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

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: 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: 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: Spontaneous splenic hemorrhage is a rare initial presentation of malignancy. The objective of this case report is to elucidate the complexities of early diagnosis of splenic metastases and the complications associated with advanced malignancies of the spleen. It is also a reminder to consider splenic metastases and hemorrhage in the differential diagnosis for nonspecific presentations, such as acute abdomen, in adults.

Case presentation: A 58-year-old female with 1 month of vague, worsening systemic symptoms and computed tomography findings suspicious for a subcapsular splenic hematoma was found to have splenic rupture. After undergoing emergency laparotomy with splenectomy, pathological samples revealed metastatic poorly differentiated adenocarcinoma of unknown origin. During a subsequent admission, she was found to be hemodynamically unstable, deemed a poor candidate for inpatient chemotherapy, and elected to proceed with comfort measures after which she died from multiorgan failure 3 weeks after initial presentation.

Discussion: Spontaneous (nontraumatic) splenic hemorrhage secondary to metastasis should remain a differential diagnosis for patients with acute abdomen and associated risk factors for primary malignancies.

Introduction: Electronic cigarette (e-cigarette) use is prevalent among young adults, yet cessation treatment options are limited and underutilized.

Methods: Wisconsin residents aged 18 to 24 who had vaped nicotine in the past month (N = 480) completed an online survey assessing vaping initiation, past quit experiences, future quit intentions, and treatment knowledge and preferences. The survey also assessed perceived physical and mental health harms of vaping nicotine and other products (eg, cannabis, cannabidiol).

Results: Most young adults had made a prior e-cigarette quit attempt, commonly motivated by concerns about addiction, cost, and health problems. Though 80% want support to quit, preferred methods of support were highly variable. The same methods (eg, medication, friends/family, health care provider, therapist) that were most endorsed as the form of support young adults were most likely to use were also among the most endorsed forms of support that young adults would not want to use. Nearly 40% of participants reported vaping cannabis and perceived vaping cannabis as significantly less harmful than vaping nicotine or tobacco for physical and mental health.

Conclusions: Vaping cessation resources that are responsive to young adults' needs and preferences are needed. The high variability in treatment preferences suggests that multiple strategies need to be offered; there is no one-size-fits-all approach. Cannabis vaping is prevalent, and an important area for future research is to examine the impact of cannabis vaping on nicotine vaping dependence, cessation, and treatment use. Strategies to reach, motivate, and engage young adults in e-cigarette cessation and cessation treatment should highlight their concerns about addiction, costs, health harms, and desired treatment options.

Introduction: Crusted scabies (Norwegian scabies) is a rare and severe presentation of skin infestation caused by the mite Sarcoptes scabiei in patients with compromised cellular immunity. Kidney transplant patients are maintained on immunosuppressive agents, which induce impaired T cell immune response that can lead to increased risk of crusted scabies.

Case presentation: We report a case of crusted scabies in a kidney transplant patient who presented with a diffuse skin rash. Diagnosis was delayed and misdiagnosed initially, with subsequent skin biopsy leading to an accurate diagnosis and complete recovery with definitive treatment.

Discussion: Unlike classical scabies, crusted scabies can occur in an atypical pattern that can be misdiagnosed as common skin lesions, and a skin biopsy is crucial to obtain an accurate diagnosis to receive definitive treatment.

Conclusions: Transplant recipients are at an increased risk of severe parasitic infections such as crusted scabies due to drug-induced impairment of their cell-mediated immune response, thus maintaining a high index of suspicion for crusted scabies as a differential diagnosis in transplant kidney patients is extremely important. Early histological diagnosis of crusted scabies is essential to prevent delayed or missed diagnosis and avoid unnecessary serious complications. The combination of an oral ivermectin and topical permethrin regimen resulted in excellent clinical outcomes in our case and is recommended as the standard treatment.