Ochsner Journal最新文献

Background: Upper extremity deep vein thrombosis accounts for a small percentage of all deep vein thrombosis cases, and internal jugular vein thrombosis is a rare subset within that category. Typically, internal jugular vein thrombosis is found in patients with predisposing risk factors such as infections, local trauma secondary to venous catheterization, intravenous drug use, and malignancy.

Case report: We describe the case of a patient with no typical risk factors for thrombus formation who developed internal jugular vein thrombosis following a deep tissue massage with a focus on the neck area. The patient developed right arm pain shortly after the massage, prompting her to present to the emergency department. Ultrasound revealed a nonocclusive thrombus in the right internal jugular vein. The patient was started on rivaroxaban, and her symptoms resolved.

Conclusion: Deep tissue massage is not a well-established cause of internal jugular vein thrombosis. This case emphasizes the importance of obtaining a thorough patient history to assess for uncommon traumatic causes of internal jugular vein thrombosis.

Background: Surgical manipulation in the sinonasal cavity may transiently increase airflow resistance in patients with obstructive sleep apnea (OSA), predisposing them to inspiratory collapse of the oropharynx and/or hypopharynx. We hypothesized that patients with OSA undergoing sinonasal surgery would have higher rates of unplanned postoperative admission and respiratory complications than patients without OSA.

Methods: In this retrospective cohort study, patients ≥18 years undergoing sinonasal surgery were compared to patients having oropharyngeal, laryngeal, otologic, rotator cuff, and inguinal hernia surgery between January 2013 and December 2020. Cohorts were defined by the presence or absence of a preoperative diagnosis of OSA. All outcome variables were measured based on unique patient encounters for surgery; the total number of surgeries for the overall patient population (n=17,373) was greater than the total number of patients (n=11,951).

Results: Study groups consisted of 4,575 sinonasal, 2,301 oropharyngeal, 1,231 laryngeal, 1,353 otologic, 434 rotator cuff, and 2,057 inguinal hernia surgical patients. Among patients undergoing sinonasal surgery, patients with OSA had more unplanned admissions than patients without OSA (risk ratio [RR] 3.12; 95% CI 2.07-4.70). In all surgery groups, postoperative supplemental oxygen therapy was required more often in patients with OSA. Patients with OSA had the greatest incidence of oxygen desaturation after oropharyngeal surgery (RR 1.95; 95% CI 1.34-2.85). Incidence of 30-day readmission did not differ between patients with and without OSA in any surgical group.

Conclusion: In this study, patients with OSA undergoing sinonasal surgery had a greater risk of unplanned hospital admission than patients without OSA, and patients with OSA undergoing oropharyngeal surgery had a greater risk of postoperative desaturation than patients without OSA. Patients with OSA undergoing any surgery had a greater incidence of supplemental oxygen requirement compared to patients without OSA.

Background: Cobalt, a ferromagnetic metal with a wide range of uses, has been known to cause systemic toxicity in humans that results in thyroid dysfunction, cardiomyopathy, hematologic abnormalities, and neuropathy. Arthroprosthetic cobaltism is a term used to describe systemic cobalt toxicity originating from cobalt-containing prosthetic joints. Ocular toxicity from elevated serum levels of cobalt is a rare phenomenon.

Case report: We describe a case of bilateral toxic optic neuropathy resulting from a damaged cobalt-containing shoulder prosthesis in a 76-year-old female. The patient exhibited classic clinical findings of toxic optic neuropathy, with painless insidious vision loss, dyschromatopsia, and bilateral central scotomas. Clinical testing showed a progressive reduction in the thickness of the peripapillary retinal nerve fiber layer and ganglion cell complex on optical coherence tomography. Magnetic resonance imaging of the brain and orbits without contrast were unrevealing. Extensive laboratory testing ruled out infectious, inflammatory, demyelinating, and nutritional causes of optic neuropathy. However, slightly elevated levels of serum cobalt were found. Considering the possibility of arthroprosthetic cobaltism, arthrocentesis from the patient's shoulder prosthesis was performed and revealed that the cobalt levels in her synovial fluid were 35 times higher than the normal limit. Replacement of the damaged prosthetic joint resulted in a decrease in the patient's serum cobalt levels and improvement of her vision.

Conclusion: While arthroprosthetic cobaltism from hip joints has been reported, to our knowledge, ours is the first case to prove a damaged shoulder prosthesis was the etiology. The patient's relatively low levels of serum cobalt and the lack of systemic features are also intriguing.

Background: Spinal epidural abscess, the collection of purulent material in the epidural space, can cause spinal cord compression and neurologic deficits, including paralysis. Management of spinal epidural abscess includes antibiotic therapy and surgical decompression. Limited evidence is available to guide the extent of surgical decompression necessary for symptom and abscess resolution. Treatment depends on a variety of factors including the size, orientation (ventral or dorsal), and location of the spinal epidural abscess, along with patient-specific factors such as neurologic status.

Case report: A 75-year-old male presented with increasing back pain and altered mental status 7 weeks after a motor vehicle crash. The patient had elevated inflammatory markers and was without focal neurologic deficit. Advanced imaging demonstrated a ventral abscess from C2 to T11, a dorsal abscess extending from T9 to T12, ventral and dorsal abscesses from L1 to the sacrum, and myelomalacia from T10 to T12. Limited decompression was performed in the form of T9 to L1 laminectomy for evacuation of the abscess, followed by irrigation with a pediatric Foley catheter. Imaging obtained after surgical intervention and intravenous antibiotic therapy demonstrated complete resolution of the abscesses. The patient's symptoms resolved, and he was doing well at postoperative follow-up.

Conclusion: Our case suggests that extensive decompression may not be necessary for treatment of a large spinal epidural abscess, thus preserving the structural integrity of the spine and potentially minimizing morbidity.

Background: Poland syndrome is an uncommon congenital condition marked by the absence of major chest muscles, typically on one side. Individuals with congenital abnormalities such as Poland syndrome are at increased risk for cancer.

Case report: A 53-year-old male with undiagnosed Poland syndrome initially presented with dysphagia. The patient had a 20 pack-year smoking history but had quit smoking at the time of presentation. Endoscopic ultrasound showed a large obstructing mass in the distal third of the esophagus, and computed tomography (CT) scan showed an esophageal mass and congenital absence of the left pectoralis major and pectoralis minor muscles. Positron emission tomography-CT (PET-CT) showed a hypermetabolic mass with no evidence of distant metastases. The patient was treated with radiation, chemotherapy, and distal esophagectomy. PET-CT obtained nearly a year postoperatively showed no esophageal mass but some reactive hilar and mediastinal lymph nodes. The patient is monitored annually via CT imaging for recurrent or metastatic disease.

Conclusion: While Poland syndrome has been associated with various malignancies, to our knowledge, the occurrence of esophageal adenocarcinoma in a patient with Poland syndrome has not been previously reported.

Background: Episodic assessment of sensitization patterns within a geographic area helps to monitor the role that specific aeroallergens may play in triggering allergic disease. An assessment of sensitization patterns in New Orleans, Louisiana, after Hurricane Katrina identified patterns of sensitization that were different from pre-Katrina studies. Whether the patterns had changed since the post-Katrina assessment was unknown. We therefore sought to evaluate the current sensitization patterns in the greater New Orleans area.

Methods: Seven hundred seventy-six unique patients with at least 1 sensitization identified on a standard 58-allergen skin test panel that includes 24 fungal extracts were evaluated for prevalence, unique sensitization within an allergen group, and patterns of sensitization across patients.

Results: Expected results included a high prevalence of sensitization to house dust mites, grass pollen, and spores of Alternaria and Aspergillus. Surprising results included a high prevalence of Acremonium sensitization and very low sensitization to other fungi. Sensitization patterns for patients did not cluster within phylogenetic patterns for most of the pollen and fungal extracts.

Conclusion: Ongoing refinement of extracts used in skin prick testing will help to monitor changing patterns of sensitization. This monitoring is especially important as climate change, changes in plant cultivation, and urbanization alter ecosystems.

Background: A renal arteriovenous fistula (RAVF) is an abnormal connection between the artery and vein of the kidney and can result from idiopathic, congenital, or traumatic causes. In the general population, this pathology is rare and has the potential to be life-threatening. The incidence in pregnancy is even rarer.

Case report: A pregnant 33-year-old gravida 5, para 4 patient presented with gross hematuria and passage of clots and was diagnosed with a right renal lower pole arteriovenous fistula at 36 weeks, 6 days' gestation. The patient developed gestational hypertension but did not demonstrate severe features of preeclampsia She underwent labor induction, uncomplicated spontaneous vaginal delivery, and subsequent endovascular embolization of the fistula. Hematuria and hypertension resolved postembolization.

Conclusion: Because RAVF presents with nonspecific symptoms that mimic other causes of hematuria and hypertension in pregnancy, this rare vascular anomaly poses challenges in diagnosis and management in pregnant patients. Our case was also challenging because of the late-stage pregnancy diagnosis. The case highlights the challenges of diagnosing and managing RAVF during pregnancy and underscores the importance of a multidisciplinary approach.

Background: Early identification and antimicrobial susceptibility testing (AST) of bloodstream pathogens are important for promptly determining the appropriate therapy. Currently, positive blood culture results (identification and AST) are reported in 2 to 4 days. The T2Resistance (T2R) Panel (T2 Biosystems, Inc) uses DNA amplification with magnetic resonance from 3 mL of whole blood for direct detection of 13 antibiotic resistance genes: bla _KPC, bla _NDM, bla _VIM, bla _IMP, bla _OXA-48, bla _CTX-M-14/15, AmpC bla _CMY/DHA, vanA/B, and mecA/C. We compared the accuracy of T2R testing to AST for positive blood cultures.

Methods: This investigator-sponsored, single-center study prospectively enrolled 802 patients with a standard of care blood culture. Five hundred forty-seven patients had adequate blood for culture and T2R testing. Blood cultures with positive isolates were identified, and AST was performed. Blood samples with positive blood cultures were tested with the T2R Panel.

Results: Blood cultures were positive for 58/547 (10.6%) patients. Contaminants (18/547 [3.3%]) were excluded. T2R testing results (n=31) showed 2 bla _CTX-M-14/15 genes with 100% sensitivity; the remaining gram-negative resistance genes were not detected, so sensitivity could not accurately be determined. Specificity was 100% for the 16 gram-negative bacilli. Three enterococci and 2 Staphylococcus aureus showed 100% sensitivity/specificity. However, 10 coagulase-negative staphylococci showed 17% sensitivity/100% specificity. Antibiotic resistance genes identified were 2 bla _CTX-M-14/15, 2 mecA/C, and 1 vanA/B. T2R testing results were obtained in an average of 7 hours.

Conclusion: T2R testing is highly specific (100%) for the 13 antibiotic resistance genes on the panel. Sensitivity was 100% for the genes detected but was low (17%) for coagulase-negative staphylococci. T2R testing has the potential to diagnose certain antibiotic resistance genes from bacterial bloodstream infections in hours vs the days required for a positive blood culture with AST. Additional studies that include larger numbers of samples with antimicrobial resistance genes are needed.