Cutaneous signs of child abuse

Maltreatment of children is a major public health crisis, and it is estimated that each year more than 3 million children are victims of abuse. Safeguarding the welfare of children is a priority, and it is the moral and ethical responsibility of healthcare professionals to detect cases of abuse and intervene appropriately to prevent further harm. Clinicians are often challenged to differentiate signs of child abuse from skin conditions that mimic maltreatment. Because cutaneous injury represents the most recognizable and common form of abuse, dermatologists are often called upon to help distinguish signs of intentional injury from skin conditions that mimic maltreatment. However, few resources specific to dermatologic signs of abuse exist to aid in diagnosis. A review of the literature will provide an educational resource to assist dermatologists and other clinicians in differentiating cutaneous signs of child abuse, including physical and sexual abuse, from mimickers of inflicted injury. LEARNING OBJECTIVE: After completing this learning activity, participants should be able to distinguish signs of intentional injury from skin conditions that mimic maltreatment and understand the clinician's role in the diagnosis and reporting of cases of suspected child abuse.

Osteopontin polymorphisms and disease course in multiple sclerosis.

Osteopontin (OPN), also known as early T-cell activating gene (Eta-1), has been recently shown to be a critical factor in the progression of experimental autoimmune encephalomyelitis, and perhaps multiple sclerosis (MS). Here we investigated whether the 327T/C, 795C/T, 1128A/G or 1284A/C single-nucleotide polymorphisms in the OPN gene were correlated with susceptibility or any of the several clinical end points in a cohort of 821 MS patients. Overall, we observed no evidence of genetic association between the OPN polymorphisms and MS. Although not reaching statistical significance, a modest trend for association with disease course was detected in patients carrying at least one wild-type 1284A allele, suggesting an effect on disease course. Patients with this genotype were less likely to have a mild disease course and were at increased risk for a secondary-progressive clinical type.

HLA-DR2 dose effect on susceptibility to multiple sclerosis and influence on disease course.

Models of disease susceptibility in multiple sclerosis (MS) often assume a dominant action for the HLA-DRB1*1501 allele and its associated haplotype (DRB1*1501-DQB1*0602 or DR2). A robust and phenotypically well-characterized MS data set was used to explore this model in more detail. A dose effect of HLA-DR2 haplotypes on MS susceptibility was revealed. This observation suggests that, in addition to the role of HLA-DR2 in MS, two copies of a susceptibility haplotype further increase disease risk. Second, we report that DR2 haplotypes modify disease expression. There is a paucity of benign MS and an increase of severe MS in individuals homozygous for DR2. Concepts of the molecular mechanisms that underlie linkage and association of the human leukocyte antigen (HLA) region to MS need to be revised to accommodate these data.

Crescentic glomerulonephritis complicating idiopathic membranous glomerulonephropathy.

We describe the course of a patient with multiple rectal abscesses and progressive renal dysfunction. A renal biopsy demonstrated a membranous glomerulopathy associated with extensive crescent formation. No underlying cause for the glomerulonephritis could be identified and, specifically, the anti-GBM antibody present in other similar cases was not found. There appears to be a subset of patients with membranous glomerulopathy in whom crescents develop with rapid loss of renal function. Anti-GBM antibody is not necessary in the pathogenesis of this lesion.

Recovery from rapidly progressive glomerulonephritis. Improvement after plasmapheresis and immunosuppression.

Two patients with rapidly advancing renal insufficiency underwent biopsy and were found to have crescentic glomerulonephritis. Patient 1 demonstrated findings compatible with Goodpasture's syndrome. Crescents were present in 100% of his glomeruli. Patient 2 had findings of immune complex-mediated glomerulonephritis and crescents in greater than 90% of his glomeruli. Both patients were treated with high-dose prednisone, cyclophosphamide, and plasmapheresis. Patient 2 additionally required hemodialysis for a brief period. Renal function improved in both patients and has not deteriorated after follow-up of 14 and 18 months, respectively. Repeated renal biopsies were performed in each patient. Our findings suggest that clinical improvement and histologic healing are possible in rapidly progressive glomerulonephritis despite the initial presence of crescents in every glomerulus.

Hepatic coma after open heart surgery.

Fulminant hepatic failure has been reported in patients with chronic congestive heart failure. Two patients in whom jaundice and coma followed cardiac surgery were studied to find the possible etiology. Clinical, biochemical, and histologic evaluations revealed low cardiac output; elevated levels of bilirubin, lactic dehydrogenase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase; prolonged prothrombin time; and centrizonal necrosis of hepatocytes with sinusoidal dilatation. No other possible causes of hapatic dysfunction and coma were identified. We conclude that acute postoperative congestive heart failure may cause fulminant hepatic failure and metabolic encephalopathy.

Hypernatremia in hepatic failure.

The presence of hypernatremia in patients with hepatic failure has not received major attention. We examined the records of 25 patients admitted to the hospital with decompensated liver disease (usually Laënnec's cirrhosis) and found hypernatremia in 15. Probable causes include increased insensible water losses, impairment of water intake due to encephalopathy, and the use of osmotic cathartics with hypotonic enteric losses. Patients in this series showing hypernatremia had a mortality of 87%. Mortality in those without hypernatremia was 60%. The presence of increased serum sodium concentrations in patients with decompensated liver disease is an ominous but correctable abnormality reflecting a disturbance in water balance.

Mesangial proliferative glomerulonephritis in mixed connective tissue disease (MCTD).

A patient who had clinical and serologic evidence for Mixed Connective Tissue Disease (MCTD) developed mesangial proliferative glomerulonephritis with demonstrable immune complexes. Most cases of MCTD with a renal lesion have exhibited membranous glomerular lesions. Since the prevalence of renal involvement in MCTD has ranged from 5-20%, it is possible that too few cases have been studied to describe fully the range of renal lesions seen in this disease entity.

Renal artery thrombosis in a young woman taking oral contraceptives.

PIP: Retrospective studies indicate that oral contraceptive use is associated with an increased risk of venous thromboembolic disease, but the evidence linking oral contraceptive use with the development of arterial thrombosis is limited. In view of this paucity of evidence, the case report of a young women taking oral contraceptives and treated at the Naval Regional Medical Center in San Diego for sudden renal artery thrombosis without any predisposing cause, is of some significance. The 22 year old patient had no physical evidence or history indicative of trauma or systemic disease; however, she reported taking Orthonovum 1/50 for the 6 months preceeding the event and smoking a pack of cigarettes/day. These factors, in combination, may have predisposed her to arterial thrombosis. Included is a photograph of the patient's angiograph showing the occlusion.^ieng

Treatment of alkalosis with ammonium chloride: a case report.

Coma due to ammonium chloride used in the treatment of severe metabolic alkalosis is reported in a patient with normal hepatic and renal function. All symptoms resolved following discontinuance. Ammonium chloride should be abandoned as a treatment for metabolic alkalosis.

Reticuloendothelial and mesangial function in murine immune complex glomerulonephritis.

The function of the mesangial and reticuloendothelial system was evaluated in normal mice and in mice with nephritis induced by lymphocytic choriomeningitis (LCM) virus infection. Heat-aggregated human immunoglobulin (AlgG) and colloidal carbon served as traceable materials which could be detected in animals' blood and tissues. LCM virus-infected proteinuric (LCM-P) mice, as compared to normal mice or LCM-infected nonproteinuric (LCM) mice, had greater accumulation of AIgG in their glomeruli at all times of examination following i.p. injection of AIgG. The removal rate of AIgG from the kidney, however, was the same in normal and LCM-P mice, indicating an unimpaired mesangial clearing system. This suggested that other mechanisms were responsible for the increased glomerular accumulation of AIgG in LCM-P mice. Reticuloendothelial function was examined directly by i.v. injection of AIgG or colloidal carbon. The data demonstrate that in this model of immune complex glomerulonephritis, colloidal material tested was removed from the blood at a slower rate than it was in normal mice. Deficient clearance of endogenous blood-borne immune complex-like material may be one of the factors playing a role in the accumulation of immune complex-like material in the glomeruli of these nephritic animals.

Hazards of computerized tomography: renal failure following contrast injection.

Acute renal failure in a diabetic patient following contrast injection for computerized tomography is discussed. Like a variety of serious complications associated with contrast media, dye-induced renal failure is an important iatrogenic complication to which the diabetic population may be unusually susceptible.