An Osteopathic Approach to Complex Regional Pain Syndrome (CRPS)

Complex Regional Pain Syndrome (CRPS) is a chronic neuropathic pain condition in a region of the body where the pain experienced by the patient is disproportionate to the stimuli preceding the pain. In this case, a 52-year-old post-menopausal woman presents with chronic distal limb pain due to a left ankle contusion from a work injury. Previous treatments that focused on specific symptoms failed. However, the patient was then evaluated and treated comprehensively by an osteopathic physician. Treatment was tailored to individual patient needs based on the five models of osteopathic care. Within a 1.5 years period of integrative osteopathic treatment that utilized osteopathic manipulative treatment (OMT) in addition to medications and supplements, the patient was able to start walking again with only mild discomfort. This individualized approach seemed to improve her quality of life, and overall satisfaction with her health, psyche, and well-being. The patient is now discharged from the practice, has resumed normal daily activities, and is working full-time as a cashier.

Verrucous carcinoma of vulva associated with lichen sclerosus and condyloma: case report

Vulvar Verrucous Carcinoma (VVC) is a rare lesion, with few described cases. It has low metastatic potential with high morbidity due to the necessity of extensive resections, although. Previously, VVC was considered a synonym to the Buschke-Lowenstein Tumor (BLT) or Giant Condyloma Acuminatum (GCA). Lichen Sclerosus (LS) is associated with Vulvar Intraepithelial Neoplasia (VIN) and Vulvar Squamous-cell carcinoma (SCC); association with VVC is also described. The case of a 60-year-old menopausal woman is reported; she had chronic itching and an extensive verrucous lesion in vulva, initially diagnosed and treated as condyloma acuminatum; there was recurrence as verrucous carcinoma associated to LS. Excision with margins was performed and clobetasol and imiquimod were used. Patient had complete remission with no further recurrences. Distinction between VVC and BLT can be difficult; current literature considers them different entities. Human papillomavirus (HPV) infection and the presence of LS play a controversial role in these injuries.

Post-Transfusion Takotsubo Cardiomyopathy

In three recent cases an initial transfusion-related adverse event (TRAE) occurred that had a significant respiratory component, and other features suggesting a severe allergic reaction. All were treated as such. Shortly after treatment the nature of the event changed to something resembling transfusion-associated circulatory overload (TACO). These cases suggest the possibility that a severe TRAE that is not TACO may precipitate TACO. In other words, some transfusions, sometimes, may deliver a 'double whammy'. A possible mechanism might be through the development of Takotsubo, or stress, cardiomyopathy - a cause of acute, reversible, heart failure. Takotsubo cardiomyopathy typically presents with chest pain or shortness of breath. Ventricular wall dysfunction occurs, and characteristic echocardiographic abnormalities are seen. ECG and biochemical features suggest cardiac ischaemia. It is commoner in post-menopausal women. A range of 'stressors' - hypotension, asthma attacks, accidents, medical procedures, pain, bad news, etc. - may precipitate it. 1 Catecholamines such as adrenaline are believed to play a central role. They cause direct toxicity to the myocardium, and also coronary artery spasm, and increased cardiac workload. 2 One other such case is reported. There, a 48 years old post-menopausal woman developed acute reversible heart failure with the features of Takotsubo cardiomyopathy, following urticaria and pruritus, whilst having a platelet transfusion. No adrenaline was given, but the authors postulate that adrenergic and histaminergic elements may have combined to produce the effect on the heart. 3 Thus, in some patients the 'perfect storm' compounded of borderline cardiac function,catecholamine release (secondary to the stress of the underlying disorder, the transfusion, and the TRAE),histamine release (in allergic TRAE),the treatment of the allergic reaction with adrenalinerecent or ongoing volume overload may be sufficient to precipitate or exacerbate TACO. Careful consideration of cases with similar features is needed. Potential precipitating factors are modifiable or preventable. References: 1. https://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome 2. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.116.027121 3. Zhou JQ, Choe E, Ang L, et al. Stress-induced cardiomyopathy associated with a transfusion reaction: A case of potential crosstalk between the histaminic and adrenergic systems. Exp Clin Cardiol.2011; 16: 30-32 Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Diabetes insipidus as the first manifestation of granulomatosis with polyangiitis: A case report

Background: Granulomatosis with Polyangiitis (GPA) is a necrotizing granulomatosis vasculitis that may influence most organs, but posterior pituitary involvement as the first manifestation is unusual. However, there are some case reports in this regard. Case presentation: A 49-year-old menopausal woman presented with polyuria, polydipsia and weight loss over time headache, purulent nasal discharge, malaise, ear pain developed. After right myringotomy due to secretory otitis media and nasal cavity biopsy, the symptoms exacerbated. Diabetes insipidus was documented by Deprivation test. Thus, 20 microgram nasal spray DDAVP was prescribed. Pituitary MRI +/- Gad demonstrated pituitary involvement. Pituitary axis hormone evaluation was consistent with menopausal state. Chest spiral CT scan showed speculated border soft tissue mass lesion. GPA confirmed with ACR criteria and C-ANCA positive. Therefore, corticosteroid and rituximab were started. Symptoms of DI responded well to the treatment and the spray dosage was decreased. Conclusion: DI can be the first manifestation of GPA; although it is rare, it is worth to be diagnosed early and serious treatment of vasculitis should be started to prevent irreversible damage to the hypophysis cell and unnecessary procedure. Keywords: GPA; granalomatosis vasculitis; diabetes insipidus.

Journey of a fish from the vagina to the bladder: a case report

Foreign bodies in the genitourinary tracts are not uncommon and is often a challenge to remove them from the bladder. This case is a peculiar one where there was a migration of a live fish from the vagina to the bladder. A 60- year- old post-menopausal woman while taking bath in a pond felt that there was an entry of fish into the vagina. Her complaints were pain and bleeding per vagina and there was no leakage of urine. At the peripheral health facility, she underwent exploration of the vagina under local anesthesia after placing the foley catheter which was draining blood-stained urine. The patient was then referred to us. There was a laceration at the right anterolateral fornix. Fish could be palpated with the finger. She underwent routine blood tests and CT KUB which revealed a foreign body at the right anterolateral side of the vagina. Cystoscopy showed a laceration of 1×1 cm noted in the posterior wall of bladder approximately 1cm above right ureteric orifice, through which the fish was seen. Through speculum examination, the rent was visible and the remnants of the fish were removed vaginally. Laparotomy and rent repair was done because of the rent in the bladder. Foreign bodies into the bladder are common and invariably seen among children, women who have psychiatric problems. Common foreign bodies seen are broomsticks, toothbrushes, pencils, gauze, sutures, clips, IUCD, etc. Fish as a foreign body is a very rare condition. The unusual entry of a fish into the vagina has eroded and entered the bladder. Prompt investigations like CT scans and cystoscopy can help in the removal of foreign bodies.

August 2021 Imaging Case of the Month: Unilateral Peripheral Lung Opacity

No abstract available. Article truncated after 150 words. Clinical History: A 56-year-old post-menopausal woman was referred to endocrinology after a routine screening bone densitometry scan suggested osteoporosis. She had undergone this testing after she developed back pain following a pulled muscle for which she saw a chiropractor. The patient had no significant past medical history and she was actively involved in exercise. She denied use of alcohol, drugs, and smoking. She had no allergies and was not taking any medications. Her past surgical history included Lasik surgery, breast augmentation 15 years earlier, and surgery for a deviated septum. Physical examination showed a thin patient, afebrile, with a largely normal physical exam, although her pulse was intermittently irregular. Her blood pressure was 130 / 80 mmHg with a normal respiratory rate. Pulse oximetry showed a room air saturation of 98%. When asked about her irregular pulse, the patient recalled that she had episodes of “heart racing” for which she …

Endometrioma mimicking ovarian malignancy in a post-menopausal woman

Endometriosis is an estrogen dependant disorder of reproductive-age women. It is uncommon after menopause, however, peripheral estrogen production may account for endometriosis in post-menopausal women. We reported a case of a 68 year old post-menopausal woman with an adnexal mass suspected malignant ovarian tumor on imaging and normal serum CA 125 levels. Total hysterectomy with bilateral salpingo-oophorectomy was done. The final histopathology revealed the diagnosis of ovarian endometriosis. Rarely, ovarian endometrioma can mimic ovarian malignancy in a post-menopausal woman.