Wisconsin Medical Journal最新文献

Introduction: Primary malignant melanoma of the esophagus constitutes 0.1% to 0.5% of all primary malignant esophageal neoplasms. Melanocytes are present within the squamous epithelium of the esophagus in the stratum basale layer with melanocytosis rare within the esophagus. Primary esophageal melanoma is aggressive and has a poor survival rate; 80% of patients have metastatic disease at diagnosis. Resection surgery is usually first-line treatment for localized primary malignant esophageal melanoma, but recurrence rates remain high. Tumor-specific immunotherapy has shown promising results. We report a case of primary malignant esophageal melanoma with metastasis to the liver treated with immunotherapy.

Case presentation: A 66-year-old woman presented with 2 months of progressive dysphagia and 3 episodes of hematemesis the previous night. Endoscopic examination showed a hypervascular distal esophageal mass. Biopsy was positive for S-100, SOX-10, and HMB-45 and showed rare mitotic figures with scattered pigment, consistent with melanoma. She was scheduled for esophagectomy initially, but instead pursued immunotherapy after liver metastasis was diagnosed during preop magnetic resonance imaging. Immunotherapy consisted of 8 cycles of pembrolizumab, followed by 4 months nivolumab and ipilimumab. The patient remains in remission 3 years after completing immunotherapy.

Discussion/conclusions: Our patient was diagnosed with primary malignant esophageal melanoma of the distal esophagus with metastasis to the liver, a presentation that typically has a poor prognosis. Despite this, remission was achieved with immunotherapy without surgical intervention. Only a small number of cases of primary esophageal melanoma treated with immunotherapy have been reported-one showcasing tumor stabilization following several cycles of therapy with eventual metastasis, while our patient had a stable response to treatment. Further exploration of medical management with immunotherapy should be conducted, as it represents an alternative treatment for patients who do not have the option of surgical management.

We present a case report highlighting a 47-year-old woman who developed warfarin-induced calciphylaxis. She initially developed bilateral leg wounds secondary to restraint straps from helicopter transportation to a higher level of care for treatment of critical aortic stenosis. She was started on warfarin following surgical implantation of a mechanical aortic valve. After her wounds failed to heal, a punch biopsy of the wounds demonstrated ulceration, altered vasculature, and soft tissue calcification. The pathology confirmed the clinical concern for calciphylaxis, which is most often diagnosed in patients with a history of end-stage renal disease on hemodialysis. However, our patient did not demonstrate evidence of renal disease prior to the onset of calciphylaxis. Her wounds began to heal after treatment with sodium thiosulfate and changing her anticoagulation from warfarin to rivaroxaban.

Takotsubo syndrome is characterized by transient regional left ventricular wall motion abnormalities and elevated troponin levels like those seen in classic myocardial infarction but without evidence of obstructive coronary artery disease. We present two uncommon cases of Takotsubo syndrome. In Case 1, a 64-year-old man presented with chronic obstructive pulmonary disease exacerbation who later developed chest pain and acute hypoxic respiratory failure. In Case 2, a 77-year-old woman with myasthenia gravis was admitted for acute hypoxic hypercapnic respiratory failure requiring mechanical ventilation following a myasthenic crisis. In both cases, serum high sensitivity troponin was elevated, electrocardiograph showed findings suggestive of infarction, and coronary angiogram did not show evidence of obstructive coronary artery disease. Echocardiogram in both patients revealed abnormal left ventricular wall motion, likely secondary to Takotsubo syndrome. Takotsubo syndrome is uncommon in the setting of chronic obstructive pulmonary disease exacerbation or myasthenic crisis, and proposed mechanisms for the disease include catecholamine surge, vasospasm of coronary arteries, and microvascular dysfunction. Takotsubo syndrome is reversible; thus, it is important to remove any trigger leading to catecholamine surge. Identification of such triggers and early diagnosis could help optimize pharmacotherapy.

Introduction: Children sustain dentoalveolar trauma and lose teeth at the same rate regardless of socioeconomic status; however, debate surrounds these rates in adults. It is known socioeconomic status plays a major role in access and treatment in health care. This study aims to clarify the role of socioeconomic status as a risk factor for dentoalveolar trauma in adults.

Methods: A single center retrospective chart review took place from January 2011 through December 2020 for patients requiring oral maxillofacial surgery consultation in the emergency department, due to either dentoalveolar trauma (Group 1) or other dental condition (Group 2). Demographic information including age, sex, race, marital status, employment status, and type of insurance were collected. Odds ratios were calculated by chi-square analysis with significance set at P < 0.05.

Results: Over the course of 10 years, 247 patients (53% female) required an oral maxillofacial surgery consultation, with 65 (26%) sustaining dentoalveolar trauma. Within this group, there were significantly more subjects who were Black, single, insured with Medicaid, unemployed, and 18 - 39 years old. In the nontraumatic control group, there were significantly more subjects who were White, married, insured with Medicare, and 40 - 59 years old.

Conclusions: Among those seen in the emergency department requiring an oral maxillofacial surgery consultation, those with dentoalveolar trauma have an increased likelihood of being single, Black, insured with Medicaid, unemployed, and 18 - 39 years old. Further research is needed to determine causality and the most critical/influential socioeconomic status factor in sustaining dentoalveolar trauma. Identifying these factors can assist in developing future community-based prevention and educational programs.

Background: Temporal artery biopsy is ordered when clinical symptoms and an elevated C-reactive protein values and/or erythrocyte sedimentation rates suggest giant cell arteritis. The percentage of temporal artery biopsies positive for giant cell arteritis is low. The objectives of our study were to analyze the diagnostic yield of temporal artery biopsies at an independent academic medical center and to develop a risk stratification model for triaging patients for possible temporal artery biopsy.

Methods: We retrospectively reviewed the electronic health records of all patients who underwent temporal artery biopsy in our institution from January 2010 through February 2020. We compared clinical symptoms and inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) values of patients whose specimens were positive for giant cell arteritis with those of patients with negative specimens. Statistical analysis included descriptive statistics, chi-square test, and multivariable logistic regression. A risk stratification tool, which included point assignments and measures of performance, was developed.

Results: Of 497 temporal artery biopsies for giant cell arteritis performed, 66 were positive and 431 were negative. Jaw/tongue claudication, elevated inflammatory marker values, and age were associated with a positive result. Using our risk stratification tool, 3.4% of low-risk patients, 14.5% of medium-risk patients, and 43.9% of high-risk patients were positive for giant cell arteritis.

Conclusions: Jaw/tongue claudication, age, and elevated inflammatory markers were associated with positive biopsy results. Our diagnostic yield was much lower when compared with a benchmark yield determined in a published systematic review. A risk stratification tool was developed based on age and the presence of independent risk factors.

Introduction: Our goal was to identify if the cases of influenza declined in the state of Wisconsin during the COVID-19 pandemic and, if so, what factors may have been responsible for this decline.

Methods: Influenza rates during the 2018-2019 and 2020-2021 seasons were compared using data from Respiratory Virus Surveillance Reports from the Wisconsin Department of Health Services and the Centers for Disease Control and Prevention.

Results: The number of cases and hospitalizations due to influenza decreased significantly during the 2020-2021 influenza season compared to the 2018-2019 season, although mortality rates increased during 2020-2021.

Discussion: Reducing the burden of illnesses, hospitalizations, and deaths due to influenza on the health care system is imperative. Taking the same preventive measures used during the COVID-19 pandemic, such as wearing masks, physical distancing, and frequent handwashing, should be advised, especially for the most vulnerable patient populations.

Paroxysmal hematoma of the fingers, or Achenbach syndrome, is a rare vascular disorder of benign course and unknown etiology. The clinical manifestations are sudden onset, paroxysmal spontaneous subcutaneous hematomas, and edema and pain in the fingers and hands. The clinical course is self-limited and does not leave permanent sequela. The diagnosis is clinical, and complementary studies are often unnecessary. We present the clinical case of a 69-year-old woman diagnosed with Achenbach syndrome in a primary care center in Colombia.