Successful treatment of malakoplakia of the liver and skin in a pediatric liver transplant patient.

BACKGROUND: Malakoplakia occurs uncommonly at any age, but pediatric reports are exceptionally limited. Malakoplakia appears primarily in the urinary tract, although involvement of essentially all organs has been reported, cutaneous malakoplakia is very uncommon and liver involvement is the rarest. METHOD: We report the first pediatric case of concurrent hepatic and cutaneous malakoplakia in a pediatric liver transplant recipient. We also provide a literature review for cutaneous malakoplakia cases in children. RESULT: A 16-year-old male received a deceased-donor liver transplant for autoimmune hepatitis, present with the persistence of the liver mass of unknown etiology and cutaneous plaque-like lesions around the surgical scar. Core biopsies taken from the skin and abdominal wall lesions demonstrated histiocytes containing Michaelis-Gutmann bodies (MGB) revealing the diagnosis. The patient successfully was treated with antibiotics alone for 9 months without surgical intervention or a decrease in immunosuppressive therapy. CONCLUSION: This case demonstrates the need to include malakoplakia in the differential diagnosis of mass-forming lesions after solid transplantation and increase awareness of this very rare entity in pediatrics.

Psychiatric symptoms as a clinical presentation of Cushing's syndrome.

Cushing's syndrome can present with a spectrum of symptoms; however, it is less recognised that psychiatric symptoms can form part of the clinical presenting features. In the investigations for an organic cause for a psychiatric illness, Cushing's syndrome needs to be considered, especially if there are other features such as hirsutism or hypertension. In this article, the two cases reported demonstrate that a prompt diagnosis is not only important for psychiatric management but also crucial for timely institution of the necessary treatment of life-threatening causes of hypercortisolaemia such as metastatic adrenal carcinoma.

Survivors of self-inflicted stab wounds.

OBJECTIVE: There are a number of studies describing the survivors of self-incised wounds, but few studies have described the psychiatric condition of survivors of self-inflicted stab wounds. We aimed to describe the characteristics of a complete series of patients treated for self-inflicted stab wounds in a major hospital, and to compare the characteristics of patients with psychotic illness to those with other conditions. METHODS: A review of the files of all patients who had a psychiatric evaluation after presenting for treatment following deliberate self-harm. Stab wounds were defined as wounds made by a sharp instrument in which the width was less than the depth. RESULTS: There were 41 survivors of self-inflicted stab wounds among 2119 patients assessed after deliberate self-harm. Of these, 15 were diagnosed with a psychotic illness and the remainder had other conditions, including depression, personality disorder and substance use disorder. There was little difference in the demographic features, clinical variables and in the proportion who were intoxicated between patients diagnosed with psychotic illness and those with other disorders. The patients with psychosis were more likely to have inflicted multiple stab wounds, to have stabbed their chest or abdomen and to have reported the intention of committing suicide. CONCLUSIONS: The results suggest that a significant proportion of patients who present for treatment after stabbing themselves suffer from a psychotic illness. However, there were few differences in the characteristics of the patients who had a diagnosis of psychosis and those with other disorders.

Suicide attempts by jumping and psychotic illness.

BACKGROUND: Several recent studies have reported that serious violence towards self and others is more common in the first episode of psychosis than after treatment. AIM: To estimate the proportion of survivors of suicide attempts during psychotic illness by jumping from a height who had not previously received treatment with antipsychotic medication. METHODS: An audit of the medical records of patients admitted to nine designated trauma centres in New South Wales, Australia, after surviving a jump of more than 3 m. Jumping was defined using routine hospital ascribed International Classification of Diseases (ICD) codes. The height of the jump and all clinical data were extracted from case notes. RESULTS: The files of 160 survivors of jumps of more than 3 m were examined, which included 70 who were diagnosed with a psychotic illness (44%). Thirty-one of the 70 diagnosed with a psychotic illness (44%, 95% confidence interval [CI] 32-56%) had never received treatment for psychosis and hence were in the first episode of psychosis. One in five (19.4%) of all survivors of a suicide attempt by jumping had an undiagnosed and untreated psychosis that was often characterized by frightening delusional beliefs. CONCLUSION: A large proportion of the survivors of suicide attempts by jumping were diagnosed with a psychotic illness, which confirms an association between psychosis and suicide by jumping. Some suicides might not have been linked to psychosis had the patient not survived the suicide attempt, suggesting that the contribution of schizophrenia to suicide mortality might have been underestimated in psychological autopsy studies. The finding that nearly half of the survivors diagnosed to have a psychotic illness had never received treatment with antipsychotic medication indicates a greatly increased risk of suicide by jumping in the first episode of psychosis when compared to the annual risk after treatment.