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In a 6-month period, three patients aged 5-11 years were transferred to our tertiary care children's hospital for management of severe complications following adenotonsillectomy. The first patient presented with headaches and lethargy and was found to have a sagittal sinus thrombosis from severe dehydration. The second patient was admitted immediately following an intra-operative oral cavity fire due to electrocautery malfunction. She suffered partial-thickness burns to the buccal mucosa, palate, and lips. The third patient was admitted with torticollis. Grisel's syndrome was initially suspected, but a thorough work up resulted in the diagnosis of a conversion disorder. These cases comprise an interesting cohort of three little-known complications of adenotonsillectomy.
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PMID:Three extraordinary complications of adenotonsillectomy. 1628 Jan 74

Cerebral venous sinus thrombosis (CVST) is a rare and potentially deadly condition. Common etiologies include hypercoagulable diseases, low flow states, dehydration, adjacent infectious processes, oral contraceptives, hormonal replacement therapy, pregnancy, and puerperium. Symptoms include nausea, seizures, severe focal neurological deficits, coma, and headache (the most common presenting symptom). Anticoagulation is the mainstay of treatment for CVST. Transvenous clot lysis can be performed using injected thrombolytic agents and specialized catheters for clot retrieval.
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PMID:Cerebral venous sinus thrombosis. 1637 32

Intravenous immunoglobulin (IVIg) is administered for various indications and generally considered a safe therapy. Most of the adverse effects (AEs) associated with IVIg administration are mild and transient. The immediate AEs include headache, flushing, malaise, chest tightness, fever, chills, myalgia, fatigue, dyspnea, back pain, nausea, vomiting, diarrhea, blood pressure changes, tachycardia, and anaphylactic reactions, especially in IgA-deficient patients. Late AEs are rare and include acute renal failure, thromboembolic events, aseptic meningitis, neutropenia, and autoimmune hemolytic anemia, skin reactions, and rare events of arthritis. Pseudohyponatremia following IVIg is important to be recognized. Renal failure, usually oliguric and transient, occurs mostly on using sucrose-containing products owing to osmotic injury. Among high-risk patients who have a previous renal disease, dehydration, diabetes mellitus, advanced age, hypertension, hyperviscosity, or are treated by other nephrotoxic medications, administration of a non-sucrose-containing IVIg product after accomplishing hydration, in a low concentration and a slow infusion rate while supervising urine output and kidney function, is recommended. Thromboembolic complications occur because of hyperviscosity especially in patients having risk factors including advanced age, previous thromboembolic diseases, being bedridden, diabetes mellitus, hypertension, dyslipidemia, or those receiving high-dose IVIg in a rapid infusion rate. Immediate AEs can be treated by the slowing or temporary discontinuation of the infusion and symptomatic therapy with analgesics, nonsteroidal anti-inflammatory drugs, antihistamines, and glucocorticoids in more severe reactions. Slow infusion rate of low concentration of IVIg products and hydration, especially in high-risk patients, may prevent renal failure, thromboembolic events, and aseptic meningitis.
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PMID:Intravenous immunoglobulin: adverse effects and safe administration. 1639 92

A total of 1,885 blood and stool samples of four main protozoan parasitic infections were retrospectively reviewed from January, 2000 to April, 2004. Eleven of the 1,350 stool samples were shown positive for Cryptosporidium and Giardia infections; one of the 5 cases was clinically diagnosed as gastrointestinal cryptosporidiosis, while 6 cases were giardiasis. In patients with giardiasis, children were among the high-risk groups, making up 66.7% of these patients. The common presenting signs and symptoms were: diarrhea (83.3%), loss of appetite (83.3%), lethargy (83.3%), fever (66.7%), nausea/vomiting (50.0%), abdominal pain (16.7%), dehydration (16.7%) and rigor and chills (16.7%). Metronidazole was the drug of choice and was given to all symptomatic patients (83.3%). For the blood samples, 28 of the 92 peripheral smears for Plasmodium spp infection were diagnosed as malaria. The age range was from 4 to 57, with a median of 32.5 years. The sex ratio (M:F) was 3.6:1, while the age group of 30-44 years was the most commonly affected in both sexes. The majority of patients were foreigners (60.7%) and non-professional (39%). Plasmodium vivax (71%) infection was the most common pathogen found in these patients, along with a history of traveling to an endemic area of malaria (31%). The predominant presenting signs and symptoms were: fever (27%), rigor and chills (24%), nausea/vomiting (15%) and headache (8%). Chloroquine and primaquine was the most common anti-malarial regimen used (78.6%) in these patients. The seroprevalence of toxoplasmosis in different groups was 258/443 (58%): seropositive for IgG 143 (32.3%); IgM 67 (15%); and IgG + IgM 48 (10.8%). The age range was from 1 to 85, with a mean of 34 (+/- SD 16.6) years. The predominant age group was 21 to 40 years (126; 28.4%). The sex ratio (M:F) was 1.2:1. Subjects were predominantly male (142; 32%) and the Malay (117; 26.4%). Of these, 32 cases were clinically diagnosed with ocular toxoplasmosis. The range of age was from 10 to 56 years with a mean of 30.5 (+/- SD 12.05) years. The sex ratio (M:F) was 1:1.7. The majority were in the age group of 21 to 40 years, female (20; 62.5%), and Malay (17; 53%). They were also single (16; 50%), unemployed (12; 37%), and resided outside Kuala Lumpur (21; 65.6%). The more common clinical presentations were blurring of vision (25; 78%), floaters (10; 31%) and pain in the eye (7; 22%). We found that funduscopic examination (100%) and seropositivity for anti-Toxoplasma antibodies (93.7%) were the main reasons for investigation. Choroidoretinitis was the most common clinical diagnosis (69%), while clindamycin was the most frequently used antimicrobial in all cases. Among HIV-infected patients, 10 cases were diagnosed as AIDS-related toxoplasmic encephalitis (TE) (9 were active and 1 had relapse TE). In addition, 1 case was confirmed as congenital toxoplasmosis.
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PMID:Parasitic infections in Malaysia: changing and challenges. 1643 80

A retrospective study was conducted in nine patients with rabies admitted to a hospital of Fortaleza, Brazil. Autopsy was performed in all cases. The ages ranged from three to 81 years and six were males. They all were bitten by dogs. The time between the accident and the hospital admission ranged from 20 to 120 days (mean 45 +/- 34 days). The time until death ranged from one to nine days (mean 3.3 +/- 5.5 days). The signs and symptoms presented were fever, hydrophobia, aerophobia, agitation, disorientation, dyspnea, sialorrhea, vomiting, oliguria, sore throat, pain and hypoesthesia in the site of the bite, headache, syncope, cough, hematemesis, mydriasis, hematuria, constipation, cervical pain and priapism. In three out of six patients, there was evidence of acute renal failure, defined as serum creatinine > or = 1.4 mg/dL. The post-mortem findings in the kidneys were mild to moderate glomerular congestion and mild to intense peritubular capillary congestion. Acute tubular necrosis was seen in only two cases. This study shows some evidence of renal involvement in rabies. Histopathologic findings are nonspecific, so hemodynamic instability, caused by autonomic dysfunction, hydrophobia and dehydration must be responsible for acute renal failure in rabies.
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PMID:Renal involvement in human rabies: clinical manifestations and autopsy findings of nine cases from northeast of Brazil. 1655 20

Melioidosis which is infection with Burkholderia pseudomallei, is an important cause of sepsis in India, southeast Asia and northern Australia. Mortality is high and treatment is problematic. Neurological melioidosis is unusual but meningoencephalitis, encephalomyelitis and brain microabscess can occur Dural sinus thrombosis is not an uncommon cerebrovascular disorder with various etiologies. Hypercoagulable state, pregnancy, dehydration, certain blood dyscrasia and contraceptive pills are common causes however meningitis and local head & neck infections may lead to this condition. Dural sinus thrombosis complicating septicemic melioidosis has never been reported. The authors report a 42-year-old Thai man suffering from septicemic melioidosis with dural sinus thrombosis. He had high fever, headache, left hemiparesis, focal seizure and increased intracranial pressure. Diabetes and mild alcoholic cirrhosis were diagnosed in this admission. CT scan, MRI brain and MRV revealed superior saggital sinus thrombosis with complicating venous infarction over right posterior parietal lobe. Hemoculture demonstrated Burkholderia pseudomallei and CSF was acellular Investigations for causes of dural sinus thrombosis were all negative. This patient gradually improved after treatment with ceftazidime, antiepileptic drug and heparin without clinical recurrence. Neuromelioidosis is a rare syndrome that may present as brain abscess, encephalitis or meningoencephalitis. The authors report dural sinus thrombosis associated with septicemic melioidosis. The authors' hypothesis of venous thrombosis in the presented case is sepsis induced hypercoagulable state. Physicians should be aware of cerebral venous thrombosis in case of suspicious melioidosis with neurological involvement. Prompt treatment with intravenous heparin and antibiotic is potentially effective.
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PMID:Dural sinus thrombosis in melioidosis: the first case report. 1657 13

To provide a descriptive analysis of emergency department (ED) patients with spina bifida, a retrospective chart review was conducted of ED patients with spina bifida. Data describing demographics, chief complaints, diagnostics, diagnoses, and disposition were collected. There were 125 patients with 258 ED visits. The most common presenting complaints included fever (n = 55), vomiting (36), headache (32), abdominal pain (23), and genitourinary symptoms (20). The most common diagnoses included urinary tract infection (n = 55), cellulitis (26), seizure (21), headache (17), dehydration (12), and shunt failure (11). Atypical presentations of conditions commonly associated with spina bifida occurred frequently. Forty-three percent of patients were admitted. In conclusion, spina bifida patients often present with serious illness requiring admission and with complications of their underlying condition. Therefore, atypical presentations of commonly associated conditions must be considered.
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PMID:Descriptive analysis of 258 emergency department visits by spina bifida patients. 1679 48

Conventional wisdom teaches that chronic headaches typically improve and often abate during pregnancy, leading many clinicians to take a wait-and-see approach of delaying treatment in hopes of seeing spontaneous improvement. Although headaches do improve in later pregnancy for up to 50% of chronic headache sufferers, headaches persist and may even worsen for the remainder. Clinicians must recognize that treating headache during pregnancy is important in order to limit excessive use of over-the-counter pain remedies, dehydration, and pain- related disability. Safe and effective medication and nonmedication treatment options are available for the pregnant headache sufferer, including both acute care and preventive therapies. Care of the pregnant headache patient should begin before she is known to be pregnant, when the fertile female is initially established as a patient. Preconception planning should include modification of medication regimes to include medications safe for use during early pregnancy, when the woman may not yet realize she is pregnant, and effective nonmedication therapies, such as relaxation, biofeedback, and lifestyle modification.
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PMID:Headache in pregnancy. 1728 86

Cerebral sinus vein thrombosis is rare in children. So far, only three other cases have been reported in a child with diabetes mellitus. This 10 year-old female presented with classic signs of diabetic ketoacidosis which resolved with standard fluid and insulin therapy. Headache persisted despite biochemical improvement and 6th nerve palsy became evident on Day 3. On Day 5, sudden deterioration in mental status to the point of coma with loss of airway protective reflexes prompted repeat imaging including magnetic resonance venography which demonstrated thrombosis of the superior sagittal, straight, right transverse, right sigmoid and proximal posterior aspect of the left transverse sinuses. Selective thrombolysis using rTPA was performed emergently. Complete lysis of the thrombosed veins was observed within 35 hours. Low molecular weight heparin was continued for 6 months. Significant clinical improvement was noted within 48 hours of the procedure. Six weeks later recovery was complete. Complete hematological work-up for hypercoagulable state revealed a heterozygous mutation of the prothrombin gene (G20210A). Children with this mutation are generally asymptomatic unless challenged by a second risk factor, in this case by severe dehydration and diabetic ketoacidosis. Our patient presented a unique diagnostic challenge at the time of her acute neurological deterioration. Rapid, aggressive intervention with super-selective thrombolysis resulted in complete resolution of severe and potentially life devastating neurological symptoms.
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PMID:Resolution of severe sinus vein thrombosis with super selective thrombolysis in a pre-adolescent with diabetic ketoacidosis and a prothrombin gene mutation. 1766 98

Exertional heat illness is primarily a multi-system disorder results from the combined effect of exertional and thermoregulation stress. The severity of exertional heat illness can be classified as mild, intermediate and severe from non-specific symptoms like thirst, myalgia, poor concentration, hysteria, vomiting, weakness, cramps, impaired judgement, headache, diarrhea, fatigue, hyperventilation, anxiety, and nausea to more severe symptoms like exertional dehydration, heat cramps, heat exhaustion, heat injury, heatstroke, rhabdomyolysis, and acute renal failure. At its early stage, it is quite difficult to find out the severity of disease with manual screening because of overlapping of symptoms. Therefore, one need to classify automatically the disease based on symptoms. The 7:10:1 backpropagation artificial neural network model has been used to predict the clinical outcome from the symptoms that are routinely available to clinicians. The model has found to be effective in differentiating the different stages of exertional heat-illness with an overall performance of 100%.
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PMID:Backpropagation ANN-based prediction of exertional heat illness. 1804 Dec 90


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