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Human parvovirus B19 infection can cause erythema infectiosum (EI) and several other clinical presentations. Central nervous system (CNS) involvement is rare, and only a few reports of encephalitis and aseptic meningitis have been published. Here, we describe 2 cases of B19 infection in a family presenting different clinical features. A 30 year old female with a 7-day history of headache, malaise, myalgias, joint pains, and rash was seen. Physical examination revealed a maculopapular rash on the patient's body, and arthritis of the hands. She completely recovered in 1 week. Two days before, her 6 year old son had been admitted to a clinic with a 1-day history of fever, headache, abdominal pain and vomiting. On admission, he was alert, and physical examination revealed neck stiffness, Kerning and Brudzinski signs, and a petechial rash on his trunk and extremities. Cerebrospinal fluid analysis was normal. He completely recovered in 5 days. Acute and convalescent sera of both patients were positive for specific IgM antibody to B19. Human parvovirus B19 should be considered in the differential diagnosis of aseptic meningitis, particularly during outbreaks of erythema infectiosum. The disease may mimic meningococcemia and bacterial meningitis.
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PMID:Two family members with a syndrome of headache and rash caused by human parvovirus B19. 1129 Mar 13

Typical urticarial lesions are transient cutaneous swellings of sudden onset, often itchy, persisting for less than 24 hours and resolving to leave normal appearing skin. Angioedema lesions are similar subcutaneous lesions. Atypical urticarias persist for longer than 24 hours, may be painful and bruised in appearance and accompanied with severe systemic symptoms. Conditions where prolonged weals are present include delayed pressure urticaria and urticarial vasculitis. These conditions do not respond well to antihistamine therapy. In delayed pressure urticaria, weals appear after a delay of hours at sites of sustained pressure on the skin and occur in association with ordinary chronic 'idiopathic' urticaria. Weals of urticarial vasculitis show histological features of venulitis, and can be accompanied by arthralgia and abdominal pain. Rarely, the condition is due to infective or autoimmune disease. Urticarial diseases, sometimes with features of urticarial vasculitis, and with associated systemic features include Schnitzler's Syndrome, Still's disease and Muckle-Wells syndrome. The latter syndrome is linked with chromosome 1q44, as is autosomal dominant cold urticaria, an unusual physical urticaria. Persistent cholinergic erythema, a variant of cholinergic urticaria, has been mistaken for a drug eruption or cutaneous mastocytosis. Rarely, food and exercise induced urticaria and anaphylaxis occur when exercise follows a specific food or any meal within a few hours. The early stages of inflammatory disease may be mistaken for urticaria and angioedema, but lesions usually persist for longer than 48 hours and are accompanied by epidermal changes.
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PMID:Unusual urticarias. 1177 Jul 21

A 44-year-old female British travel guide suddenly had fever, nausea, vomiting, and diarrhea develop during her stay in South India. Four days later she was transported to our hospital. At admission she had a high temperature, impaired respiration, and abdominal pain. Clinical examination revealed bilateral pleural effusion, hepatomegaly, and ascites. Two days later the patient showed a generalized macular rash with a conspicuous sparing of small islands of normal skin. Hemorrhagic erythema on the palms and soles as well as focal petechiae on the hard palate and scleral and conjunctival bleeding were also observed. Hypotension and renal insufficiency developed 1 week after the illness started. Laboratory investigations revealed highly elevated levels of hepatic enzymes, severe hemolytic anemia, decreased platelet counts, and abnormal coagulation values. The presumptive clinical diagnosis of dengue hemorrhagic fever was supported by serologic testing that disclosed sustained high titers of hemagglutination inhibition antibodies. Symptomatic therapy with substitution of volume and albumin, blood transfusions, and administration of antipyretics resulted in complete recovery within 6 weeks.
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PMID:Dengue hemorrhagic fever in a British travel guide. 1186 82

Atopic dermatitis is a typical chronic inflammatory skin disease that usually occurs in individuals with a personal or family history of atopy. Children with atopic dermatitis frequently present IgE-mediated food sensitization, the most commonly involved foods being egg and cow's milk. However, controversy currently surrounds whether food allergy is an etiological factor in atopic dermatitis or whether it is simply an associated factor, accompanying this disease as one more expression of the patient's atopic predisposition. Approximately 40 % of neonates and small children with moderate-to-severe atopic dermatitis present food allergy confirmed by double-blind provocation tests but this allergy does not seem to be the cause of dermatitis since in many cases onset occurs before the food responsible for allergic sensitization is introduced into the newborn's diet.Studies of double-blind provocation tests with food in patients with atopic dermatitis demonstrate mainly immediate reactions compatible with an IgE-mediated allergy. These reactions occur between 5 minutes and 2 hours and present mainly cutaneous symptoms (pruritus, erythema, morbilliform exanthema, wheals) and to a lesser extent, digestive manifestations (nausea, vomiting, abdominal pain, diarrhea), as well as respiratory symptoms (wheezing, nasal congestion, sneezing, coughing). However, these reactions do not indicate the development of dermatitis.Some authors believe that responses to the food in provocation tests may also be delayed, appearing mainly in the following 48 hours, and clinically manifested as exacerbation of dermatitis. However, delayed symptoms are difficult to diagnose and attributing these symptoms to a particular foodstuff may not be possible.Delayed reactions have been attributed to a non-IgE-mediated immunological mechanism and patch tests with food have been proposed for their diagnosis. In our experience and in that of other authors, the results of patch tests with cow's milk do not seem very specific and could be due, at least in part, to the irritant effect of these patches on the reactive skin of children with atopic dermatitis.The involvement of foods in atopic dermatitis will always be difficult to demonstrate given that an exclusion diet is not usually required for its resolution. Food is just one among several possible exacerbating factors and consequently identification of its precise role in the course of the disease is difficult. Further double-blind prospective studies are required to demonstrate the effectiveness of exclusion diets in the treatment of atopic dermatitis.Apart from the controversy surrounding the etiological role of foods, the most important point in atopic dermatitis is to understand that the child is atopic, that is, predisposed to developing sensitivity to environmental allergens; in the first few years of life to foods and subsequently to aeroallergens. Consequently, possible allergic sensitization to foods should be evaluated in children with atopic dermatitis to avoid allergic reactions and to prevent the possible development of allergic respiratory disease later in life.
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PMID:[Etiologic implication of foods in atopic dermatitis: evidence against]. 1198 42

A 37-year-old woman presented with increasing abdominal pain and jaundice. Six weeks before admission, she developed persistent diarrhea and jaundice of the skin. She also bruised easily, and her gums bled. In the subsequent weeks, her appetite decreased, she was fatigued, and she had nausea, vomiting, and abdominal distension. She had a history of drinking 1 quart of vodka every day for 20 years, with brief periods of abstinence; she stopped consuming alcohol 11 days before admission because it no longer provided symptomatic relief. Her past medical history was also notable for depression, including a suicide attempt 4 years earlier. She did not smoke, use illicit drugs, or have unprotected sexual intercourse. She had received no blood transfusions and had not traveled recently. She took no medications, except for occasional ibuprofen. On physical examination, she was thin and deeply jaundiced, and she trembled and responded slowly to questions. She was afebrile but tachypneic, and she had orthostatic hypotension. Her HEENT examination was notable for scleral and sublingual icterus, as well as crusted blood on her gums and teeth. The jugular veins were flat. The cardiac examination revealed tachycardia (heart rate, 103 beats per minute) without murmurs, rubs, or gallops. The abdomen was nontender and protuberant, with hypoactive bowel sounds; the spleen was not palpable, and there was no fluid wave or caput medusae. The liver percussed to 18 cm, with a smooth edge extending 10 cm below the costal margin. She had cutaneous telangiectases on her chest and bilateral palmar erythema. There was no peripheral edema. The neurologic examination was notable for asterixis. Her stool was guaiac positive. Laboratory studies revealed the following values: hematocrit, 21.2%; white blood cells, 17,310/mm(3); ammonia, 42 micromol/L; serum creatinine, 3.9 mg/dL; serum urea nitrogen, 70 mg/dL; albumin, 2.1 g/dL; total bilirubin, 26.8 mg/dL; alanine aminotransferase, 14 U/L; aspartate aminotransferase, 77 U/L; alkaline phosphatase, 138 U/L; prothrombin time, 103 seconds (international normalized ratio, 10.6); and urinary sodium, <5 mg/dL. Urinalysis revealed an elevated specific gravity and numerous muddy granular casts. Hepatitis A, B, and C serologies were negative. On abdominal ultrasound examination, there was no ascites, and the liver was echogenic. The portal and hepatic veins were patent, and the hepatic arteries were normal. The spleen measured 14 cm. What is the diagnosis?
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PMID:Cases from the Osler Medical Service at Johns Hopkins University. 1258 38

Functioning gastroenteropancreatic endocrine tumors produce and secrete different substances that can be detected in the plasma and cause hormone-related syndromes. Symptoms such as diarrhea associated either with typical skin rash or peptic ulcer disease may be suggestive of the presence of intestinal carcinoid or gastrinoma. Other clinical manifestations such as severe hypoglycemia, diabetes, necrolytic erythema and gallbladder disease may also indicate an endocrine tumor. Sometimes, patients present no, or just vague, symptoms such as dyspepsia or abdominal pain and nonfunctioning endocrine tumors in these patients can be found incidentally during diagnostic imaging procedures or at operation. Usually, the diagnosis is established by the measurement of the specific tumor marker in the plasma and, sometimes, in the urine. In some cases, normal basal hormone levels are observed even in the presence of typical symptoms. Therefore, stimulatory tests such as the secretin test for gastrinomas are required to establish the diagnosis. General markers for the diagnosis of gastroenteropancreatic endocrine tumors are also available. Among these, chromogranin A has proved to be of great value for diagnosing nonfunctioning tumors and is considered the most sensitive general marker. The availability of both specific and general markers as well as stimulatory tests may enable the clinician to diagnose functioning gastroenteropancreatic endocrine tumors at an early stage and to recognize nonfunctioning tumors.
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PMID:Biochemical diagnosis of gastroenteropancreatic endocrine tumors. 1271 97

Identifying children with acute pharyngitis caused by group A beta-hemolytic Streptococcus (GABHS) is an important task for pediatricians. This study examined the value of certain clinical symptoms and signs in predicting a positive culture result. A total of 442 children who presented at the outpatient department with pharyngeal erythema were enrolled. The clinical features of patients with positive throat cultures for GABHS were compared to those with negative culture results. Throat cultures were positive for GABHS in 120 (27%) patients. Patients aged between 5 and 10 years had a higher prevalence of GABHS pharyngitis. Significant differences between the groups with and without GABHS pharyngitis were noted for the presence of sore throat (p < 0.001), tonsillar swelling (p < 0.001), anterior cervical adenopathy (p = 0.004), and scarlatiniform rash (p < 0.001), but not for the presence of fever, cough, rhinorrhea, abdominal pain, headache, tonsillar exudate, or palatal petechiae. Despite these strong associations, none of these symptoms or signs had both high sensitivity and specificity, and the positive predictive values of these individual findings were never greater than 50%. The results indicate that diagnosis based on clinical grounds alone is unreliable although there are certain individual symptoms and signs that are associated with GABHS pharyngitis. These symptoms and signs may be helpful in modifying estimates of probability of infection with GABHS. Throat cultures in suspected patients remain mandatory.
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PMID:Predictive value of clinical features in differentiating group A beta-hemolytic streptococcal pharyngitis in children. 1274 28

A five-year-old boy presented to his family physician with painless swelling of both lips. One year later he developed abdominal pain, nonbloody diarrhea, weight loss and joint pains. Colonoscopic examination demonstrated patchy erythema, friability and multiple aph-thous ulcers consistent with the appearance of Crohn's colitis, and treatment with prednisone was initiated. Colonic biopsies displayed a chronic inflammatory cell infiltrate, focal cryptitis and fissure formation. The patient's lip swelling relapsed on multiple occasions when steroids were tapered, despite minimal intestinal symptoms of Crohn's disease. The objective of the present report is to alert physicians to this unusual presentation of Crohn's disease and that cheilitis may run a protracted course.
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PMID:Crohn's disease and cheilitis. 1291 19

Transplant recipients are at higher risk for infection and malignancy due to therapies aimed at preventing rejection. Early detection and successful treatment of such complications is of pivotal importance for both patient and graft survival. In this study, we evaluated findings of 91 colonoscopies and colonic histopathologic findings in recipients who presented with lower gastrointestinal system complaints between January 1996 and January 2003. The study group included 79 renal and liver transplant patients. The indications for colonoscopy were diarrhea (n = 58), abdominal pain (n = 5), hematochezia (n = 19), unexplained anemia (n = 5), thickening of a colonic segment detected on computerized tomography (n = 2), screening for lymphoma (n = 1), and Kaposi's sarcoma (n = 1). During the procedures, all suspicious lesions were biopsied and specimens of normal-appearing mucosa collected when deemed necessary in relation to the clinical complaints. The endoscopic findings were classified as follows: 0 = "normal," with clear visualization of the vascular network and normal-appearing mucosa; 1 = "erythema", with tissues showing erythema, edema, hyperemia, and loss of normal vascular network; 2 = "ulcerative," with tissues exhibiting ulceration and fragility; and 3 = "coincidental findings," such as polyp or angiodysplasia. Colonoscopic and/or histopathologic abnormalities were detected in 44.5% of the 91 colonoscopy procedures. The results indicate that colonoscopy is a valuable diagnostic tool for evaluation of transplant recipients with lower gastrointestinal complaints. After an initial workup colonoscopy is important to establish an accurate diagnosis.
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PMID:Colonoscopy is a useful diagnostic tool for transplant recipients with lower abdominal symptoms. 1501 43

Graft-versus-host disease(GVHD) colitis after allogeneic bone marrow transplantation or peripheral blood stem cell transplantation was often accompanied with upper gastro-intestinal symptoms such as upper abdominal pain. We investigated 7 cases of gastro-duodenal lesions with GVHD colitis. Endoscopic features of gastric lesions with GVHD were turbidity(100%), erythema(100%), erosions(85.7%), easy bleeding of mucosa(71.4%) and duodenal involvement(71.4%), histological findings of those were infiltration of inflammatory cells(100%), dilatation of capillaries(100%), hemorrhage(71.4%), stromal edema(85.7%), degenerated glands and apoptotic bodies(100%). Those findings resembled with endoscopic and histological features of GVHD colitis, so we diagnosed those lesions as GVHD gastro-duodenitis. Clinically GVHD colitis with gastro-duodenitis was severe compared with colitis without gastro-duodenitis.
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PMID:[GVHD gastro-duodenitis]. 1503


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