WMJ : official publication of the State Medical Society of Wisconsin最新文献

Introduction: Multiple myeloma is a hematologic malignancy characterized by clonal proliferation of plasma cells. It is rare in young adults and may present in atypical forms, complicating timely diagnosis.

Case presentation: Patient 1 was a 23-year-old female who presented with subacute onset of leg pain, progressive weakness, and urinary retention. Lumbar spine magnetic resonance imaging (MRI) revealed a sacral mass causing cauda equina syndrome. Biopsy confirmed the diagnosis of plasmacytoma. At discharge, she exhibited gait abnormalities, neuropathic pain, and persistent urinary retention. She functioned at a modified independent level, using a manual wheelchair for mobility and performing intermittent self-catheterization. Patient 2 was a 28-year-old female who presented with acute onset of leg pain, weakness, and urinary retention. MRI of the spine revealed an epidural mass extending from T1 to T11, resulting in spinal cord compression. She underwent thoracolumbosacral laminectomies, and biopsy confirmed plasmacytoma. At discharge, she had motor complete paraplegia, neuropathic pain, and urinary retention managed with intermittent self-catheterization. She was modified independent, using a manual wheelchair for mobility.

Discussion: Despite advances in diagnosis and treatment, multiple myeloma remains a complex disease that poses diagnostic and therapeutic challenges. These cases emphasize the importance of standardized treatment protocols in management of spinal cord compressive plasmacytoma.

Conclusions: Early diagnosis, coordinated multidisciplinary care, and comprehensive rehabilitation are essential for improved management and outcomes.

Introduction: Surgical site infection (SSI) after lower extremity procedures is a persistent source of significant morbidity for vascular surgery patients. Frailty scores capture risk factors for postoperative outcomes associated with SSI. This study aimed to retrospectively evaluate the association between SSI and a validated measure of frailty, the Vascular Quality Initiative-Risk Analysis Index (VQI-RAI).

Methods: A retrospective review was performed of patients who underwent open lower extremity revascularization at a single independent academic medical center from January 1, 2007, through December 31, 2019. Frailty score was calculated using VQI-RAI, a composite score based on patient demographic and clinical variables. VQI-RAI scores were compared between patients who developed SSI and those who did not. SSI outcomes were compared between patients defined as frail (VQI-RAI ≥ 35) and not frail (VQI-RAI <  35).

Results: The study population comprised 1130 patients. The overall SSI rate was 8.1%. The median VQI-RAI score was 29 for patients with SSI and 28 for patients without SSI (P = 0.4). No significant association was observed between VQI-RAI and SSI or between patients defined as frail and not frail. Of the individual components of the VQI-RAI score, only body mass index was significantly associated with SSI (P <  .0001).

Conclusions: VQI-RAI frailty score was not associated with risk of SSI in our study population; however, body mass index was significantly associated with SSI. Obesity poses a high risk of SSI, whereas frailty alone may not be associated with an increased risk of SSI.

Introduction: PAPASH spectrum syndrome is a rare autoinflammatory condition encompassing psoriatic arthritis, pyoderma gangrenosum, acne, and hidradenitis suppurativa. Despite the individual prevalence of these conditions, their concurrent manifestation poses a diagnostic challenge that requires high clinical suspicion. This case illustrates the consequences of delayed recognition of this condition and underscores the crucial need for a multidisciplinary approach to optimize management.

Case presentation: We report the case of a 34-year-old African American man with a prior diagnosis of rheumatoid arthritis who developed migratory arthritis, pustular acne, and hidradenitis suppurativa. Despite suggestive clinical features, delayed access to biologic therapy contributed to disease progression and resulted in hospitalization. After extensive genetic and clinical evaluation, he was diagnosed with PAPASH syndrome.

Discussion: PAPASH syndrome is linked to mutations in the PSTPIP1 gene and the overexpression of specific chemokines, which dysregulate interleukin-1 signaling and cause persistent inflammation. Although tumor necrosis factor-α inhibitors remain first-line therapy, limited literature exists on comprehensive treatment strategies, and further research is needed. This case demonstrates how ongoing diagnostic ambiguity and the absence of clear treatment guidelines can complicate the management of PAPASH syndrome.

Conclusions: This case emphasizes the importance of prompt identification of PAPASH syndrome in patients presenting with overlapping inflammatory conditions and highlights the need for clinical vigilance, timely initiation of biologic agents, and coordinated care to improve outcomes in this rare but serious disorder.

Introduction: Nearly 90% of persons living with dementia experience behavioral and psychological symptoms of dementia (BPSD). Primary care clinicians may require more training to address these symptoms.

Methods: We surveyed Wisconsin primary care clinicians to assess their current approaches, needs, and interest in future educational interventions related to managing BPSD.

Results: Over 60% of clinicians reported lack of ability or training in managing BPSD, while over 75% expressed interest in educational interventions that included discussion of treatment algorithms or virtual didactics.

Discussion: Given the apparent widespread demand and need for educational interventions on BPSD for primary care clinicians, future studies are needed to assess the efficacy of such interventions in improving clinicians' preparedness to care for patients with BPSD.

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug hypersensitivity reaction.

Case presentation: A 59-year-old male with a history of stage IV chronic kidney disease, polycystic kidney disease, hypertension, and hyperuricemia on allopurinol presented to the emergency department directly from an outpatient nephrology appointment with concern for severe DRESS syndrome with acute-on-chronic kidney failure, liver failure, and pancreatic involvement.

Discussion: The existing literature on the course of DRESS syndrome in patients with preexisting kidney dysfunction is limited.

Conclusions: We report a case of DRESS syndrome in a patient with chronic kidney disease who presented after initiating allopurinol for hyperuricemia. Care should be taken to quickly identify DRESS, stop the offending agent, and initiate systemic corticosteroids to prevent long-term morbidity and mortality. Furthermore, patient counseling should emphasize follow-up to identify and treat potential long-term sequelae, including thyroiditis and cardiac disease.

Introduction: Xylazine association with fentanyl poses an emerging threat to public health. We conducted a retrospective study to analyze xylazine-related fatal overdoses in Milwaukee County, Wisconsin from 2019 through 2023.

Methods: Using medical examiner data, we compared fatal xylazine overdoses (n = 243) with fentanyl overdoses without xylazine (n = 1946). Demographic, polysubstance, temporal, and geographic characteristics were analyzed.

Results: Xylazine fatalities have surged since 2019, exhibiting different polysubstance profiles than fentanyl overdoses without xylazine. We identified 8 geospatial clusters contributing to 64% of xylazine overdoses.

Discussion: We encourage localized interventions to address the xylazine-fentanyl syndemic. Policy measures such as Wisconsin Act 217, which legalized xylazine testing materials, promote evidence-based harm reduction tools to mitigate the risks associated with xylazine's increasing prevalence in the Midwest.

Introduction: Rhabdomyolysis is a common but complex medical condition that typically presents with asymptomatic muscle enzyme elevation and follows a benign course. Cases of rhabdomyolysis associated with mononeuropathy, mononeuropathy multiplex, and peripheral neuropathy are uncommon.

Case presentation: We present the case of a 28-year-old man with focal weakness of the left leg that developed after he fell to the floor and was immobilized on his left side for a prolonged length of time (ie, 6-8 hours). Further evaluation revealed rhabdomyolysis associated with unilateral sciatic neuropathy but no evidence of compartment syndrome.

Discussion: Severe cases of rhabdomyolysis, with or without compartment syndrome, can result in compressive neuropathies. We provide a detailed anatomic description of the sciatic nerve and review its associated clinical syndromes.

Conclusions: In cases of rhabdomyolysis associated with focal limb weakness that follows a myotomal distribution, compressive mononeuropathy should be considered in the differential diagnosis.

Introduction: Carpal tunnel syndrome is the most common peripheral entrapment neuropathy, often associated with structural and functional changes in the median nerve and thenar muscles. Neuromuscular ultrasound is increasingly used to complement nerve conduction studies in carpal tunnel syndrome evaluation, yet its potential for assessing muscle integrity remains underexplored. This pilot study examined correlations between median nerve cross-sectional area (MNCSA) and abductor pollicis brevis (APB) muscle characteristics on ultrasound.

Methods: Veterans were enrolled at the Clement J. Zablocki VA Medical Center from July to November 2023. Inclusion criteria were age ≥18 years, carpal tunnel syndrome confirmed by nerve conduction studies, and planned carpal tunnel release. Exclusion criteria included prior carpal tunnel release, upper limb trauma or surgery, hand deformities, peripheral neuropathy, and diabetes. Ultrasound images of the median nerve and APB were obtained. Using Adobe Photoshop, APB echogenicity (grayscale value, black/white ratio) and cross-sectional area in longitudinal and transverse views were calculated and analyzed for correlation with MNCSA.

Results: Ten participants were included. Strong negative correlations were observed between MNCSA and APB cross-sectional area in longitudinal and transverse views (Pearson coefficients, -0.51 and -0.50, respectively). Weak to moderate positive associations were found between MNCSA and APB echogenicity values (0.32 and 0.24, respectively).

Conclusions: APB characteristics on ultrasound, including echogenicity and cross-sectional area, may serve as complementary indicators of carpal tunnel syndrome. Future research should include larger samples, control groups, and assessment of correlations with carpal tunnel syndrome severity on nerve conduction studies.