Abstract 16926: Outside The Box But All Squeezed In: A 23-year-old Man With Progressive Dyspnea After Overseas Travel

Case Presentation: A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus ( Figure ). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam; we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Re-examination identified a red-brown plaque on the patient’s thigh; biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis. Discussion: Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with “out-of-the-box” thinking.

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Refractory Ascites as the Only Presenting Symptom of Chronic Calcified Constrictive Pericarditis: A Diagnostic Challenge

The Heart Surgery Forum ◽

10.1532/hsf98.2013251 ◽

2014 ◽

Vol 17 (1) ◽

pp. 42

Author(s):

Shi-Min Yuan

Keyword(s):

Computed Tomography ◽

Liver Cirrhosis ◽

Female Patient ◽

Constrictive Pericarditis ◽

Delayed Diagnosis ◽

Young Female ◽

Refractory Ascites ◽

Diagnostic Challenge ◽

Massive Ascites ◽

History Of

Extracardiac manifestations of constrictive pericarditis, such as massive ascites and liver cirrhosis, often cover the true situation and lead to a delayed diagnosis. A young female patient was referred to this hospital due to a 4-year history of refractory ascites as the only presenting symptom. A diagnosis of chronic calcified constrictive pericarditis was eventually established based on echocardiography, ultrasonography, and computed tomography. Cardiac catheterization was not performed. Pericardiectomy led to relief of her ascites. Refractory ascites warrants thorough investigation for constrictive pericarditis.

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807 Diagnostic Pathways of Patients Authorized for Obstructive Sleep Apnea Testing and Treatment: A Retrospective Claims Analysis

SLEEP ◽

10.1093/sleep/zsab072.804 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A315-A315

Author(s):

Binh Nguyen ◽

Aliza Gordon ◽

Stefanida Blake ◽

Lakshmi Kalluri ◽

Winnie Chi ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Laboratory Testing ◽

Diagnostic Testing ◽

Prior Authorization ◽

Home Test ◽

Home Testing ◽

Obstructive Sleep ◽

Osa Treatment ◽

Diagnostic Pathways ◽

Lab Test

Abstract Introduction Obstructive Sleep Apnea (OSA) has been shown to reduce health-related quality of life and is associated with cardiovascular disease and other negative health outcomes. However, many patients with suspected OSA are never tested, thereby remaining undiagnosed and untreated. In this study, we explore the diagnostic pathways and eventual treatment of individuals with suspected OSA. Methods We conducted a retrospective, observational study, linking claims and prior authorization data of a large, geographically diverse health insurer’s commercial and Medicare Advantage members. Our sample included adults with suspected OSA and no prior OSA history, whose diagnostic testing had been approved through prior authorization (N=75,011). Using a 3-month time window following authorization, we searched for a claim to match the authorized service (home or laboratory sleep testing). We also looked for subsequent prior authorization for OSA treatment (Positive Airway Pressure (PAP) or oral appliance) and corresponding claims for those treatments within the 3-month authorization window. Results Among the study sample (N=75,011), 40,002 (53.3%) had home testing only, 17,319 (23.1%) had laboratory testing only, and 6,053 (8.1%) had a home test followed by a laboratory test. Only 476 (0.6%) had a home test after the date of a lab test. 11,161 individuals (14.9%) did not complete any sleep test. Of the 63,850 individuals with any sleep testing, 39,062 (61.2%) received prior authorization for initiating OSA treatment, and 36,158 (92.6%) of them had a corresponding claim for treatment. Conclusion One in eight adults with suspected OSA for whom diagnostic testing was authorized did not undergo testing; among those who tested, home testing was most common. While it is clinically appropriate to follow a negative home test with a lab test since a home test cannot rule out OSA (only confirm it), the study notes that a significant number of those with a home test require follow-up laboratory testing. Together, this represents an opportunity for reducing barriers to testing and improvement in home testing technology. Support (if any) This study was funded by Anthem, Inc.

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Tuberculosis in Otorhinolaryngology: Clinical Presentation and Diagnostic Challenges

International Journal of Otolaryngology ◽

10.1155/2011/686894 ◽

2011 ◽

Vol 2011 ◽

pp. 1-4 ◽

Cited By ~ 11

Author(s):

Rajiv C. Michael ◽

Joy S. Michael

Keyword(s):

Mycobacterium Tuberculosis ◽

Pulmonary Tuberculosis ◽

Clinical Presentation ◽

Extrapulmonary Tuberculosis ◽

Common Type ◽

The Body ◽

Diagnostic Challenge ◽

Cervical Adenitis ◽

Important Form

Tuberculosis affects all tissues of the body, although some more commonly than the others. Pulmonary tuberculosis is the most common type of tuberculosis accounting for approximately 80% of the tuberculosis cases. Tuberculosis of the otorhinolaryngeal region is one of the rarer forms of extrapulmonary tuberculosis but still poses a significant clinical and diagnostic challenge. Over three years, only five out of 121 patients suspected to have tuberculosis of the otorhinolaryngeal region (cervical adenitis excluded) hadMycobacterium tuberculosisculture-proven disease. Additional 7 had histology-proven tuberculosis. Only one patient had concomitant sputum-positive pulmonary tuberculosis. We look at the various clinical and laboratory aspects of tuberculosis of the otorhinolaryngeal region that would help to diagnose this uncommon but important form of extrapulmonary tuberculosis.

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Tuberculous Pachymeningitis Presenting as a Diffused Dural Thickening in a Patient with Chronic Headache and Recurrent Neurological Abnormalities for More than a Decade: A Case Report and a Review of the Literature

Case Reports in Infectious Diseases ◽

10.1155/2018/3012034 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5

Author(s):

C. L. Fonseka ◽

T. E. Kanakkahewa ◽

S. D. A. L. Singhapura ◽

J. S. Hewavithana ◽

L. P. Kolambage ◽

...

Keyword(s):

Case Report ◽

Chronic Headache ◽

Facial Nerve Palsy ◽

Extrapulmonary Tuberculosis ◽

Granulomatous Inflammation ◽

Mantoux Test ◽

Resonance Imaging ◽

Neurological Signs ◽

Neurological Abnormalities ◽

Contrast Enhanced

Background. Tuberculous pachymeningitis is a rare form of extrapulmonary tuberculosis usually suspected from the detection of thickening of the dura in contrast-enhanced magnetic resonance imaging. Progressive nature of the disease can lead to chronic headache with focal neurological signs due to compression from the thickened dura. Case Report. We report a 40-year-old female who presented with chronic headache over a decade associated with recurrent neurological abnormalities including optic neuritis, hemisensory loss, migraine, facial nerve palsy, and recurrent vertigo. Although there was an initial perceived response to steroids, the patient had a subsequent progressive course. On investigations, she was found to have a diffused dural thickening on contrast MRI with a strongly positive Mantoux test with caseating necrotizing granulomatous inflammation on dural histology. With initiation of antituberculous medication with steroids, the patient markedly improved, and the medication for tuberculosis was continued for a year with good response. Conclusion. Primary tuberculous pachymeningitis should be suspected in a patient complaining of prolonged headache with focal neurological signs when MRI evidence of dural thickening is detected, and another focus of tuberculosis was not found. Prompt suspicion with image-guided dural biopsy for histology would help to confirm the diagnosis.

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Primary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries

BMJ Open ◽

10.1136/bmjopen-2021-049257 ◽

2021 ◽

Vol 11 (7) ◽

pp. e049257

Author(s):

Alike W van der Velden ◽

Eva A Bax ◽

Emily Bongard ◽

Rune Munck Aabenhus ◽

Marilena Anastasaki ◽

...

Keyword(s):

Primary Care ◽

Tract Infection ◽

Respiratory Tract ◽

Respiratory Tract Infection ◽

Laboratory Testing ◽

Diagnostic Testing ◽

European Countries ◽

Fine Tuning ◽

Face To Face ◽

Degree Of Confidence

ObjectiveTo describe primary health care (consultation characteristics and management) for patients contacting their general practitioner (GP) with a respiratory tract infection (RTI) early on in the COVID-19 pandemic in contrasting European countries, with comparison to prepandemic findings.SettingPrimary care in 16 countries (79 practices), when no routine SARS-CoV-2 testing was generally available.Design and participantsBefore (n=4376) and early in the pandemic (n=3301), patients with RTI symptoms were registered in this prospective audit study.Outcome measuresConsultation characteristics (type of contact and use of PPE) and management characteristics (clinical assessments, diagnostic testing, prescribing, advice and referral) were registered. Differences in these characteristics between countries and between pandemic and prepandemic care are described.ResultsCare for patients with RTIs rapidly switched to telephone/video consultations (10% in Armenia, 91% in Denmark), and when consultations were face-to-face, GPs used PPE during 97% (95% CI 96% to 98%) of contacts. Laboratory testing for SARS-CoV-2 in primary care patients with RTIs was rapidly implemented in Denmark (59%) and Germany (31%), while overall testing for C reactive protein decreased. The proportion of patients prescribed antibiotics varied considerably between countries (3% in Belgium, 48% in UK) and was lower during the pandemic compared with the months before, except for Greece, Poland and UK. GPs provided frequent and varied COVID-related advice and more frequently scheduled a follow-up contact (50%, 95% CI 48% to 52%). GPs reported a slightly higher degree of confidence in the likely effectiveness of their management in face-to-face (73% (very) confident, 95% CI 71% to 76%) than in virtual consultations (69%, 95% CI 67% to 71%).ConclusionsDespite between-country variation in consultation characteristics, access to SARS-CoV-2 laboratory testing and medication prescribing, GPs reported a high degree of confidence in managing their patients with RTIs in the emerging pandemic. Insight in the highly variable pandemic responses, as measured in this multicountry audit, can aid in fine-tuning national action and in coordinating a pan-European response during future pandemic threats.

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Isolated Pancreatic Tuberculosis Mimicking Pancreatic Cancer: A Diagnostic Challenge

Case Reports in Gastrointestinal Medicine ◽

10.1155/2018/7871503 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Abhishek Bhurwal ◽

Muhammad Masoodul Haq ◽

Sunil Sapru ◽

Matthew Tortora ◽

Dhanasekaran Ramasamy

Keyword(s):

Pancreatic Tumor ◽

Extrapulmonary Tuberculosis ◽

Rare Condition ◽

Abdominal Tuberculosis ◽

Needle Aspiration ◽

Diagnostic Challenge ◽

Prognostic Implication ◽

Pancreatic Tuberculosis ◽

Antituberculosis Therapy ◽

Persistent Abdominal Pain

Isolated pancreatic tuberculosis is an exceedingly rare condition, even in areas of the world where the disease is highly prevalent. Abdominal tuberculosis is a common form of extrapulmonary tuberculosis but involvement of the pancreas is very rare. We report a case of isolated pancreatic tuberculosis presenting as a pancreatic mass in a patient with persistent abdominal pain and jaundice. Clinically and radiologically, the mass mimicked a malignant pancreatic tumor with a vastly different prognostic implication and therapeutic approach. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) can provide valuable diagnostic information in this scenario. After the tissue showed evidence of acid-fast bacilli and the cultures showed growth of Mycobacterium tuberculosis, antituberculosis therapy was initiated. Conservative management is usually successful in alleviating symptoms and leading to a cure. The excellent response to ATT makes it imperative that these patients are diagnosed early and managed appropriately to avoid unnecessary surgery and associated morbidity.

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Current nursing practice of point-of-care laboratory diagnostic testing in critical care units

American Journal of Critical Care ◽

10.4037/ajcc1995.4.6.429 ◽

1995 ◽

Vol 4 (6) ◽

pp. 429-434 ◽

Cited By ~ 20

Author(s):

Lamb LSJr ◽

RS Parrish ◽

SF Goran ◽

MH Biel

Keyword(s):

Critical Care ◽

Patient Care ◽

Laboratory Testing ◽

Point Of Care ◽

Diagnostic Testing ◽

Critical Care Nurses ◽

Point Of Care Testing ◽

Critical Care Units ◽

In Vitro Diagnostic

BACKGROUND: The development of user-friendly laboratory analyzers, combined with the need for rapid assessment of critically ill patients, has led to the performance of in vitro diagnostic testing at the point of care by personnel without formal laboratory training. OBJECTIVES: To determine the range of laboratory testing performed by critical care nurses and their attitudes toward this role. METHODS: A survey of critical care nursing consultants was conducted, using a modified Likert scale, to assess objective measures of point-of-care testing practice in critical care units and to determine nurses' attitudes toward the practice of point-of-care testing. Statistical analysis was performed to determine significant trends in responses. RESULTS: Of the units responding to the survey, 35% used critical care nurses exclusively to perform point-of-care testing, 32.5% used laboratory technicians and critical care nurses, and 25% used other personnel. Of critical care nurses performing laboratory testing, 95.5% performed blood glucose analysis; 18.7%, arterial blood gas analysis; 4.5%, electrolyte analysis; 4.5%, hematology profiles; and 22.7%, other testing. Most agreed that stat tests were not reported promptly, thereby necessitating bedside testing. Respondents indicated that they would prefer that laboratory personnel operate in vitro diagnostic equipment and that requirements for critical care nurses to perform laboratory testing detracted from other patient care duties. CONCLUSIONS: Most nurses who perform point-of-care testing responded that it was necessary and helpful in patient management. However, they would prefer, because of their other patient care responsibilities, that laboratory personnel take this responsibility.

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Borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis: A rare association

Journal of Pathology of Nepal ◽

10.3126/jpn.v9i1.23382 ◽

2019 ◽

Vol 9 (1) ◽

pp. 1505-1507

Author(s):

Palzum Sherpa ◽

Amit Amatya ◽

Trishna Kakshapati

Keyword(s):

Pulmonary Tuberculosis ◽

Extrapulmonary Tuberculosis ◽

Granulomatous Inflammation ◽

Simultaneous Occurrence ◽

Lupus Vulgaris ◽

Posterior Aspect ◽

Mycobacterial Infections ◽

Cutaneous Tuberculosis ◽

First Case ◽

Tuberculoid Leprosy

Tuberculosis and leprosy are chronic mycobacterial infections that elicit granulomatous inflammation. The incidence of co-existence of pulmonary tuberculosis and leprosy has ranged from 2.5%-13.4%.1 Cutaneous tuberculosis is a variant of extrapulmonary tuberculosis and its simultaneous occurrence with leprosy is uncommon. The concomitant presence of leprosy, pulmonary as well as cutaneous tuberculosis is rare. We report a case of borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis in a 45 years male who presented to the dermatology outpatient department with three morphologically distinct skin lesions over the posterior aspect of right leg. Ours is presumably the first case reported from Nepal, a country where both of these mycobacterial infections are endemic.

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A Case of Reactive Cervical Lymphadenopathy with Fat Necrosis Impinging on Adjacent Vascular Structures

Case Reports in Otolaryngology ◽

10.1155/2016/6019501 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Albert Y. Han ◽

Jacob F. Lentz ◽

Edward C. Kuan ◽

Hiwot H. Araya ◽

Mohammad Kamgar

Keyword(s):

Lymph Node ◽

Internal Jugular Vein ◽

Contraceptive Use ◽

Jugular Vein ◽

Diagnostic Testing ◽

Cervical Lymphadenopathy ◽

Neck Mass ◽

Fat Necrosis ◽

Diagnostic Challenge ◽

Jugular Vein Thrombosis

A tender neck mass in adults can be a diagnostic challenge due to a wide differential diagnosis, which ranges from reactive lymphadenopathy to malignancy. In this report, we describe a case of a young female with an unusually large and tender reactive lymph node with fat necrosis. The diagnostic imaging findings alone mimicked that of scrofula and malignancy, which prompted a complete workup. Additionally, the enlarged lymph node was compressing the internal jugular vein in the setting of oral contraceptive use by the patient, raising concern for Lemierre’s syndrome or internal jugular vein thrombosis. This report shows how, in the appropriate clinical context, and especially with the involvement of adjacent respiratory or neurovascular structures, aggressive diagnostic testing can be indicated.

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Evaluation of prolonged febrile illness in elderly

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20194203 ◽

2019 ◽

Vol 6 (5) ◽

pp. 1513

Author(s):

Nirmal Chandra Sahu ◽

Prafulla Kumar Dash ◽

Arindam Maitra ◽

Samarendra Nath Das ◽

Saroj Kumar Tripathy

Keyword(s):

Extrapulmonary Tuberculosis ◽

Febrile Illness ◽

High Morbidity ◽

Effective Management ◽

Elderly Age ◽

Medical College ◽

Institutional Ethics ◽

A Prospective Study ◽

Infectious Etiology

Background: Febrile illness in elderly patients in hospitals is a challenge to the physician for diagnosis and treatment due to high morbidity as well as mortality and it increases if the febrile illness is prolonged. So proper evaluation and effective management is necessary for a better outcome. Keeping in mind the scarcity of studies in elderly febrile illness in India this study was taken up.Method: A prospective study was designed in medical ICU of S.C.B Medical college and Hospital, Cuttack Odisha, India. 50 patients were included in this study from July 2007 to December 2008. Institutional Ethics Committee cleared the study.Results: In 50 elderly (Age>60 yrs) patients of prolonged febrile illness, 36 (72%) were male and 14 (28%) were female. All had fever for >21 days. Pallor was the commonest sign (62%). 30 patients had infectious etiology, 15 had malignancies. Tuberculosis was the commonest infection (28%) comprising of 46.66% of infectious etiology with Pulmonary Tuberculosis (PTB) in 20% and Extrapulmonary Tuberculosis (ETB) in 26.66%. Malignancies accounted for 30% of cases with Non-Hodgkin’s lymphoma (NHL) in 33.33% being the commonest amongst the malignancies. On follow up of 50 patients 21 (42%) got cured.Conclusion: Febrile illness in elderly needs carefully evaluation as infections account for most of the cases and Tuberculosis in our part of India as a major cause in these patients is treatable. Malignancies remain the second most common cause where timely intervention goes a long way in reducing morbidity and mortality.

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