A 7-week-old Nepali girl with a perianal ulcer: brief report.

Cytomegalovirus (CMV) can rarely present with skin findings. Cutaneous CMV is most often found in patients who are immunocompromised because of acquired immunodeficiency syndrome, lymphoma, or other conditions. We present a rare case of an immunocompetent 7-week-old girl with a perianal ulcer attributed to CMV.

Atrial fibrillation from thyroid storm.

BACKGROUND: Thyroid storm is an often-discussed but rare presentation to emergency departments (EDs). The clinical presentation of a thyroid storm is the result of a hyperthyroid state that may result in significant morbidity or disability, or even death. Typically, patients are aware of their hyperthyroid condition, and may be able to recognize an episode of thyroid storm. However, the first presentation of hyperthyroidism could, in fact, be from thyrotoxic crisis. OBJECTIVES: To review the presentation of thyroid storm, including tachycardia, hyperpyrexia, agitation, and altered mental status, which can be easily misdiagnosed as drug intoxication. CASE REPORT: We present the case of an otherwise healthy young adult who was sent to the ED by an outpatient care provider for generalized and vague symptoms of "feeling unwell" that was eventually diagnosed in the ED as thyrotoxic crisis. CONCLUSION: We use this case to emphasize that thyrotoxic crisis should be at least considered in the differential diagnosis of a patient with this presentation, and to highlight how, even with apparently usual and effective treatments, a patient may still decompensate.

Altered mental status from acyclovir.

BACKGROUND: Acyclovir is widely used in the treatment of herpes virus infections, particularly herpes simplex virus and varicella-zoster virus. Acyclovir, when given promptly upon the start of a herpes zoster eruption, speeds healing and diminishes acute pain. OBJECTIVES: Because acyclovir is a commonly used medication, it is crucial for health providers to be aware of appropriate dosing as well as possible side effects. We present this case to increase awareness of the potential for inappropriate dosing of acyclovir and the presentations of patients with toxic effects. CASE REPORT: We report the case of a 65-year-old man with a past medical history significant for chronic kidney disease who presented to the Emergency Department with progressive confusion and ataxia over 2 days. Thorough questioning in the patient's native language revealed that he had recently started a medication for a "rash." Neither he nor his family knew the name of the new medication; further investigation revealed it to be acyclovir. Although other diagnoses were considered in the differential diagnosis for this patient with altered mental status, he was treated for presumed acyclovir toxicity and given prompt dialysis, upon which his symptoms resolved. CONCLUSION: It is important for physicians to remember that even common medications such as acyclovir can have serious side effects and complications. In this case, renal dosing was not used in a patient on hemodialysis. Acyclovir must be renally dosed and carefully monitored through drug level measurement in patients with limited kidney function to prevent serious side effects, such as the neurological sequelae demonstrated in this case report. Emergency physicians should be aware of the potential for inappropriate dosing of this medication and the presentations of patients with toxic effects.

A toddler with facial nodules: a case of idiopathic facial aseptic granuloma.

We describe the case of a 3-year-old boy who presented with several asymptomatic facial nodules present for six months. A skin biopsy obtained from the nodules showed a moderately well-defined granuloma in the superficial and deep dermis. A squamous epithelial lined cyst, extravasated keratin, or shadow cells were not identified. Bartonella henselae titers and the Coccidioidomycosis immitis immunodiffusion test were negative; a Tuberculin Skin Test was non-reactive. Fite, Periodic acid-Schiff (PAS) and Gomori-Grocott methenamine silver (GMS) stains failed to identify microorganisms. In addition, tissue cultures for bacteria, fungus, and acid fast bacilli were negative. In light of the clinical findings, histology, and negative cultures, a diagnosis of idiopathic facial aseptic granuloma (IFAG) was made. After the biopsy, the child was treated with erythromycin and clarithromycin, each for one month, and the lesions slowly improved.

Postoperative pain following foot and ankle surgery: a prospective study.

BACKGROUND: Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain. MATERIALS AND METHODS: A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively. RESULTS: The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain. CONCLUSION: The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.

Pott's Puffy tumor after minor head trauma.

Posttraumatic osteomyelitis may occur as a direct result of bony injury after trauma or arise as a nosocomial infection after the treatment of trauma. Most cases arise after an open fracture, but bony infection can also arise from spread of infection from contiguous soft tissues or by puncture wounds. Motor vehicle accidents, sport injuries, and the use of orthopedic hardware to manage trauma have contributed to the apparent increase in prevalence of posttraumatic osteomyelitis. We report on a case of Pott's Puffy tumor in a previously healthy woman who had an episode of minor forehead trauma 1 month before presentation to the emergency department (ED), complaining of persistent headache and swelling of her forehead. Results of computed tomography (CT) revealed features characteristic of this condition. After postobliteration of the left frontal sinus via a bicoronal approach with an iliac crest bone graft and some dental extractions and 2 weeks of antibiotic therapy, the patient achieved a complete recovery.

Regional multilineage differentiation potential of meniscal fibrochondrocytes: implications for meniscus repair.

The knee menisci are wedge-shaped semilunar fibrocartilaginous structures that reside between the femur and tibia and function to transmit and distribute load. These structures have characteristics of both fibrous and cartilaginous tissues. The cartilage-like inner region and the fibrous vascularized outer region each has a distinct extracellular matrix, and resident meniscal fibrochondrocytes (MFCs) with distinct morphologies dependent on their location. Damage to the meniscus is common, and disruption of tissue structure and function result in erosion of the underlying articular cartilage. It has been observed that damage in the vascular periphery undergoes spontaneous repair, whereas damage of the inner region does not heal. While vascularity of the peripheral region plays a role in healing, recent findings have also suggested that local cellular composition influences local healing capacity. This study examined the variation in multipotential characteristics of cell populations isolated from different regions of the bovine meniscus. MFCs were isolated from the outer (vascular), inner (avascular), and horn (mixed) regions and induced toward chondrogenic, adipogenic, and osteogenic lineages. The results of this study suggest that MFCs from all regions of the meniscus possess a multilineage differentiation capability, particularly toward chondrogenesis and adipogenesis. MFCs from the outer region were most plastic, differentiating along all three mesenchymal lineages. These findings may underlie the experimental observation of improved integration of meniscus grafts from the outer zone and may have implications for developing strategies of cell-based meniscus repair.

Synthesis and physicochemical analysis of interpenetrating networks containing modified gelatin and poly(ethylene glycol) diacrylate.

The interrelated effects of gelatin modification, content, and poly(ethylene glycol) molecular weight on the melting temperature, surface hydrophilicity, tensile properties, swelling/degradation, and drug-release kinetics of a novel interpenetrating network (IPN) system containing gelatin and poly(ethylene glycol) diacrylate were evaluated. Gelatin content had a large effect on the IPN melting temperature and Delta H. Modifying gelatin with ethylenediaminetetraacetic acid and/or monomethoxy poly(ethylene glycol) monoacetate ester as well as increasing poly(ethylene glycol) diacrylate molecular weight increased the surface hydrophilicity. Increasing the gelatin weight percent increased the IPN elasticity at room temperature. When buffer and elevated temperature were present in the testing environment, the elasticity of all IPNs tested decreased. IPNs showed an enhanced elasticity and strength when compared with glutaraldehyde-fixed gelatin hydrogels. The extent of IPN swelling and degradation was increased by increasing the gelatin content or by modifying gelatin. The time to complete sample degradation was longer for IPNs when compared with gelatin crosslinked with glutaraldehyde. Modifications to the IPN system increased the maximum percent of chlorhexidine digluconate released from the IPNs. The rate of complete drug release was slower from IPNs than from glutaraldehyde-fixed gelatin matrices. A wide range of IPN physicochemical properties was obtained through formulation changes and chemical modifications.