Cervicalgia without alarm signs. Conservative treatment with a success rate of 75%-90%.

A 35-year-old man, a letter carrier, with no history of interest, who comes to the emergency department for acute cervical pain of 24 hours of evolution, without previous trauma, which radiates to the left arm up to the hand and is accompanied by paresthesia in the radial border of the forearm. She presents no objectifiable loss of strength, preserves neck mobility although it is painful and contracture of the paravertebral musculature is appreciated. The first attitude will be:

Conservative treatment with nonsteroidal anti-inflammatory drugs, local heat and relative rest.

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to outpatient traumatology consultations.

Sudden Onset of Severe Cervical Pain in an Adolescent Girl: Case Report and Review of Literature.

A previously healthy 13-year-old girl presented with a 9-day history of acute onset severe neck pain associated with limited range of movement. Medical evaluation at day 2 was suggestive of muscle contracture, and she was discharged home with diazepam, antiinflammatory agents, and rest; however, she returned because of progressive clinical worsening with left arm distal paresthesia and paralysis since day 3. There was no history of trauma or other systemic complaints, and her familial medical history was unremarkable.Physical examination revealed left cervical and paravertebral tenderness on palpation with severe limitation of cervical and trunk movements; neurologic examination revealed left forearm and hand weakness and paralysis (grade II/V) with thenarhypothenar atrophy. Laboratory studies including coagulation profile were normal. Magnetic resonance imaging revealed an epidural hematoma from C4-T1 without underlying cause apparent on magnetic resonance angiography. On day 12, she underwent C3-7 laminotomy with laminoplasty and complete drainage of the hematoma. After 5 months of follow-up, she displays no neurological deficits. The spontaneous spinal epidural hematoma is a rare neurosurgical emergency in children. It usually presents acutely with neurologic deficits, but the initial presentation may be atypical or insidious, delaying diagnosis and intervention. Definitive diagnosis is made by magnetic resonance imaging and implies a high index of suspicion. Surgical drainage of the hematoma is the mainstay of treatment with favorable prognosis even in cases with a delayed diagnosis.

Stinger (medicine)

Diagnosis and treatment Stingers are best diagnosed by a medical professional. This person will assess the athlete's pain, range of head and neck motion, arm numbness, and muscle strength. Often, the affected athlete is allowed to return to play within a short time, but persistent symptoms will result in removal. Athletes are also advised to receive regular evaluations until symptoms have ceased, specifically, the restoration of pain-free mobility. If they have not after two weeks, or increase, additional tests such as magnetic resonance imaging (MRI) can be performed to detect a more serious injury, such as a herniated disc. The order of treatments applied depends on whether the athlete's main complaint is pain or weakness. Both can be treated with an analgesic, anti-inflammatory medication, ice and heat, restriction of movement, and if necessary, cervical collar or traction. Surgery is only necessary in the most severe cases.

Neurology_Adams

A common cause of neck, shoulder, and arm pain is disc herniation in the lower cervical region; the process is comparable to disc herniation in the lumbar region but gives rise, of course, to a different set of symptoms (Table 10-1). The problem appears most often without a clear and immediate cause, but it may develop after trauma, which may be major or minor (from sudden hyperextension of the neck, falls, diving accidents, forceful manipulations as discussed by Kristoff and Odom). The roots most commonly involved are the seventh (in 70 percent of cases) and the sixth (in 20 percent of cases); fifthand eighth-root compression makes up the remaining 10 percent (Yoss et al). The clinical diagnosis is established by a fairly discrete distribution of pain or paresthesias that corresponds to a single cervical root, reflex loss in the segment of the root, and by elicitation of exaggerated root pain with mechanical tests such as the Spurling maneuver, in which the examiner exerts downward

Cervical Radiculopathy -- Introduction

Neck pain is a common condition that can cause significant discomfort and disability in patients of different ages. Workers who have experienced neck pain account for up to 40% of work absenteeism. [1] [2] [3] Cervical radiculopathy, on the other hand, is a condition where the nerve root of a spinal nerve is compressed or impaired, causing the pain and symptoms to spread beyond the neck and radiate to other areas of the body, such as the arms, neck, chest, upper back, and shoulders. Due to the nerve impingement, muscle weakness and impaired deep tendon reflexes are often observed.

[Hyperextension trauma in patients with cervical spondylosis].

PURPOSE OF THE STUDY To evaluate retrospectively a group of patients with hyperextension injury to the cervical spine who were treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague, between 2003 and 2006. MATERIAL The group comprised 22 patients, 17 men (77 %) and five women (23 %) in the age range of 35 to 81 years, with an average of 59.5 years. All patients had, in association with the injury, neurological deficit of varying degree. METHODS All patients underwent X-ray and magnetic resonance imaging examination and received methylprednisolone according to the National Acute Spinal Cord Injury Study (NASCIS) 2 trial. Eleven patients had urgent surgery within 24 hours of injury; eight patients were operated on within an interval of 3 days to 2 months because of the seriousness of their state and multiple morbidity; and three patients were treated conservatively. Neurological deficit in terms of upper- and lower-limb mobility was evaluated by the American Spinal Injury Association (ASIA) motor score. The values obtained for the urgently operated patients and for those operated on after a time interval were compared by Wilcoxons two-sample test. The other aspects evaluated included trauma aetiology, level of spinal cord injury, manner of treatment, and intra-operative and post-operative complications. RESULTS The most frequent cause of injury was a low-height fall (13 patients; 59 %); car accidents ranked second (9 patients; 41 %). In five patients (22.7 %) ebriety was found. Eighteen patients had no skeletal injury (81.8 %). Four patients (18.2 %). Four patients (18.2 %) suffered fractures of articular or spinous processes, but the anterior column skeleton was intact in all. The segment most frequently affected by myopathy was C3-C4, then C4-C5 and C5-C6. Decompression was carried out to the extent of myopathy; and in the adjacent segments only if significant stenosis was present. In both subgroups of surgically treated patients (urgent and delayed management), comparisons of the ASIA scores at the time of injury and at one-year follow-up showed no significat improvement in post-operative mobility, as evaluated by Wilcoxons two-sample test at a level of significance a = 5 %. No intra-operative or post-operative complications, except for early death, were recorded. In all patients the wound healed by first intention and no loosening of instrumentation was foud on follow-ups at the out-patient departments. DISCUSSION Although the greatest narrowing of the spinal canal due to spondylosis occurs at the C5-C6 segment, the C4-C5 segment sustained most injuries. Although some relevant papers report no significant difference in improved neurological deficit between patients treated surgically and those undergoing conservative therapy, we prefer surgical management, in most of the cases from the anterior approach, which allows us to remove dorsal osteophytes and perform careful decompression to prevent damage to nerve structures and to preserve those which are still intact. There was no significant difference in the outcome between urgent and delayed trauma management, which is unusual amongst other injuries associated with neurological lesions and this indicates that the timing of surgery must be strictly individual and should be carried out at a time when operative benefit outweighs operative burden. The surgical treatment used should, in the first place, lead to early recuperation and rehabilitation. CONCLUSIONS Hyperextension injuries of the cervical spine are usually associated with serious neurological deficit. A correct algorithm of examination will result in good treatment outcomes. However, these injuries require a therapy that is long-lasting and difficult, with a need for cooperation of anaesthesiologists, spinal surgeons, physical therapists and, last but not least, psychologists. Key words: cervical spine, hyperextension injury, spondylosis, myelopathy.

Cervical Myofascial Pain -- History and Physical

The history of a patient presenting with the cervical myofascial syndrome can vary greatly. Patients can sometimes present with a history of acute trauma, or the pain may be insidious. Symptoms may be worse with repetitive tasks, certain movements, or even certain postural positions throughout the day. The pain can be nagging or acute, and it can be local or radiate out from the neck to the surrounding area. The range of motion of the cervical spine may be limited and painful, and the patient may also complain of some tightness or a local twitch response, similar to a spasm. Generally, the area is tender to palpation and can be described as deep, and constant. On physical exam, poor posture may be noted, with slumped shoulders or decreased cervical lordosis. No atrophy should be noted in cervical musculature. On palpation, finding trigger points in the area of pain is very likely. A trigger point is an area of hyperirritability that radiates pain when palpated. A taut band may be noted in the skeletal muscle or surrounding fascia. [4] Limitation of the range of motion of the cervical spine may be associated. The neurological exam, including strength, sensation, and reflexes of the upper extremities will be normal.

InternalMed_Harrison

The natural history of neck pain with acute radiculopathy due to disk disease is favorable, and many patients will improve without specific therapy. Although there are no randomized trials of NSAIDs for neck pain, a course of NSAIDs, acetaminophen, or both, with or without muscle relaxants, is reasonable as initial therapy. Other nonsurgical treatments are commonly used, including opioid analgesics, oral glucocorticoids, cervical traction, and immobilization with a hard or soft cervical collar. However, there are no randomized trials that establish the effectiveness of these treatments. Soft cervical collars can be modestly helpful by limiting spontaneous and reflex neck movements that exacerbate pain.

Ankylosing spondylitis

These diagnostic criteria include: Inflammatory back pain:Chronic, inflammatory back pain is defined when at least four out of five of the following parameters are present: (1) Age of onset below 40 years old, (2) insidious onset, (3) improvement with exercise, (4) no improvement with rest, and (5) pain at night (with improvement upon getting up) Past history of inflammation in the joints, heels, or tendon-bone attachments Family history for axial spondyloarthritis or other associated rheumatic/autoimmune conditions Positive for the biomarker HLA-B27 Good response to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) Signs of elevated inflammation (C-reactive protein and erythrocyte sedimentation rate) Manifestation of psoriasis, inflammatory bowel disease, or inflammation of the eye (uveitis) If these criteria still do not give a compelling diagnosis magnetic resonance imaging (MRI) may be useful. MRI can show inflammation of the sacroiliac joint. Imaging

[Acute radicular paralysis of arm and hand].

Patients with cervical radicular lesions present themselves with neck pain and stiffness on the one side and with neurological deficits of radicular distribution on the other side. The most frequent cause is a root compression due to a herniated disk or spondylotic changes of the spine. The management of the patients and the differential diagnosis are discussed.

Spinal Cord Injury and Postdural Puncture Headache following Cervical Interlaminar Epidural Steroid Injection: A Case Report.

<iBackground</i: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. <iCase report</i: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. <iConclusions</i: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher.

Diagnostic Uncertainty in Cervical Radiculopathy.

Cervical radiculopathy is defined as a pathological process affecting the cervical nerve root(s). While not an uncommon entity, this report describes a case of cervical radiculopathy in an active duty Marine with unique features to include the C5 nerve root as the primary point of injury with corresponding severe motor weakness that warranted expedited workup. This expedited workup included early referral to Neurology for nerve conduction and electromyography (EMG) studies that were ultimately diagnostic in the setting of equivocal Magnetic Resonance Imaging findings. This highlight of this case is the demonstration of the utility of EMG in cervical radiculopathy evaluation, which aided in an efficient and effective treatment course. We contend that in cases of cervical radiculopathy with a focal deficit of profound weakness with shoulder abduction and elbow flexion, obtaining nerve conduction studies and EMGs within the first 4 to 6 weeks of presentation should be viewed as essential for the long-term recovery and effective management of the injured service member, particularly when injury to the upper trunk of the brachial plexus can also account for these specific motor deficits. This report will cover a brief review of the pathophysiology, evaluation, and natural history of cervical radiculopathy with special attention paid to the timing and efficacy of EMG.

Acute Calcific Tendonitis of the Longus Colli: An Uncommon Cause of Neck Pain in the Emergency Department.

The longus colli muscle has three major parts that originate and insert in the upper cervical and thoracic spine. It is a weak flexor of the neck, and when contracted also serves to rotate the neck to the ipsilateral side. It is innervated by the anterior rami of the C2-C6 spinal nerves and receives its blood supply from the anterior cervical and inferior thyroid arteries. In a post motor vehicle collision (MVC) patients presenting weeks later, the physician has to ensure there is no subacute fracture. Clinically, these patients present with severe anterior neck pain that will often be described as a deep pain. A 43-year-old female with a past medical history of diabetes and prior surgical history of a tonsillectomy and uvulectomy presented with sudden onset of sore throat that woke her up from sleep at 3:00 am. Associated with the sore throat, she had hoarseness of her voice, difficulty breathing and felt that her throat was closing. She forced herself to vomit and then felt better. She denied any fevers or chills. Later, the patient mentioned that she had chronic neck pain from a prior accident and had been told that she has C5-C6 stenosis. About a week prior, she had been involved in another MVC and had some neck pain after that. Significantly, she was also on lisinopril for her hypertension (HTN). She was tolerating secretions, protecting her airway and no gross inflammation was noted on physical exam. On labs, there was no leukocytosis noted. Soft tissue neck X-ray showed reversal of the cervical lordosis, degenerative and erosive changes at C4-C5 and C5-C6, and thickening of the prevertebral soft tissues. She obtained a CT of the neck and cervical spine that showed osteophyte complexes at C4-C5 and C5-C6, as well as calcific tendonitis of the longus colli with a moderate amount of prevertebral free fluid. Neurosurgery was consulted from the ED who recommended getting an MRI of the neck, and consulting ENT as well. ENT happened to be in the ED and performed a bedside laryngoscopy that showed edema of the left arytenoid with full functionality of the vocal cords, and no signs of airway compromise. The patient was started on steroids, antibiotics, H2 blockers, and the ACE-inhibitor was discontinued due to suspected angioedema per ENT. She was also admitted to the ICU for airway monitoring. The MRI of the neck again showed calcific tendonitis of the longus colli with moderate prevertebral fluid. Meanwhile, the patient had complete resolution of her symptoms in 24 hours and she was cleared from both neurosurgery and ENT to be discharged. Acute calcific tendonitis is due to the deposition of calcium hydroxyapatite, which can cause significant pain and edema. In terms of calcific tendonitis of the longus colli muscle, this condition is frequently misdiagnosed and continues to be a challenge, especially in the emergency department. The differential diagnosis is diverse in etiology and severity, ranging from meningitis and retropharyngeal abscess to vertebral fracture and muscle strain.

Cervical Radiculopathy -- History and Physical

When performing a physical examination, it is crucial to position the patient in a way that allows for the isolation of individual reflex arcs. This helps accurately assess the patient's overall reflex response. Given the individual variation in deep tendon reflexes, comparing both sides of the neck is more important than overall magnitude. If there is nerve impingement, the affected side is reduced relative to the unaffected side. Reduced muscle strength, innervated by the affected nerve, is a significant physical sign.

Myeloid Sarcoma Presenting as Low Back Pain in the Pediatric Emergency Department.

Low back pain is a common symptom in the pediatric population; approximately half of all children present with at least one episode of low back pain. The majority of cases are due to nonspecific causes such as musculoskeletal trauma with spontaneous regression. On some occasions, however, life-threatening diseases have to be considered. A 15-year-old girl presented to the Pediatric Emergency Department for a history of continuous 2-day duration of low back pain and transient paresthesia of the right gluteal area. Low back pain was diagnosed and nonsteroidal anti-inflammatory treatment combined with rest were prescribed. After 7 days, worsening of the clinical conditions was observed with bilateral gluteus paresthesia. A corset was recommended, and magnetic resonance imaging (MRI) and rheumatological evaluation were prescribed on an outpatient basis. After 5 days she was hospitalized due to urinary incontinence and persistence of pain. Blood tests revealed neutrophil leukocytosis associated with mild anemia, thrombocytopenia, hyperuricemia, and increased lactate dehydrogenase. MRI examination of the spine demonstrated a mass involving the sacral canal and the presacral region, extending through the sacral foramina, along the nerve roots. Similar tissue was found at multiple levels in the spine and in the right orbit. Bone marrow aspiration and biopsy highlighted the presence of myeloid blasts and myeloid dysplasia, consequently, myeloid sarcoma was diagnosed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case demonstrates the importance of prompt identification of diagnostic "red flags" in childhood low back pain, indicating the need for diagnostic investigations such as MRI and blood tests.

[Cervical radiculopathy].

Cervical radiculopathy is a common cause of pain in the arm. It is caused by nerve root compression in the neck, as a consequence of a herniated disc, or spondyliotic foraminal stenosis. It causes severe pain, especially during the first few weeks, and paraesthesias in the forearm and hand. Patients also suffer from neck pain and loss of strength in the relevant arm. The arm pain can be exacerbated by certain movements of the head; these should be avoided as much as possible. Diagnosis can be made on the basis of history and physical examination. The pain generally disappears without active patient treatment. A semi-rigid cervical collar is recommended to accelerate pain relief. In cases of persistent pain, surgery will be considered. In such cases an MRI should be performed to show the cause and level of nerve root compression.

Costochondritis

Treatment Costochondritis is referred to as being self-limited, which is a condition in which will typically resolve on its own without treatment. Conservative methods are often the first method to treat the condition. If the condition is a result of trauma or over-use of the upper extremity, individuals will be told to rest and avoid activities. Pain relief medications (analgesics) such as acetaminophen, or the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or meloxicam may be suggested to relieve discomfort. If the pain is localized, occasionally creams and patches containing compounds such as capsaicin, NSAIDs, or lidocaine may be used. Heat or ice compresses may also be used for treatment.

Linear Neck Pain and Prolonged Cough Caused by Takayasu Arteritis.

The clinical manifestations of Takayasu arteritis (TA) greatly vary, and this ultimately leads to a delay in diagnosis. We describe a case of TA presenting with two coexisting rare symptoms of linear neck pain and prolonged cough. A 28-year-old Japanese female with a six-month history of ulcerative colitis presented with recurrent left neck pain, cough, and fever. The neck pain and fever started five months ago. Her symptoms briefly improved with nonsteroidal anti-inflammatory drug therapy, but eventually recurred one month prior to her latest presentation to the hospital, which was accompanied by a dry cough. Physical examination revealed a blood pressure discrepancy, with systolic blood pressure being >10 mmHg lower in her left arm than in her right arm, a bilateral carotid bruit, a weak left radial pulse and radio-radial delay without coolness in the upper extremities, and linear pulsatile tenderness in her left neck along the common carotid artery. No supraclavicular or infraclavicular bruit was noted. The erythrocyte sedimentation rate was elevated at 66 mm/hour. After obtaining the images from a contrast-enhanced computed tomography, she was diagnosed with TA. All her symptoms improved with prednisone therapy. Notably, neck pain and cough are both late-stage symptoms of TA, which are seen in 9.7% and 1.5% of patients, respectively. Although her unspecific symptoms could have been easily misdiagnosed, the recurring exacerbation of symptoms warranted careful attention to a focused physical examination. In conclusion, neck pain and cough are both uncommon presentations of TA, which may lead to physicians underdiagnosing it. It is important to recognize neck pain and cough as presenting complaints in patients with TA.

Radium

History

[Cervico-brachialgias, a delicate differential diagnosis: apropos of a patient with recurrent loss of consciousness in herniated disk].

A protrusion of a intervertebral disc can be the cause of a painful hand-shoulder syndrome. Such a situation can be difficult to interpret particularly if it is associated with repeated (recurrent?) loss of consciousness. The presented patient illustrates the complexity of this syndrome and emphasizes the importance of the history and clinical examination. One should not be reluctant to repeat these investigations, in particular the examination of reflexes. The value of nuclear magnetic resonance studies in the diagnostic approach is outlined. A cervical disc protrusion is part of the differential diagnosis of unconsciousness of undetermined cause. Its pathogenesis remains to be elucidated. In the presented patient the causal relation is unquestionable since symptoms subsided after surgery. It is an example over our limited knowledge about the pathophysiology of peripheral nervous-system diseases.

[Pediatric intervertebral disc calcification: A rare cause of acquired torticollis. Case report].

Pain and cervical muscle spasm are common reasons why parents bring children to the pediatric emergency department. The first steps are the gathering of medical history of the patient and a physical examination. If musculoskeletal damage is suspected, cervical spine x-rays should be obtained. An intervertebral disc calcification finding, in the absence of other radiological lesions should suggest pediatric intervertebral disc calcification. To present a case of intervertebral disc calcification, a rare condition that must be considered in the differential diagnosis of torticollis and neck pain in childhood. A seven-year-old male patient without morbid history and no history of trauma or rough sport practice. He consulted the emergency room for pain and cervical contracture for the last six days. C reactive protein and red cell sedimentatio rates were slightly elevated. Imaging studies showed calcification of the C5-C6 intrvertebral disc and anterior disc protrusion. The patient was hospitalized for evaluation and pain management, with good clinical response and continue afterwards with non-steroidal anti-inflammatory drugs and a soft collar. At the 6-month-follow up, the patient had resolved symptoms and calcifications. Pediatric intervertebral disc calcification is a rare cause of acquired torticollis, with a benign and self-limited outcome. Conservative management, as well as clinical and imaging follow-up is recommended.

[Evolution and characteristics of primary care patients with painful shoulder].

To describe the population attending teaching health centres in Area V, Asturias, to consult for painful shoulder. To describe the examination, diagnosis, treatment and clinical response. Longitudinal, descriptive study. Teaching health centres in Area V, Asturias. Patients consulting because of pain in their shoulders in October and November 2002. Two measurements, the first of which in December 2002 appraised age, sex, job, time off work, arc of pain, flection, internal-external rotation, and diagnostic impression. The second, in May 2003, assessed evolution, x-rays, echography, medication, infiltration, physiotherapy, exercises at home, referral to specialist, and final diagnosis. Bivariant and kappa index descriptive analyses were run. 110 cases, 58.2% women and 41.8% men, with an average age of 57 (95% CI, 54.17-59.79), were included. 52.7% were retired; no particular job predominated; 7.3% were off work; 30% had had no examination of arc of movement; 70% evolved satisfactorily. The most common diagnosis was cuff tendinitis, with initial and final diagnosis coinciding well. 77.4% of patients took NSAIDs; 16% were infiltrated; 32.1% did physiotherapy; and 36.8%, exercises at home. 65.1% had no x-ray and only 6.6% had echographies, all of which found something. There was no statistically significant relationship between medication or infiltration and favourable evolution; and there was, between physiotherapy or exercises and favourable evolution. Most patients were middle-aged, women, pensioners, and had little time off work. Two-thirds evolved well. Examinations were incomplete and few complementary tests were run.

Neck complaints in the pediatric emergency department: a consecutive case series of 170 children.

To describe the spectrum of pathologies responsible for neck ailments in a primary care pediatric emergency setting and evaluate their outcome. All children aged 16 years or younger, who presented to the emergency department of the Children's Hospital of Lausanne during a 1-year period, were retrospectively identified and charts were reviewed. Causes of neck complaints were classified as traumatic (group 1), infectious (group 2), postural (group 3), or miscellaneous (group 4) according to the final diagnosis. History and physical examination findings, radiological and laboratory results, as well as patient outcomes were recorded. During the study period, 28,722 children were observed in the emergency department, and 170 were identified as having neck complaints. The number of patients with neck ailments in group 1 was 105 (62%). Group 2 contained 33 patients (19%), of which 28 (16.5%) had a viral infection and 5 (2.9%) had a bacterial infection. Group 3 contained 30 children (17.6%) and group 4 contained 2 children (1.2%). Cervical spine radiography was performed on an emergency basis in 60 children (57 in group 1, 2 in group 2, and 1 in group 3). Significant abnormalities were observed in 6 children. Cervical computed tomography (CT) was performed in 9 children, from which 5 were in group 1, 3 were in group 2, and 1 was in group 4. The CT scan revealed pathologic findings in 6 children. Follow-up data were available in 135 patients (79.4%), of which 129 (95.6%) experienced complete recovery in less than 2 weeks. Admission to the hospital was necessary in 4 children (1 in group 1 and 3 in group 2), including 2 for emergency surgical drainage of retropharyngeal abscesses. One child with posttraumatic torticollis was treated conservatively as an outpatient and recovered in 7 weeks. One child was had his/her condition eventually diagnosed with osteoid osteoma and treated with oral nonsteroidal anti-inflammatory drug. Most cases of neck ailments in children presenting to the emergency department were due to trauma or infection, which were effectively managed as outpatients. When signs and symptoms suggested an emergent cause, CT provided a definitive diagnosis. The evaluation of a child presenting with acute neck complaints should be based on history and physical examination. Plain radiographs and CT scan are contributive in selected cases.

[Cervical ribs. Therapeutic deliberations apropos of 10 cases].

The authors report ten cases of cervical ribs operated upon in 7 patients. The predominantly neurological symptoms and signs were associated with vascular problems in 3 cases, with intermittent compression of the sub-clavian vessels. Treatment consisted of resection of the cervical rib and the first rib via an extra-pleural axillary approach using the technique described by Roos. It gave 10 good results with a follow-up of 6 months to 3 years. The authors emphasise the fact that this pathology falls within the context of compressive syndromes of the root of the upper limb or thoracic outlet syndrome. Such a conception justifies associated resection of the first rib which should give better long term results than simple resection of the extra rib.

Nicolau's syndrome: A rare but preventable iatrogenic disease.

Dear Editor, Nicolau's syndrome, also called embolia cutis medicamentosa or livedoid dermatitis, is a rare injection site reaction characterized by immediate intense pain at the injection site followed by erythema and a hemorrhagic patch with a livedoid reticular pattern after injections of non-steroidal anti-inflammatory drugs (NSAIDS), antiepileptics, antibiotics, antihistaminics, corticosteroids, etc. (1). To the best of our knowledge, only one case of Nicolau's syndrome has been reported after the use of triamcinolone acetonide. Herein we report two cases of Nicolau's syndrome caused by intramuscular injections of triamcinolone acetonide and diclofenac sodium, respectively. CASE 1 A 24-year-old male patient presented with severe pain and bluish discoloration of the right arm for 2 days, which he had noticed shortly after receiving an intramuscular injection of triamcinolone for recurrent episodes of urticaria by a local practitioner in the right deltoid region. On examination, there was a livedoid pattern of non-blanchable, violaceous discoloration extending from the deltoid area to the distal third of the forearm with associated induration (Figure 1, a, b). The local area was warm and tender to the touch. There was no regional lymphadenopathy, and the rest of the examination was normal. The patient's platelet count, bleeding and clotting times, prothrombin time, and international normalized ratio (INR) were unremarkable. There was no previous history of any bleeding disorder. The patient denied any intake of drugs like aspirin, warfarin, etc. Subsequently, the patient developed an ulcer on the forearm, which was managed by topical and systemic antibiotics to prevent any secondary infection of the wound. CASE 2 A 40-year-old female patient presented with complaints of pain and discoloration of the left gluteal region after receiving an intramuscular injection of diclofenac sodium for her arthralgia. A large ecchymotic patch with reticular borders was found on the gluteal region, extending to the lateral aspect of thigh (Figure 2). It was tender to the touch, non-indurated, and the local temperature was raised. There was no regional lymphadenopathy. No other abnormality was detected on examination. All routine investigations were within normal limits. Platelet count, bleeding, clotting and prothrombin times, and international normalized ratio (INR) were within normal limits. The lesions resolved within few weeks without any complications. Nicolau syndrome was first described in the early 1920s by Freudenthal and Nicolau as an adverse effect of using intramuscular injections of bismuth salts in the treatment of syphilis. Since then, several case reports of this disease occurring after intramuscular, intra-articular, intravenous, and subcutaneous injections have appeared in the literature associated with a variety of drugs like NSAIDs, vitamin K, penicillin, antihistamines, corticosteroids, local anesthetics, vaccines, polidocanol, and pegylated interferon alpha (1). The pathogenesis of Nicolau syndrome is unknown, though intra and periarterial injection of the drug is a possible cause. Stimulation of the sympathetic nerve due to periarterial injection causes spasms and consequent ischemia. Inadvertent intra-arterial injections may cause emboli and occlusion. A lipophilic drug may penetrate the vessel and produce physical occlusion like fat embolism. Cytotoxic drugs may produce perivascular inflammation and ischemic necrosis. NSAIDs are believed to additionally induce ischemic necrosis due to their inhibition of cyclooxygenase and, consequently, prostaglandins (2). The clinical features of the disease have been divided into three phases in a review by Kim et al. (3). The authors describe an initial phase characterized by intense pain with subsequent erythema. This is followed 1-3 days later by an acute phase, when an indurated, tender plaque with livedoid pattern develops. The final phase occurs between 5 days and 2 weeks later. Necrosis ensues in this stage, with possible ulceration. Diagnosis is chiefly clinical, and histopathology shows necrotic changes and vascular thrombosis. However, a biopsy was not performed in our cases because both lesions were painful. Management strategies are variable and range from conservative management with analgesics and antibiotics to active surgical debridement (4). Complications include deformities, contractures or even death. The patient in our first case developed ulceration which healed normally, while the second case resolved without any complications. Nicolau syndrome can be avoided by precautions such as aspirating the needle before injecting to check for blood, use of Z-track injection technique, proper site of injection, avoiding large doses at a single site, and regular change of sites if multiple injections are to be given (5). Nicolau syndrome is a rare disease. There are a few case reports of it occurring after diclofenac injection (1-5). We could only find one case report of this syndrome after intramuscular injection (IM) of triamcinolone in a patient with lichen planus (3), and our case is the second reported case of this syndrome as a result of triamcinolone acetonide injection, which adds to the significance to the present article.

[A case of delayed cervical epidural hematoma with C5 nerve root palsy after posterior cervical laminoplasty].

Delayed postoperative spinal epidural hematoma (DPSEH) is a rare and potentially devastating complication of laminoplasty, and cervical nerve root palsy occurs more frequently than DPSEH, especially with C5 nerve root palsy. The authors describe a case of DPSEH with C5 nerve root palsy that developed in a patient 3 days after he underwent laminoplasty. In this case, a 78-year-old man with a history that having taken Aspirin without the doctor's instruction for 5-6 years, he underwent cervical laminoplasty for mild myelopathy. On the 3rd postoperative day, he complained of weakness of his left upper extremity and could not raise his left arm. The symptom aggravated in the next few days. On the 9th postoperative day, there was an obvious motor deficit of both upper and lower extremities. Magnetic resonance imaging demonstrated abnormal signal characteristics consistent with a hematoma at levels C3-C4, compressing spinal cord. The clot was evacuated during emergency revision surgery, and the postoperative course after the operation was uneventful and the muscle strength was improved five days later. Therefore, the symptoms of DPSEH are not so typical that its possibility should be kept in mind. Sometimes a differential diagnosis should be made with C5 nerve root palsy which may only represent weakness of upper extremities. The authors recommend that magnetic resonance imaging is helpful for the diagnosis of DPSEH and a revision surgery should be taken as soon as possible once the hematoma causing the neurologic deterioration was confirmed.

History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).

It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is "only" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, "daddy" he will need to ask his mother: "what letter is the letter D?" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, "if he is counting he will forget what comes after 4 and what comes after 9." Mother reports he will start crying for no apparent reason and if she asks why, he will say "I don't know why." Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, "This was not an issue before his head trauma." At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as "excellent." Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?

Cervalces scotti

Evolution

Acute bilateral spontaneous forearm compartment syndrome.

Acute spontaneous compartment syndrome of the forearm is rarely reported in the literature. It is typically associated with trauma or thromboembolism in the acute setting and repetitive exertional stress in the chronic setting. However it is rare for it to present bilaterally with no apparent underlying cause. We report the case of a young 31-year-old lady who presented to our Emergency Department with bilateral compartment syndrome of the forearm. Her presenting complaints included acute severe pain and swelling of the forearms bilaterally, with a decreased range of movement of the wrist and fingers. She also complained of numbness in all fingers. She had no history of recent trauma and ultrasound scans showed no evidence of vascular compromise. Past medical history was notable only for idiopathic hypertension and coeliac disease. The patient was taken to theatre urgently where flexor and extensor compartments and carpal tunnel were decompressed. Pronator Teres was found to be dusky initially but turned pink after decompression. All other muscles were normal. An interesting fact of this case was that combination of the high compartment pressures and anaesthetic related hypotension caused the forearm pulses to become impalpable at induction, these returned intra-operatively. The patient has been seen in the outpatient department following discharge. She is well apart from some mildly reduced grip strength in her right hand likely due to carpal tunnel decompression. No cause was found for the scenario after extensive medical investigation.

Radish

History

Cervical intradural disc herniation with Brown-Séquard syndrome: case report and literature review.

To report a rare case of cervical intradural disc herniation (IDH) with Brown-Séquard syndrome and to review the related literature. Pathogenesis, preoperative diagnosis, and the surgical technique are discussed, and previous literature reports are reviewed. A 44-year-old woman complained of weakness of the left upper and lower extremities and paresthesias in the right limbs after a bicycle ride 3 days earlier. She had a history of neck pain for 2 years prior. CT showed obvious ossification of the posterior longitudinal ligament (OPLL), and MRI revealed C3-7 disc herniations, with a positive "halo sign" around the herniated C4/5. We performed emergency decompression through anterior cervical corpectomy, and vertebrotomy decompression and fusion. At review 3 months after surgery, the patient's neck pain was markedly relieved, and motor strength in the limbs had improved. At 1 year after surgery, she had recovered completely. Cervical IDH is a rare condition that may be related to the traumatic inflammatory response and OPLL. Relatively rare imaging features such as the hawk-beak sign, halo sign, Y sign, and epidural gas sign could help in preoperative diagnosis. Prompt anterior cervical decompression is the preferred treatment for this condition.

[Transient neurological manifestations disclosing spontaneous acute cervical epidural hematoma].

Spontaneous cervical epidural hematomas are uncommon lesions that usually produce permanent neurological deficit unless there is early surgical decompression. They are now well-recognized by scan X and especially by sagittal MRI of the spine. We describe 2 patients, a 24 year-old man and a 79 year-old woman with no previous history of trauma who were admitted in emergency for a sudden weakness of limbs, respectively a tetraplegia and a right hemiplegia. Both patients complained of inaugural and acute neck pain. Motor deficit completely resolved in few hours and MRI of the spine showed on T1 a signal isointense, extending respectively from C3 to C6 and C5 to C7, consistent with an hematoma. Laboratory data and angiography were normal. Surgery was recused. Neck pain lasted about a week. Follow-up MRI, in one case, was normal two months later. Cervical epidural hematomas revealed by transient neurological findings that completely and permanently resolved are exceptional. They could mimic ischemic myelopathy and should be considered in the differential diagnosis of other painful vascular conditions like symptomatic vertebral dissection to avoid inappropriate anticoagulation. Conservative management in these cases may be proposed if spontaneous neurological resolution is confirmed by MRI.

Neurology_Adams

When the protruded disc lies between the sixth and seventh vertebrae, there is involvement of the seventh cervical root as outlined in Table 10-1. The pain is then in the region of the shoulder blade, or spine of the scapula, and posterolateral upper arm; it may project to the elbow and dorsal forearm, index and middle fingers, or all the fingers. Occasionally discomfort is felt in the pectoral or axillary region. Tenderness is most pronounced over the medial aspect of the shoulder blade opposite the third to fourth thoracic spinous processes and in the supraclavicular area and triceps region. Paresthesia and sensory loss are most evident in the index and middle fingers. Weakness involves the extensors of the forearm and sometimes of the wrist; occasionally the handgrip is weak as well; the triceps may be weak and the triceps reflex is usually diminished or absent; the biceps and supinator reflexes are preserved.


The first thing is to know the diagnosis of the clinical case that we are presented with, it is a primary immune thrombocytopenia (ITP), only the platelet series is altered with normal coagulation. The first test to be performed is a peripheral blood smear to check if these platelets are real and there is no pseudothrombopenia due to platelet aggregates. In the enlargement study, antinuclear antibodies (ANA) are requested to rule out autoimmune pathologies that may be the cause of the thrombopenia and another test that would be indicated although in this case the patient is young and does not present signs of seriousness (leukopenia, anemia, no response to first line treatment...) is the performance of a bone marrow aspirate, to see if there are thromboforming megakaryocytes and thus confirm that the platelet destruction is of peripheral origin. But what is not indicated is the determination of the JAK-2 mutation, which is used in the diagnosis of chronic myeloproliferative syndromes, which is not the case here.

The first thing is to know the diagnosis of the clinical case that we are presented with, it is a primary immune thrombocytopenia (ITP), only the platelet series is altered with normal coagulation. The first test to be performed is a peripheral blood smear to check if these platelets are real and there is no pseudothrombopenia due to platelet aggregates. In the enlargement study, antinuclear antibodies (ANA) are requested to rule out autoimmune pathologies that may be the cause of the thrombopenia and another test that would be indicated although in this case the patient is young and does not present signs of seriousness (leukopenia, anemia, no response to first line treatment...) is the performance of a bone marrow aspirate, to see if there are thromboforming megakaryocytes and thus confirm that the platelet destruction is of peripheral origin. [HIDDEN]

A 25-year-old woman presents to the emergency department with ecchymosis and petechiae in the lower extremities and gingivorrhage in the last few days. Her blood count showed the following data: Hb 13 g/dL, leukocytes 8,500/microL with normal leukocyte formula and platelets 9,000/mm3. The determination of coagulation times is normal. Which of the following diagnostic tests should NOT be performed?

List of MeSH codes (E01)

– cytodiagnosis – amniocentesis – biopsy – biopsy, needle – biopsy, fine-needle – chorionic villi sampling – conization – sentinel lymph node biopsy – chorionic villi sampling – cytopathogenic effect, viral – spinal puncture – vaginal smears – hematologic tests – blood cell count – erythrocyte count – reticulocyte count – leukocyte count – lymphocyte count – cd4 lymphocyte count – cd4-cd8 ratio – platelet count – blood coagulation tests – international normalized ratio – partial thromboplastin time – prothrombin time – thrombelastography – thrombin time – whole blood coagulation time – blood grouping and crossmatching – blood sedimentation – bone marrow examination – erythrocyte aggregation – erythrocyte indices – figlu test – hematocrit – hemoglobinometry – osmotic fragility – platelet function tests – bleeding time – clot retraction – platelet count – schilling test

Case of haemophagocytic lymphohistiocytosis following Epstein-Barr virus infection.

Haemophagocytic lymphohistiocytosis (HLH) is a rare diagnosis that carries a high degree of mortality. We present this case of a previously healthy 22-year-old woman, who was admitted acutely ill to the hospital. One week prior, she had been seen by her primary care physician for fatigue and malaise. At that time, she was noted to have anterior and posterior cervical lymphadenopathy. She was referred to the emergency room and was diagnosed with acute Epstein-Barr virus (EBV) mononucleosis based on her clinical symptoms and positive heterophile antibody test. She was discharged after an uneventful 48-hour stay on the wards. She represented 7 days after discharge with cough, fatigue, nausea, vomiting, epigastric abdominal pain, diarrhoea, weight loss and subjective fevers. She had also reported haematemesis, epistaxis and melaena. Vital signs included temperature 36.9°C, blood pressure 90/50 mm Hg, heart rate 130 beats per minute and respiratory rate 32 breaths per minute. Physical examination was notable for an acutely ill appearing woman with scleral icterus, hepatosplenomegaly and palpable cervical and axillary lymphadenopathy. Complete blood count showed pancytopaenia with haemoglobin 59 g/L (normal 120-160 g/L), white blood cell count 2.7×10<sup9</sup/L (normal 4-10.5×10<sup9</sup/L) and platelet count 50×10<sup9</sup/L (normal 150-450×10<sup9</sup/L). The white blood cell count differential included 58% neutrophils (normal 38%-77%) with immature neutrophils in band form elevated at 45% (normal <14%), 16% lymphocytes (normal 20%-48%), 7% monocytes (normal <12%) and no eosinophils (normal <6%). Blood smear revealed anisocytosis, poikilocytosis and hypochromia. Coagulation panel showed elevated levels of d-dimer level at 1.39 µg/mL (normal <0.45 µg/mL), prolonged prothrombin time at 34.4 s (normal 11-15 s), prolonged activated partial thromboplastin time of 55.6 s (normal 25-34 s), prolonged international normalised ratio at 3.31 (normal <1.1) and low fibrinogen 60 mg/dL (normal >200 mg/dL). Lipid panel showed cholesterol at 114 mg/dL (normal 125-200 mg/dL), triglycerides 207 mg/dL (normal 30-150 mg/dL), high-density lipoprotein cholesterol 10 mg/dL (normal 40-60 mg/dL) and low-density lipoprotein cholesterol 63 mg/dL (normal <100 mg/dL). Other lab abnormalities included elevated ferritin of 6513 ng/mL (normal 10-150 ng/mL) and elevated lactate dehydrogenase of 1071 unit/L (normal 95-240 unit/L). Soluble interleukin-2 receptor alpha level was elevated at 60 727 units/mL (normal 223-710 units/mL). Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed abnormal tracer localisation within the paratracheal, hilar, pelvic, abdominal and subcarinal lymph nodes, along with FDG-PET positive hepatosplenomegaly. A bone marrow biopsy showed hypercellular marrow (95% cellularity) with trilineage haematopoiesis, haemophagocytic cells, polytypic plasmacytosis and T-cell lymphocytosis, along with positive latent membrane protein-1 immunohistochemical staining for EBV. EBV quantitative DNA PCR showed >1 million copies. These findings were consistent with a diagnosis of HLH secondary to EBV infection. Despite intense therapy with the HLH-94 protocol, the patient expired from her illness after a prolonged hospital course.

Amegakaryocytic thrombocytopenia with a positive direct Coombs' test.

A 50-year-old previously well woman developed a sudden onset of ecchymoses and petechiae over the trunk and extremities and gum bleeding. There was no history of alcohol use or drug ingestion. Physical examination was normal except for the ecchymoses, purpuric rash, and gum bleeding. Complete blood count showed Hb 8.0 g/dl, leucocytes 10.9 x 10(9)/L with a normal differential, platelets 8 x 10(9)/L and reticulocytes, 4%. The bone marrow was normocellular and showed absence of megakaryocytes; there was normoblastic erythroid hyperplasia and the myelopoiesis was normal. The direct Coombs test result was positive. There was poor response to treatment with prednisone and bolus doses of vincristine. Therapy with danazol resulted in the complete normalization of the blood counts, and the patient remains well 32 months after diagnosis and is currently taking 100 mg danazol daily.

[Macrothrombocytopenia with deafness, nephritis, cataract, short small intestine, and double ureter].

A 23 year old female, born in 1957, was diagnosed as having idiopathic thrombocytopenic purpura at the age of 3 and treated with prednisolone during her childhood with no response. On her regular check-up in 1978, facial edema and proteinuria suggested renal disease. The family history was negative for bleeding diathesis or renal disease. Close examination revealed the following: WBC 4,200/microliters without leukocyte inclusions, RBC 3.42 x 10(6)/microliters, Hb 11.7 g/dl. PT 10.6 sec, APTT 28.9 sec. Platelet count 4,500/microliters by HEMATRAK 360, and 40 x 10(3)/microliters measured by microscopic method. Giant platelets were noted on peripheral blood smear with an average diameter of 6.1 microns. Bleeding time (Duke) was 12.0 min. Number of megakaryocytes was increased although platelet production was remarkably decreased. Results of platelet aggregation and retention tests were normal. Platelet life span (T1/2) was 2.3 days. Sensory neural hearing loss, congenital cataract, double ureter and short small intestine were also found. Chromosome analysis showed 46XX. She underwent splenectomy resulting in increase of the platelet count to 226 x 10(3)/microliters. The increased platelet count, however, gradually decreased to the initial count in 2 years although the bleeding tendency was improved. In 1987, renal function deteriorated, causing intractable hypertension. The serum creatinine was 4.8 mg/dl. The following year she developed cerebral bleeding and died 4 days after the episode. The serum creatinine was 8.6 mg/dl.

[Meningococcemia: Different Serotypes in the Same Region].

Meningococcal infections are important health problems causing high morbidity and mortality. Neisseria meningitidis have 13 serogroups. A, B, C, Y and W135 are the most common causes of invasive disease among those serogroups. The distribution of the serogroups differs according to the geographical regions and the age groups. In this case report, two cases of meningococcemia infected with serogroup C and Y of N.meningitidis rarely seen in our country were presented. First case was a two and a half year-old female patient who has admitted to our pediatric emergency unit with fever and rash spreading from lower extremities to her body. The patient had diffuse purpuric rash with generalized weakness and tendency to sleep at admission. The patient has been suspected as meningococcemia because of the skin rash, tendency to sleep and hypotension. Antibiotics treatment was started immediately and lumber puncture was performed. In blood tests, leukocyte count: 3600/mm3 (61% neutrophils), hemoglobin: 11.1 g/ dl, platelet count: 127.000/mm3 , C-reactive protein: 10 mg/dl, erythrocyte sedimentation rate: 6 mm/ hour, prothrombin time: 28.8 seconds (normal value= 11-16), prothrombin activity: 36%, international normalized ratio (INR): 2.13 (normal value= 1-1.5), activated partial thromboplastin time: 57.7 seconds (normal value= 25-35 sec), fibrinogen: 246 mg/dl (normal value= 200-400 mg/dl) and in cerebrospinal fluid protein: 21 mg/dl and glucose: 62 mg/dl were found. There were eight cells in the microscopic examination. Skin rashes were increased and the patient became hypotensive. No microorganisms were isolated in blood and cerebrospinal cultures. N.meningitidis serogroup C was isolated from the cerebrospinal fluid of the patient using polymerase chain reaction (PCR). The patient suffered from immune-mediated arthritis in the sixth day of treatment and nonsteroidal anti-inflammatory drugs were given. The patient has recovered with antibiotics, fresh frozen plasma and inotropic treatment. Second case was a 13 year-old male patient who has admitted three days after the first case with a pre-diagnosis of malignancy because of pancytopenia and fever. The patient had generalized weakness and a few petechial purpuric rashes at the facial region at admission. After the admission general status of the patient has worsened rapidly and he has died as a result of cardiovascular arrest. Blood tests in admission showed leukocyte count: 6000/mm3 (79% neutrophils), hemoglobin: 17.3 mg/dl, platelet count: 16.000/mm3 , C-reactive protein: 8.63 mg/dl, prothrombin time: 92.6 seconds, prothrombin activity: 10%, INR: 6.78, activated partial thromboplastin time: 231.5 seconds. Cerebrospinal fluid obtained from postmortem lumbar puncture showed no growth (protein: 95 mg/dl, glucose: 35 mg/dl) and N.meningitidis serogroup Y was detected by PCR. Two meningococcemia cases caused by two different serogroups which are rarely seen in our region in recent years were presented at the same time period in the same hospital. This case report pointed out that surveillance has a great importance in such diseases.

[A case of systemic lupus erythematosus presenting with myelofibrosis as a cause of pancytopenia].

A 54 year-old woman who had a 6 month history of polyarthralgias, oral ulcers, weight loss and fatigue was admitted to the Urawa Municipal Hospital. She developed high fever, dyspnea and thrombocytopenia. Chest radiograph revealed massive right pleural effusion. At this time, laboratory investigations gave the following results: hemoglobin 12.7 g/dl, WBC 7700/microliters and platelet count 9.2 x 10(4)/microliters. Antibody to DNA was negative. Antinuclear antibody was positive at a titer of 320x in a centromere pattern; Anti-RNP and anti-Sm antibodies were negative. CH50 was 18.6 u/ml. C3 was 42.9 mg/dl. C4 was 11.5 mg/dl. Circulating immune complex (Clq) was 30.5 micrograms/ml. Circulating lupus anti-coagulant and anticardiolipine antibodies were positive. Thoracocentesis was performed; the material was a straw-colored exudate with over two thousands white cell per ul and showed marked reduction of complement titiers and elevated immune complex levels. She was then diagnosis as having SLE. Two weeks after admission, progressive leukopenia and anemia succeedingly occurred and resulted in severe pancytopenia. Bone marrow biopsy demonstrated marked marrow fibrosis and increased reticulin content with no evidence of malignancy. Steroid pulse therapy for 3 days started, and subsequently she was treated with 60 mg/day of prednisolone. Three weeks after starting on steroids, the massive pleural effusion was completely disappeared and complement titiers were normalized. Circulating immune complex has not been detected any more. After 8 weeks, the peripheral blood count was normalized. The dose of prednisolone was reduced progressively. On this occasion, the biopsy showed normocullular marrow with a marked reduction in the amount of reticulin.(ABSTRACT TRUNCATED AT 250 WORDS)

Extreme Thrombocytosis in a Child: Laboratory Approaches and Diagnostic Challenges.

Thrombocytosis in children as well as in adult is defined as platelet count ≥ 450 × 10<sup9</sup/L, and it is usually a reactive feature to various medical disorders. However, extreme thrombocytosis (platelet count ≥ 1000 × 10<sup9</sup/L) is an uncommon finding among pediatric and adult patients, which may indicate more than a reactive phenomenon. We describe a case of a five-year-old boy who was admitted due to recurrent epistaxis. He had no history of allergic tendency or trauma. Physical examination was unremarkable except for shotty neck nodes. Laboratory results at presentation showed normal hemoglobin and total leukocyte count with eosinophilia (0.92 × 10<sup9</sup/L), and extreme thrombocytosis. Other relevant investigations including coagulation profile, serum ferritin, liver, and renal function tests were all within normal ranges. Stool samples for ova and cysts were negative. The peripheral blood smear and bone marrow aspirate confirmed thrombocytosis with increased megakaryocytic proliferation and no artefactual reasons for the high platelets such as red blood cell fragments. Different causes of thrombocytosis in childhood were investigated after considering the possible differential diagnoses for extreme thrombocytosis.

[Autoimmune hemolytic anemia with eosinophilia in elderly patient].

A 70-year-old woman was admitted to our hospital in November 1992 for evaluation of anemia. Physical examination revealed anemia, jaundice, swelling of axial and inguinal lymph nodes, and splenomegaly. Abnormal hematological findings were as follows: Hb of 3.9 g/dl, reticulocyte count of 58.2% (61.7 x 10(4)/microliters), hyperplasia of normal erythroblasts in bone marrow, and eosinophilia (21.0%, 2352/microliters) in peripheral blood. Routine laboratory examinations revealed polycolonal hypergammaglobulinemia 3.0 g/dl, a high level of serum LDH (797 IU/I) and a total bilirubin of 2.4 mg/dl (indirect, 1.6 mg/dl). The serum haptoglobin level was very low (< 5 mg/dl). Results of serological examinations were as follows: IgG of 3366 mg/dl, CH50 of 16.0 U/ml, positive Coombs test 2+, and positive tests for antinuclear antibody, rheumatoid factor, and cold agglutinin. CRP was negative. PHA-stimulated lymphocyte blast formation, NK activity, and ADCC activity were found to be suppressed, and the percentage of CD4-positive lymphocytes in peripheral blood was also low. An axillary lymph node biopsy revealed reactive lymphadenitis. No signs or history suggested allergy, collagen disease, or parasitic infection. Autoimmune hemolytic anemia (AIHA) complicated by immunologic abnormalities and eosinophilia was diagnosed. Oral prednisolone markedly reduced the hemolytic anemia, eosinophilia, lymph node swelling, and splenomegaly, but NK activity remained low.

[A case of elderly-onset systemic lupus erythematosus (SLE) complicated with severe liver dysfunction and pancytopenia due to myelofibrosis].

A 67-year-old woman was admitted to our hospital with a fever. She had been experiencing arthralgia for about one month. On admission, she had a fever of 38.5 degrees C, was anemic and was experiencing tenderness in the joints of both hands, elbows and feet. Laboratory data revealed proteinuria, urinary cylinders, pancytopenia (WBC 900/mm3, Hb 9.5 g/dl, Plt 7.8 x 10(4)/mm3), liver dysfunction (GOT 414 IU/l, GPT 140 IU/l), and hyper-gamma globulinemia. Antibiotics and granulocyte-colony stimulating factor were administered intravenously. Bone marrow aspiration was unsuccessful, but a bone marrow biopsy revealed bone marrow fibrosis. Immunological examinations were positive for antinuclear antibodies, anti-deoxyribonucleic acid (DNA) antibodies, anti-double stranded anti- DNA antibodies, as well as a decreased level of serum complement and an increased level of serum immune complexes. Tests for viral antigens and antibodies known to cause hepatitis were negative. Based on these findings, a diagnosis of SLE accompanied by liver dysfunction and bone marrow fibrosis was made. Steroid pulse therapy was initiated, but her liver function deteriorated on the first day of steroid therapy, and she died three days later. SLE accompanied by myelofibrosis is extremely rare, and only 17 and cases have been reported to date. Among these reports, the present case is the second oldest subject and the first SLE patient to suffer from both myelofibrosis and severe liver dysfunction.

Agranulocytosis -- Evaluation

The diagnosis of agranulocytosis requires a high degree of suspicion based on signs and symptoms, medication use, recent exposure to chemical agents, and infections. A complete blood count (CBC) with the differential count is used in the initial workup. An absolute neutrophil count (ANC) of less than 100 neutrophils per microlitre of blood is necessary to diagnose the condition. The peripheral blood smear should assess neutrophil morphology. A Wright-stained peripheral smear will show a marked decrease and absence of neutrophils. Erythrocyte sedimentation rate (ESR), C reactive protein (CRP), coagulation studies (prothrombin time, partial thromboplastin time, D-dimer), lactate dehydrogenase (LDH), antinuclear antibody (ANA), rheumatoid factor (RF), liver function tests (LFT), renal function tests (RFT), and urine analysis can be used in patients with a relevant history. If the patient is febrile, cultures of the blood, urine, sputum and other suspected sites of infection should be taken. No imaging technique is used to diagnose agranulocytosis, but a chest X-ray (CXR) can be used for the initial workup. Further, bone marrow aspiration and biopsy can be used after an initial abnormal blood smear.

Pseudothrombocytopenia in a patient undergoing splenectomy of an accessory spleen. Case report.

Coagulation tests (CBC and prothrombin time) were initially conceived as a mean of screening and following rare congenital coagulopathies; the CBC provides the number of platelets per cubic milliliter. The objective of this report was to present the case of a patient who presented with an extremely low number of platelets when her blood was analyzed in an EDTA-containing tube and its numbers were normal when the blood was analyzed with citrate, alerting for the risk of erroneously administering blood products. This is the case of a 40-year-old female patient, ASA II. In 2001 she presented with thrombocytopenia and was referred to a hematologist in Manaus, in the state of Amazonas, Brazil and underwent splenectomy that same year with a diagnosis of idiopathic thrombocytopenic purpura. Since her CBCs continued to show thrombocytopenia, an abdominal ultrasound was done and showed a spherical hypoechoic image, with an echotexture similar to the spleen, measuring 2.0 x 1.7 cm, with well-defined contents (accessory spleen), and a splenectomy was indicated. One hour into the surgery, blood samples were drawn for CBC and chemistry: Hb = 11.3 g x dL(-1); Ht = 33.4%; Platelets = 35,000 microL(-1); PT = 15.2 (86.0% Activity) (INR = 1.09). Due to the minimal blood loss in the surgical field, a new test with citrate was requested to determine the platelet count (results: 138,000 platelets). The anomalous result of an isolated exam without corresponding clinical signs should not guide the treatment. All exams have a defined percentage of errors and the search for those technical errors can avoid the use of the wrong treatment.

[Thrombotic thrombocytopenic pupura (TTP)--remission following treatment with high-dose immunoglobulin].

A 60-year-old man was admitted to our hospital because of fever, hemorrhagic tendency, anemia and neurological abnormality. A blood count revealed that the hemoglobin was 6.8 g/dl, the reticulocyte was 17.3 percent with 2 erythroblasts per 100 white cells, the white cell count was 7,100/microliters and the platelet count was 0.8 x 10(4)/microliters. Peripheral blood smear demonstrated marked fragmentation of red cells. Bone marrow examination disclosed the marked erythroid hyperplasia. Although the bleeding time was prolonged (14 minutes 30 seconds), the other hemostatic data were within normal limits. The serum bilirubin level was 1.57 mg/dl; LDH level, 1,437 U/l; creatinine level, 0.92 mg/dl; BUN level 14.7 mg/dl. Haptoglobin was below 10 mg/dl. Results of immunological tests were all negative except the result of PAIgG (576.6 ng/10(7) cells). The urinalysis showed proteinuria, microhematuria and trace granular and hyaline casts. A diagnosis of thrombotic thrombocytopenic purpura was made. The patient was initially treated with prednisolone (60 mg), aspirin (1,000 mg), dipyridamole (150 mg), gabexate mesilate (1.5 g), sodium oxagrel (80 mg) daily with little response. The thirty days after admission, infusion of gamma globulin (20 g, daily) was given for 3 days. The clinical state and laboratory findings became dramatically improved shortly after the administration of gamma globulin and the laboratory data came to be normalized after 1 month. After ten months of this treatment, the patient is remained asymptomatic and the hematological data are within normal range without using any drug. A trial seems justified to confirm the value of this mode of therapy.

Polycythemia vera

Following history and examination, the British Committee for Standards in Haematology (BCSH) recommend the following tests are performed: full blood count/film (raised hematocrit; neutrophils, basophils, platelets raised in half of patients) JAK2 mutation serum ferritin renal and liver function tests If the JAK2 mutation is negative and there is no obvious secondary causes the BCSH suggest the following tests: red cell mass arterial oxygen saturation abdominal ultrasound serum erythropoietin level bone marrow aspirate and trephine cytogenetic analysis erythroid burst-forming unit (BFU-E) culture Other features that may be seen in polycythemia vera include a low ESR and a raised leukocyte alkaline phosphatase. The diagnostic criteria for polycythemia vera have recently been updated by the BCSH. This replaces the previous Polycythemia Vera Study Group criteria. JAK2-positive polycythemia vera - diagnosis requires both criteria to be present:

Gestational thrombocytopenia

In order for the physician to determine the underlying cause of the gestational thrombocytopenia, the following tests are conducted - Blood Test During routine prenatal checkups, the physician will conduct a complete blood count test to determine the components of blood. The complete blood count will provide further information about platelet levels along. The physician may conduct a blood test for platelet antibodies, which maybe produced as a result of a certain drug, such as quinine. The physician may also conduct blood clot test by adding chemicals to blood to determine how long it takes for the blood to clot. Ultrasound The physician may conduct an ultrasound around the spleen to determine if the spleen is enlarged due to an overactive spleen. The ultrasound will provide an image of the spleen and the doctor will compare it to a normal sized spleen. Bone Marrow Aspiration and/or Biopsy

InternalMed_Harrison

The history and physical examination, results of the CBC, and review of the peripheral blood smear are all critical components in the initial evaluation of thrombocytopenic patients (Fig. 140-2). The overall health of the patient and whether he or she is receiving drug treatment will influence the differential diagnosis. A healthy young adult with thrombocytopenia will have a much more limited differential diagnosis than an ill hospitalized patient who is receiving multiple medications. Except in unusual inherited disorders, decreased platelet production usually results from bone marrow disorders that also affect red blood cell (RBC) and/or white blood cell (WBC) production. Because myelodysplasia can present with isolated thrombocytopenia, the bone marrow should be examined in patients presenting with isolated thrombocytopenia who are older than 60 years of age. While inherited thrombocytopenia is rare, any prior platelet counts should be retrieved and a family history regarding

[A case of rheumatoid arthritis complicated with idiopathic thrombocytopenic purpura and Hashimoto's disease].

A 37 year old nurse with the rare combination of idiopathic thrombocytopenic purpura (ITP), Hashimoto's thyroiditis and rheumatoid arthritis (RA) was reported. In 1983, six years before her final diagnosis was made, she presented with purpura over her extremities and swelling of the cervical lymph nodes. Laboratory findings showed the following: platelet count 15 x 10(3)/microliters, the number of megakaryocyte without platelet production in bone marrow was increased, platelet life span (T1/2) 11 min. A diagnosis of ITP was made. In 1984 goiter was noticed. Laboratory data were as follows: T3 502ng/ml, T4 27.0 micrograms/dl, thyroid test x 1,600, microsome test x 409,600. She was diagnosed as having ITP and Hashimotoxicosis. She had been uneventful except temporary hyperthyroidism until 1989 when she developed morning stiffness, polyarthralgia, swelling of PIP joints, contracture of elbow joints and hallux valgus. Laboratory investigation were reported as follows. ESR 111mm/h, platelet count 31 x 10(3)/microliters, platelet associated IgG 800ng/10(7) pl, antinuclear antibody x 2,560, rheumatoid factor 1+, microsome test x 1,600, anti-DNA antibody 3U/ml. Anti-Sm antibody and anti-RNP antibody were not detected. The LE cell test was negative. Schirmer test and sialography were interpreted as normal. These findings confirmed the diagnosis of RA in addition to ITP and Hashimoto's thyroiditis. The combination of RA, ITP and Hashimoto's thyroiditis is extremely rare although these three disorders are classified as autoimmune disease.

[Erythrocytosis in a 4 year-old child: diagnostic, prognostic, therapeutical problems].

Pure erythrocytosis is rare in children. This report describes such a case. A 4 year-old boy was admitted because erythrocytosis had been found routinely before adenoidectomy. He was born in Guatemala, was adopted just after his birth, and had been living in France since that age. Clinical examination was normal. His hemogram showed: erythrocytes: 8,800,000/mm3; hemoglobin: 20.1 g/dl; hematocrit: 66.8%; reticulocytes: 262,000/mm3; platelets: 200,000/mm3; leukocytes: 6,800/mm3. The patient had been given iron salts for the past 3 months without an earlier hemogram. Total red cell mass was 1200 ml (N: 600). The myelogram was normal as was the leukocyte alkaline phosphatases, serum lysozyme and vitamin B12. Blood ferritin was low (3.5 ng/ml). In vitro cultures of erythroid precursors were normal, as was the karyotype of myeloid cells. Blood erythropoietin concentration was 20-293 mU/ml (N:4-14). All the causes of secondary polycythemia were eliminated by appropriate investigations. The patient was treated by phlebotomy in aliquots of 25 ml/kg, twice a month, for 10 months, and was given iron therapy. At the end of treatment, his hemoglobin was 14 g/dl and his hematocrit was 45%. Both progressively increased again one year later, requiring new phlebotomies. The patient was followed for 4 years but no cause for this erythrocytosis was found; it was probably congenital in origin. This case of pure erythrocytosis was associated with elevated erythropoietin production. Whether this high secretion is related to receptor dysfunction remains to be determined.

Hematopoietic stem cell transplantation

Severe reactions A study that surveyed 2,408 donors found that serious adverse events (requiring prolonged hospitalization) occurred in 15 donors (at a rate of 0.6%), although none of these events was fatal. Donors were not observed to have higher than normal rates of cancer with up to 4–8 years of follow-up. One study based on a survey of medical teams covered about 24,000 peripheral blood HSCT cases between 1993 and 2005, and found a serious cardiovascular adverse reaction rate of about one in 1,500. This study reported a cardiovascular-related fatality risk within the first 30 days of HSCT of about two in 10,000. History In 1939, a woman with aplastic anaemia received the first human bone marrow transfusion. This patient received regular blood transfusions, and an attempt was made to increase her leukocyte and platelet counts by intravenous bone marrow injection without unexpected reaction.

[Possible role of immunocompetent cells on periodic exacerbation of idiopathic thrombocytopenic purpura].

A 44 year-old man was admitted to our hospital in October, 1992 with epistaxis. Fifteen months before admission, thrombocytopenia had been pointed out, but he had no bleeding episode. At admission, neither hepatosplenomegaly nor lymph node swelling was observed. Hematological findings were as follows; WBC 10,000/microliter, Hb 14.0 g/dl, PLT 5,000/microliter, including giant platelets. Platelet associated IgG (PAIgG) was 471 ng/10(7) cells. Bone marrow aspiration revealed normocellularity with moderate increase in the number of mature megakaryocytes, but no dysplastic changes were seen. Biochemical and radiological examinations disclosed neither malignant diseases nor autoimmune diseases. Based on the diagnosis of idiopathic thrombocytopenic purpura, danazol therapy (300 mg/day) was started in November, 1992. After initiation of treatment, the platelet count changed cyclically every 4 weeks. To elecuidate the mechanism of this phenomenon, we periodically evaluated the patient's immunological background. T lymphocyte counts and subset proportions remained almost the same through out the course, whereas NK cell counts and NK activity coincided with the change of the platelet count. These results suggest that in this case NK cells may play a role in the cyclic fluctuation of platelet count by regulating the immune system.

Acute myelomonocytic leukemia

Diagnosis Criteria for AMML is confirmed if the myleoblasts and promonocytes in the bone marrow are greater than 20 percent. Also can be confirmed if the blood monocyte is 5 x 10 to the ninth power lites or higher. Testing available to diagnosis AML includes a complete blood count which is characterized by blood is taken from the vein in the arm to test for leukemia, a peripheral blood smear, and a bone marrow test. During a peripheral blood smear, a sample of blood is checked for blast cells, white blood cell amount, and changes in shape of blood cells. During a bone marrow test, bone marrow is taken from the hip bone in search of leukemia cells. Aspiration and Biopsy are two types of testing that can be done in order to obtain bone marrow. Further classification can be done for the type of AML from examining the cells shape and size. Generally you'll find immature cells which lack normal features of a cell.

Thrombocytopenia

Diagnosis Laboratory tests for thrombocytopenia might include full blood count, liver enzymes, kidney function, vitamin B12 levels, folic acid levels, erythrocyte sedimentation rate, and peripheral blood smear. If the cause for the low platelet count remains unclear, a bone marrow biopsy is usually recommended to differentiate cases of decreased platelet production from cases of peripheral platelet destruction. Thrombocytopenia in hospitalized alcoholics may be caused by spleen enlargement, folate deficiency, and most frequently, the direct toxic effect of alcohol on production, survival time, and function of platelets. Platelet count begins to rise after 2 to 5 days' abstinence from alcohol. The condition is generally benign, and clinically significant hemorrhage is rare.

[A case with petechiae due to human parvovirus B19].

We reported a case of 10-year-old girl with petechiae mainly on the truncus, although who had more than 10 x 10(4)/microliter of platelets. Smears of her bone marrow demonstrated extreme reduction of erythroblasts with giant proerythroblast like cells, which does not consist with idiopathic thrombocytopenic purpura. Human parvovirus B19 (B19) DNA was detected in her serum and throat swab using PCR and significant alterations of B19 specific IgM and IgG antibody titers were demonstrated. The petechiae subsided on the 8th day after her admission. She had not shown anemia less than Hb 10 g/dl, but her reticulocytes counts had increased up to 3.5% on the 11th day after her admission. Smears of her bone marrow on the 17th day became normal with moderate erythroblasts. It is demonstrated that the cellular receptor of this virus is an antigen of the blood group P recently. P antigen is presented not only on erythrocytes and on erythroblasts but also on megakaryocytes and endotherial cells. Therefore, it is suggested that direct injury by B19 to endothelial cells could cause petechiae in this case.

Complete blood count

Manual

Oncology

Diagnosis and staging Diagnostic and staging investigations depend on the size and type of malignancy. Blood cancer Blood investigations including hemoglobin, total leukocyte count, platelet count, peripheral smear, red cell indices. Bone marrow studies including aspiration, flow cytometry, cytogenetics, fluorescent in situ hybridisation and molecular studies. Lymphoma Excision biopsy of lymph node for histopathological examination, immunohistochemistry, and molecular studies. Blood investigations include lactate dehydrogenase (LDH), serum uric acid, and kidney function tests. Imaging tests such as computerised tomography (CT scan), positron emission tomography (PET CT). Bone marrow biopsy. Solid tumors Biopsy for histopathology and immunohistochemistry. Imaging tests like X-ray, ultrasonography, computerised tomography (CT), magnetic resonance imaging (MRI) and PET CT.

A case of focal segmental glomerulosclerosis associated with aplastic anemia.

The pathogenic mechanism of focal segmental glomerulosclerosis (FSGS) and aplastic anemia are associated with immunologic events which lead to glomerular cell injury or hematopoietic cell destruction. We present an extremely rare case of FSGS with aplastic anemia in a 30-yr-old woman. The laboratory examination showed hemoglobin 7.2 g/dL, white blood count of 4,200/ microL, platelet count 70,900/microL. Proteinuria (2+, 3.6 g/day) and microscopic hematuria were detected in urinalysis. The diagnosis of FSGS and aplastic anemia were confirmed by renal and bone marrow biopsy. She was treated with immunosuppressive therapy of prednisone 60 mg/day orally for 8 weeks and cyclosporine A 15 mg/kg/day orally. She responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts. Prednisone was maintained at the adequate doses with tapering after 8 weeks and cyclosporine was given to achieve trough serum levels of 100-200 ng/mL. At review ten month after diagnosis and initial therapy, the patient was feeling well and her blood cell counts increased to near normal (Hb 9.5 g/dL, Hct 32%, WBC 8,300/microL, platelet 123,000/microL) and renal function maintains stable with normal range proteinuria (0.25 g/day).

The role of the bone marrow examination in the diagnosis of immune thrombocytopenic purpura: case series and literature review.

The need for a bone marrow examination was assessed in patients with clinical and laboratory features consistent with ITP; the literature was reviewed. The records of all patients undergoing a bone marrow examination between January 1988 to January 1998 were retrospectively reviewed to determine which were motivated by the suspicion of ITP. Data were collected from hospital and outpatient medical and pathology records. Eighty-six patients with isolated thrombocytopenia (i.e., normal white blood cell count, hemoglobin, peripheral smear and clotting studies) were studied. The bone marrow was consistent with ITP in 82 patients, (i.e., normal or increased megakaryocytes and other hemopoietic lineages normal.) Four patients had decreased megakaryocytes, but all patients responded to corticosteroids. All 86 patients were followed up for a median of 22 months after bone marrow aspiration (range, 2-76 months.) During that time, none of the patients developed features to suggest an alternative diagnosis to ITP. The initial clinical and laboratory findings of 99 patients with acute leukemia were also reviewed; all had features atypical of ITP. These data suggest that routine performance of a bone marrow examination for the diagnosis of ITP is not necessary, provided that a thorough history and physical examination are performed and that the complete blood cell count, peripheral blood smear, and routine clotting studies show no abnormalities apart from thrombocytopenia. The findings of seven prior retrospective studies, two in adults and five in children are consistent with the previous findings. However, the value of marrow investigation in ITP remains unresolved and data from a large prospective study would be helpful.

InternalMed_Harrison

Thrombocytopenia results from one or more of three processes: (1) decreased bone marrow production; (2) sequestration, usually in an enlarged spleen; and/or (3) increased platelet destruction. Disorders of production may be either inherited or acquired. In evaluating a patient with thrombocytopenia, a key step is to review the peripheral blood smear and to first rule out “pseudothrombocytopenia,” particularly in a patient without an apparent cause for the thrombocytopenia. Pseudothrombocytopenia (Fig. 140-1B) is an in vitro artifact resulting from platelet agglutination via antibodies (usually IgG, but also IgM and IgA) when the calcium content is decreased by blood collection in ethylenediamine tetraacetic (EDTA) (the anticoagulant present in tubes [purple top] used to collect blood for complete blood counts [CBCs]). If a low platelet count is obtained in EDTA-anticoagulated blood, a blood smear should be evaluated and a platelet count determined in blood collected into sodium

Multiple visceral hematomas in a child with familial Mediterranean fever: polyarteritis nodosa.

A 14-year-old girl was diagnosed with familial Mediterranean fever (FMF) with homozygous for M694V mutation of the MEFV gene and was started on colchicine therapy 4 years before admission to our hospital. She was uncompliant to therapy and was admitted to a local hospital with complaining of fever, malaise, abdominal pain and artralgia lasting for 2 months. Multiple hypoechogenic mass lesions were detected on liver and kidneys with ultrasonography (US) and diagnosed to be hematomas by laparoscopic examination. She was referred to our hospital because of development of convulsions. On physical examination her blood pressure was 140/90 mmHg and body temperature was 39 degrees C. She was pale and extremely cachectic, with atrophic muscles of the extremities. She had diffuse abdominal tenderness and hepatosplenomegaly. Laboratory investigations revealed a hemoglobin of 9.8 g/dl, white blood cell count 9,900/mm3, platelets 213,000/mm3, erythrocyte sedimentation rate (ESR) 112 mm/h, C- reactive protein (CRP) 78 mg/L (normal < 2 mg/L) and fibrinogen 500 mg/dl. Electrolytes, renal and hepatic functions and urinalysis were normal. Examinations of peripheric blood smear and bone marrow aspiration were normal. X-rays of bones and chest showed no pathological finding. Protrombine, partial thromboplastine and bleeding times were normal. Bacterial cultures of blood, urine and stool grew no organisms. Serological tests for hepatitis B and C, cytomegalovirus, salmonella and brucella were negative.

Complete blood count

Other parameters

Severe thrombocytopenia possibly associated with TMP/SMX therapy.

To report a case of possible severe, life-threatening thrombocytopenia associated with trimethoprim/sulfamethoxazole (TMP/SMX) therapy. A 54-year-old white woman received a 10-day course of TMP/SMX for treatment of chronic sinusitis. One day after finishing the course of TMP/SMX therapy, the presented to the emergency department because of the development of scattered petechiae on both hands and blood blisters in her mouth. On admission, her complete blood cell count results revealed a severely low platelet count of 2 x 10(3)/mm3. Other laboratory test results were normal, except for elevated blood glucose (nonfasting blood glucose). TMP/SMX was believed to be the most likely cause of thrombocytopenia. She was treated successfully with a transfusion of 2 units of platelets and oral prednisone. Her platelet count increased to 110 x 10(3)/mm3 4 days after discontinuation of TMP/SMX. She was discharged on hospital day 5. On follow-up (2 wk after hospital discharge), her platelet count was normal (351 x 10(3)/mm3). TMP/SMX has been implicated as a cause of thrombocytopenia, which is defined as platelet count < 150 x 10(3)/mm3. Although it is uncommon, spontaneous severe bleeding may occur when platelet count decreases to < or = 10 x 10(3)/mm3. Thrombocytopenia associated with TMP/SMX appears to be an immune-mediated process resulting in platelet destruction by drug-dependent platelet antibodies. Treatment of thrombocytopenia associated with TMP/SMX therapy includes discontinuation of the offending drug and the use of corticosteroids. Platelet transfusion and intravenous immunoglobulin may be required in some patients. Thrombocytopenia associated with TMP/SMX therapy can be serious or life threatening because it may result in significant bleeding complications. This hematologic adverse effect of TMP/SMX may occur even with the usual recommended dosage and duration of therapy. Careful monitoring of complete blood cell count, including platelet count, before and during TMP/SMX therapy is suggested.

[Blood morphology in elderly persons over 90 years old].

In order to assess blood cell count in a late senescence we examined 56 persons (44 women and 12 men) in age 90-99, in a good condition. Over 70% of obtained results were in normal range. The most frequent abnormalities were: anemia (28.6%), leukopenia < 4,000 in 1 mm3 16.1%, thrombocytopenia < 125,000 in 1 mm3 -10.7% of subjects. In a white blood count low value of rod neutrophils and monocytes were found. The results show that the haematological diagnosis in elderly does not require any special references intervals.

Sideroblastic anemia

Diagnosis Ringed sideroblasts are seen in the bone marrow. On the peripheral blood smear can be found erythrocytes with basophilic stippling (cytoplasmic granules of RNA precipitates) and Pappenheimer bodies (cytoplasmic granules of iron). The anemia is moderate to severe and dimorphic. Microscopic viewing of the red blood cells will reveal marked unequal cell size and abnormal cell shape. Basophilic stippling is marked and target cells are common. The mean cell volume is commonly decreased (i.e., a microcytic anemia), but it may also be normal or even high. The RDW is increased with the red blood cell histogram shifted to the left. Leukocytes and platelets are normal. Bone marrow shows erythroid hyperplasia with a maturation arrest.In excess of 40% of the developing erythrocytes are ringed sideroblasts. Serum iron, percentage saturation and ferritin are increased. The total iron-binding capacity of the cells is normal to decreased. Stainable marrow hemosiderin is increased.