vertebral body with an intravertebral vacuum phenomenon. INTERVENTION AND OUTCOME: The patient was referred to his geriatrician for evaluation as a candidate for vertebroplasty or other stabilization procedures. He required a moderately high dose (60 mg) of prednisone daily to combat the symptoms of myasthenia gravis; therefore, the prognosis appears unfavorable for this patient. CONCLUSION: Clinical research is needed to determine the definitive etiology and pathophysiology of Kummell's disease. This case demonstrates that the intravertebral vacuum is a dynamic entity, subject to changes in size and shape. Previous case reports have suggested that Kummell's disease only presents as a linear, horizontal cleft. This disease needs further investigation to determine the true correlation between radiographic signs and the underlying pathophysiology.

Neuropathic osteoarthropathy in the diabetic foot.

OBJECTIVE: To discuss a case involving a 55-year-old diabetic woman with neuropathic osteoarthropathy initiated by a fall. CLINICAL FEATURES: The patient fell into a hole, injuring her left foot. Because of the anesthesia associated with her diabetic peripheral neuropathy, she did not notice the ensuing plantar puncture wound. The patient assumed that her swelling was a result of a sprain. Mild dislocation and osseous fragmentation was noted within the midfoot on radiographs. The neuropathic osteoarthropathy progressed until the patient was later casted. Plain films taken at the time of cast removal demonstrated resorption and consolidation of fragmentation, but the dislocation was unaltered. INTERVENTION AND OUTCOME: The patient was scheduled for surgery and wound debridement. However, before surgery, complications of a burn sustained on the contralateral foot required fifth ray amputation. Surgery of the left foot has been postponed until adequate postsurgical healing has occurred at the right foot amputation site. CONCLUSION: This article provides tools for the timely diagnosis and treatment of neuropathic osteoarthropathy. An increased understanding of this entity will help lead to a reduction in the incidence of delayed treatment resulting from misdiagnosis.

Bilateral acrometastasis secondary to breast cancer.

BACKGROUND: One out of every 8 women will be diagnosed with breast cancer and 1 in 28 will succumb to the disease. Skeletal metastasis occurs in 16% to 73% of breast cancer patients. OBJECTIVE: To present a comprehensive look at the pathophysiology, clinical presentation, and treatment options for skeletal metastasis secondary to breast carcinoma by discussing the case of an 80-year-old female patient with bilateral distal lower extremity metastasis following a previous diagnosis of breast cancer. CLINICAL FEATURES: The patient had severe pain in both lower extremities, which caused her to have difficulty when ambulating. She also complained of fatigue and anorexia, with an 8-lb weight loss. Chest examination revealed widespread rales without change. Her left calcaneus was tender to palpation and both feet and ankles were hot and swollen. Laboratory CA 27.29 values were 1131 on October 16, 2001, which was elevated compared with the 454 value obtained previously. Plain films of the lower extremities revealed destructive lesions of the distal left and right tibia and fibula with involvement of the left calcaneus. These findings were most consistent with metastasis. INTERVENTION AND OUTCOME: The patient refused further care and sought a hospice referral. CONCLUSION: There is no cure for acrometastasis and prognosis is poor. Treatment focuses on symptomatic relief, extended survival, and maintaining quality of life. Clinicians should consider metastasis in a patient with distal lower extremity osteolytic lesions with a previous history of breast malignancy.

Ganglioneuroma masquerading as spinal pain.

OBJECTIVE: To discuss the clinical features of ganglioneuroma and to propose it as a differential diagnosis for a young patient suffering from chronic back pain. CLINICAL FEATURES: A 25-year-old patient suffered from chronic mid-thoracic pain and a history of scoliosis. The physical examination result was unremarkable; thus radiographs were obtained. A posteroanterior and lateral chest radiograph demonstrated a well-defined opacity extending from the region of the left hilum to below the diaphragm. A differential diagnosis of a posterior mediastinal mass was advanced. Computed tomography revealed a homogenous, nonenhancing left posterior mediastinal mass with adjacent posterior rib deformity. Computed tomography (CT)-guided biopsy subsequently defined the mass as a ganglioneuroma. INTERVENTION AND OUTCOME: The mass was surgically resected. Although the patient experienced some postsurgical discomfort, she has fared well. CONCLUSION: Twenty percent of mediastinal tumors are neurogenic, and 10% of neurogenic tumors are ganglioneuromas. In spite of the rarity of this tumor, ganglioneuroma should be considered in the differential diagnosis of young patients suffering from back pain. The diagnosis is important to ascertain because surgical resection is curative and can relieve the symptoms.