Notes

Tension partition and also microstructure within size-segregating granular moves.
Primary lung cancer typically presents in the older adult with a history of significant tobacco use. We present a young adult male with a rapid onset of dyspnea, and a large pleural and pericardial effusion with tamponade, necessitating urgent surgical intervention. Copyright © 2020, Richard et al.Histoplasmosis is an endemic fungal infection that can lead to disseminated disease, especially in immunosuppressed patients. Hairy cell leukemia is a rare, slow-growing hematological malignancy. Concurrence of histoplasmosis and hairy cell leukemia is extremely rare. We describe a 69-year-old male who presented with fever, dry cough, pancytopenia, multiple pulmonary nodules, and massive splenomegaly. Histoplasma urinary antigen was positive and disease was confirmed by biopsy of lung lesions. Peripheral smear showed 'hairy cells', and bone marrow biopsy revealed findings of hairy cell leukemia. The patient was treated with intravenous amphotericin, followed by oral itraconazole. After the initial treatment of infection, treatment for hairy cell leukemia was started with cladribine. We will discuss the principles of treating disseminated histoplasmosis in the setting of immunosuppression, and hairy cell leukemia with coexisting infection. Copyright © 2020, Khan et al.Responsive nerve stimulation (RNS) represents a safe and effective treatment option for patients with medically refractory temporal lobe epilepsy. In cases of long intraparenchymal course and posterior-anterior electrode direction through occipital burr holes, disciplined stereotaxy is essential for stimulation of the appropriate target. A 13-year-old female with a history of multifocal, independent, bitemporal-onset seizures since 12 months of age showing evidence of left-sided mesial temporal sclerosis on MRI, underwent placement of bilateral mesial temporal RNS leads. An O-arm spin was performed after the placement and the images obtained were fused to the preoperative CT images. It demonstrated curvature of the leads, with some deviation from the planned trajectory, but no deviation from the target, that was worse on the left side, compared to the right; the left lead was placed first, followed by the right lead. Following discussion with our epilepsy neurology colleagues in the operating room, electrophysiological measurements from the implanted leads showed cleared epileptic activity and therefore no repositioning was pursued. Our hypothesis at that time was that cerebrospinal fluid leakage distorted the underlying ventricular anatomy causing some curvature in the lead during transventricular course and prolonged consideration during surgery. In conclusion, transventricular trajectories during RNS lead placement may lead to cerebrospinal fluid loss and associated lead deformation. The distal aspect of the lead may nonetheless reside in the desired surgical target. Neuromonitoring for epileptic signature can provide reassurance with regard to accurate lead placement, obviating the need for lead repositioning. Surgeons should also recognize that fused imaging may confuse inferred anatomic position from preoperative MRI with actual anatomy post brain shift. Copyright © 2020, Kerezoudis et al.Heterotaxy syndrome (Situs ambiguus) is a condition in which the internal organs are abnormally arranged in the chest and abdomen. Individuals with this condition have complex birth defects affecting the heart, lungs, liver, spleen, intestines, and other organs. Unlike situs inversus, it often causes serious health problems. This report describes a case of a 49-year-old Hispanic female with a significant medical history of situs ambiguous diagnosed at birth in Cuba. She has had little to no follow-up in adulthood due to being "healthy." She presented to the emergency room with intractable pain in the left lower quadrant and left flank for two days. Heterotaxy syndrome was found incidentally on CT scan of the abdomen/pelvis (plain). She was further evaluated with chest X-ray, magnetic resonance imaging of abdomen/pelvis without and with contrast, transvaginal ultrasonography, renal/bladder ultrasonography, left upper quadrant (LUQ) ultrasonography, esophagogastroduodenoscopy (EGD) with biopsy, 2D echocardiogram, and pertinent laboratory tests. Certain unusual findings included azygos continuation of the inferior vena cava (IVC), numerous spleens, atrophic pancreas, dilatation of duodenal C sweep, pelvic mass (possibly arising from right ovary), multiple nabothian cysts, and cardiac dysfunctions (such as severe mitral regurgitation). This report further aims to identify anatomic variants, previously established or otherwise not, in heterotaxy syndrome. Also, there seems to be a lack of identifiable anomalies or associations in regard to female anatomy, particular to this case being the female pelvic anatomy. As previous reports and research have stated, identification of anomalies in this syndrome is key for adequate and optimal management. Copyright © 2020, Lagrotta et al.Rapidly progressive glomerulonephritis (RPGN) is a form of glomerulonephritis characterized by loss of renal function within weeks. Myricetin cost Although a variety of underlying causes can trigger RPGN, the ultimate pathologic mechanism is the podocyte and epithelial activation leading to the crescent formation. Rituximab has been increasingly and successfully used for autoimmune conditions in recent years. Treatment of RPGN is based on the underlying condition, but specific clinical guidelines are lacking. In this article, we have tried to establish the role of rituximab in the management of patients with RPGN. All the studies we have used were found in the PubMed database, limited to studies involving adults. Animal studies and studies involving the pediatric population were excluded. The currently available literature does not support switching to rituximab as the first-line agent. It has failed to prove consistently superior to other medications. However, combined with other commonly prescribed treatment regimens, namely corticosteroids, with or without cytotoxic drugs, rituximab has shown efficacy in many studies. Therefore, we have concluded that the most prudent use of rituximab in patients with RPGN would be in those with disease refractory to standard management with corticosteroids and cytotoxic drugs or in those who have intolerable side effects. We believe that clinicians should keep reporting any cases of RPGN treated with rituximab so that a more clear pattern emerges and more exact treatment guidelines can be made. Copyright © 2020, Cancarevic et al.
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