The Sudden Onset of Unilateral Flushing and Sweating
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Differentiating Between Anxiety, Syncope & Anaphylaxis
Differentiating between anxiety, syncope & anaphylaxis Dr. Réka Gustafson Medical Health Officer Vancouver Coastal Health Introduction Anaphylaxis is a rare but much feared side-effect of vaccination. Most vaccine providers will never see a case of true anaphylaxis due to vaccination, but need to be prepared to diagnose and respond to this medical emergency. Since anaphylaxis is so rare, most of us rely on guidelines to assist us in assessment and response. Due to the highly variable presentation, and absence of clinical trials, guidelines are by necessity often vague and very conservative. Guidelines are no substitute for good clinical judgment. Anaphylaxis Guidelines • “Anaphylaxis is a potentially life-threatening IgE mediated allergic reaction” – How many people die or have died from anaphylaxis after immunization? Can we predict who is likely to die from anaphylaxis? • “Anaphylaxis is one of the rarer events reported in the post-marketing surveillance” – How rare? Will I or my colleagues ever see a case? • “Changes develop over several minutes” – What is “several”? 1, 2, 10, 20 minutes? • “Even when there are mild symptoms initially, there is a potential for progression to a severe and even irreversible outcome” – Do I park my clinical judgment at the door? What do I look for in my clinical assessment? • “Fatalities during anaphylaxis usually result from delayed administration of epinephrine and from severe cardiac and respiratory complications. “ – What is delayed? How much time do I have? What is anaphylaxis? •an acute, potentially -
Review Cutaneous Patterns Are Often the Only Clue to a a R T I C L E Complex Underlying Vascular Pathology
pp11 - 46 ABstract Review Cutaneous patterns are often the only clue to a A R T I C L E complex underlying vascular pathology. Reticulate pattern is probably one of the most important DERMATOLOGICAL dermatological signs of venous or arterial pathology involving the cutaneous microvasculature and its MANIFESTATIONS OF VENOUS presence may be the only sign of an important underlying pathology. Vascular malformations such DISEASE. PART II: Reticulate as cutis marmorata congenita telangiectasia, benign forms of livedo reticularis, and sinister conditions eruptions such as Sneddon’s syndrome can all present with a reticulate eruption. The literature dealing with this KUROSH PARSI MBBS, MSc (Med), FACP, FACD subject is confusing and full of inaccuracies. Terms Departments of Dermatology, St. Vincent’s Hospital & such as livedo reticularis, livedo racemosa, cutis Sydney Children’s Hospital, Sydney, Australia marmorata and retiform purpura have all been used to describe the same or entirely different conditions. To our knowledge, there are no published systematic reviews of reticulate eruptions in the medical Introduction literature. he reticulate pattern is probably one of the most This article is the second in a series of papers important dermatological signs that signifies the describing the dermatological manifestations of involvement of the underlying vascular networks venous disease. Given the wide scope of phlebology T and its overlap with many other specialties, this review and the cutaneous vasculature. It is seen in benign forms was divided into multiple instalments. We dedicated of livedo reticularis and in more sinister conditions such this instalment to demystifying the reticulate as Sneddon’s syndrome. There is considerable confusion pattern. -
Skin Manifestations of Illicit Drug Use Manifestações Cutâneas
RevABDV81N4.qxd 12.08.06 13:10 Page 307 307 Educação Médica Continuada Manifestações cutâneas decorrentes do uso de drogas ilícitas Skin manifestations of illicit drug use Bernardo Gontijo 1 Flávia Vasques Bittencourt 2 Lívia Flávia Sebe Lourenço 3 Resumo: O uso e abuso de drogas ilícitas é um problema significativo e de abrangência mun- dial. A Organização das Nações Unidas estima que 5% da população mundial entre os 15 e 64 anos fazem uso de drogas pelo menos uma vez por ano (prevalência anual), sendo que meta- de destes usam regularmente, isto é, pelo menos uma vez por mês. Muitos dos eventos adver- sos das drogas ilícitas surgem na pele, o que torna fundamental que o dermatologista esteja familiarizado com essas alterações. Palavras-chave: Drogas ilícitas; Drogas ilícitas/história; Drogas ilícitas/efeitos adversos; Pele; Revisão Abstract: Illicit drug use and abuse is a major problem all over the world. The United Nations estimates that 5% of world population (aged 15-64 years) use illicit drugs at least once a year (annual prevalence) and half of them use drugs regularly, that is, at least once a month. Many adverse events of illicit drugs arise on the skin and therefore dermatologists should be aware of these changes. Keywords: Street drugs; Street drugs/history; Street drugs/adverse effects; Skin; Review HISTÓRICO Há mais de cinco mil anos na Mesopotâmia, minorar o sofrimento dos condenados. região onde hoje se situa o Iraque, os poderes cal- Provavelmente seja o ópio a droga nephente à qual mantes, soníferos e anestésicos do ópio (do latim Homero se referia como “o mais poderoso destrui- opium, através do grego opion, ‘seiva, suco’) já eram dor de mágoas”.1,2 conhecidos pelos sumérios. -
What Is the Autonomic Nervous System?
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.suppl_3.iii31 on 21 August 2003. Downloaded from AUTONOMIC DISEASES: CLINICAL FEATURES AND LABORATORY EVALUATION *iii31 Christopher J Mathias J Neurol Neurosurg Psychiatry 2003;74(Suppl III):iii31–iii41 he autonomic nervous system has a craniosacral parasympathetic and a thoracolumbar sym- pathetic pathway (fig 1) and supplies every organ in the body. It influences localised organ Tfunction and also integrated processes that control vital functions such as arterial blood pres- sure and body temperature. There are specific neurotransmitters in each system that influence ganglionic and post-ganglionic function (fig 2). The symptoms and signs of autonomic disease cover a wide spectrum (table 1) that vary depending upon the aetiology (tables 2 and 3). In some they are localised (table 4). Autonomic dis- ease can result in underactivity or overactivity. Sympathetic adrenergic failure causes orthostatic (postural) hypotension and in the male ejaculatory failure, while sympathetic cholinergic failure results in anhidrosis; parasympathetic failure causes dilated pupils, a fixed heart rate, a sluggish urinary bladder, an atonic large bowel and, in the male, erectile failure. With autonomic hyperac- tivity, the reverse occurs. In some disorders, particularly in neurally mediated syncope, there may be a combination of effects, with bradycardia caused by parasympathetic activity and hypotension resulting from withdrawal of sympathetic activity. The history is of particular importance in the consideration and recognition of autonomic disease, and in separating dysfunction that may result from non-autonomic disorders. CLINICAL FEATURES c copyright. General aspects Autonomic disease may present at any age group; at birth in familial dysautonomia (Riley-Day syndrome), in teenage years in vasovagal syncope, and between the ages of 30–50 years in familial amyloid polyneuropathy (FAP). -
Quick Tips on Recognizing Cutaneous Manifestations of Systemic Disease
FEATURE ARTICLE 2.0 Quick Tips on Recognizing Contact Hours Cutaneous Manifestations of Systemic Disease Jennifer Cittadino ABSTRACT: Although many skin manifestations are isolated This article will concentrate on nonmalignant cutaneous to a dermatological disorder, some skin manifestations can manifestations of systemic disease. The body systems will berelatedtoadeeper,moresystemicissue.Theskinis be reviewed, and their associated skin manifestations will be related to other body systems and functions. The impor- discussed. Some of the skin manifestations can be seen in tance of being able to recognize these dermatological multiple systemic disorders, such as erythema nodosum, manifestations and associate them with potential systemic which can be seen in pulmonary disorders, collagen and disease can be a critical diagnostic tool for the practitioner. vascular disorders, and gastrointestinal disorders. Pictures Sometimes, these skin manifestations can be the first sign will be provided when possible. of an internal disease. Although challenging, recognition, prompt diagnosis, and treatment can alter the course of a CARDIOVASCULAR AND PULMONARY SYSTEM life-threatening illness. There are several general cutaneous signs of cardiovascular Key words: Cutaneous, Dermatology, Systemic, Skin disease that may commonly be seen. These findings may include edema, cyanosis, clubbing of the nails, and corneal he skin is the largest organ in the body and one arcus. The corneal arcus appears as a gray-white ring around of the most visible body systems. The skin has the cornea and correlates with age and cholesterol levels. a reciprocal relationship between what is visu- A diagonal earlobe crease is also reported to be a marker for alized on the surface and what is occurring coronary artery disease (Uliasz & Lebwohl, 2008). -
(MPN) Symptoms
RECOGNIZING SYMPTOMS RECOGNIZING YOUR MPN SYMPTOMS The MPN LANDMARK SURVEY* is a large-scale analysis of patients with myeloproliferative neoplasms (MPNs) and Healthcare Professionals (HCPs) who treat these rare, chronic blood cancers (813 patients; 457 hematologists/oncologists). The results from LANDMARK provide new information that validates previous findings about the effect of MPN symptoms and their impact on the lives of patients, even those with low-risk MPNs. Fatigue is a symptom of particular note. Across diseases it was reported as the most common and severe symptom, and the one that patients most wanted to resolve. Symptoms such as fatigue can be vague and challenging to quantify. It is difficult to measure tiredness and its impact on daily life. In addition to physical symptoms, patients in the survey reported emotional difficulties—feeling irritable, angry or depressed. Many patients surveyed suffered with their MPN symptoms for a year or more before diagnosis. LANDMARK helps to confirm that MPN symptoms have a significant, negative impact on daily activities and quality of life, often resulting in limited or canceled family and/or social activities. For some, it means having to miss days from work, reduce hours, or even leave their job. These issues create stress, anxiety, and financial hardship for MPN patients. This information is intended to help patients validate the impact of MPN symptoms and know that they are not alone. SYMPTOM RECOGNITION Patients in the survey often did not recognize the connection between certain symptoms they were experiencing and their MPN. For example, patients with MPNs often have difficulty sleeping; however, some patients who reported this symptom did not realize it was related to their MPN. -
Pain Assessment and Treatment in Children with Significant Impairment of the Central Nervous System Julie Hauer, Amy J
CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Pain Assessment and Treatment in Julie Hauer, MD, FAAP, a, b Amy J. Houtrow, MD, PhD, MPH, FAAP, c SECTION ON HOSPICE ChildrenAND PALLIATIVE MEDICINE, COUNCIL With ON CHILDREN Significant WITH DISABILITIES Impairment of the Central Nervous System Pain is a frequent and significant problem for children with impairment abstract of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of aComplex Care Service, Division of General Pediatrics, Boston medications for pain treatment. Behavioral pain-assessment tools are Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts; bSeven Hills Pediatric Center, Groton, reviewed in this clinical report, along with other strategies for monitoring Massachusetts; and cDepartment of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation pain after an intervention. Sources of pain in this population include Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of acute-onset pain attributable to tissue injury or inflammation resulting UPMC, Pittsburgh, Pennsylvania in nociceptive pain, with pain then expected to resolve after treatment Dr Hauer conceptualized and drafted the initial manuscript, reviewed and responded to questions and comments from all reviewers, and directed at the source. Other sources can result in chronic intermittent pain contributed to writing the final manuscript; Dr Houtrow contributed that, for many, occurs on a weekly to daily basis, commonly attributed to to the initial drafting and editing at all stages, including the final manuscript; and all authors approved the final manuscript as gastroesophageal reflux, spasticity, and hip subluxation. -
Two Faces: What About Harlequin Syndrome?
HYPERHIDROSIS TWO FACES: WHAT ABOUT HARLEQUIN SYNDROME? S Boumaiza (1) - M Korbi (1) - N Daouassi (2) - Y Soua (1) - H Belhadjali (1) - M Youssef (1) - J Zili (1) University Hospital, Department Of Dermatology, Monastir, Tunisia (1) - University Hospital, Department Of Neurology, Monastir, Tunisia (2) Background: Harlequin syndrome (HS) is a rare clinical condition characterized by a unilateral erythrosis of the face with hyperhidrosis and controlaterally a pale anhydrotic aspect. It is mainly idiopathic but it can be associated with severe diseases. Herein, we report two patients with HS. Observation: Observation N°1: A 27-year-old man with a history of migraine, consulted us for a unilateral erythrosis on his face. He reported a redness associated with a hyperhidrosis with strictly medial limits at the left side. It contrasted with anhidrosis and a normal appearance of controlateral hemiface. These attacks were triggered by exercise. They spontaneously disappeared at rest. The clinical examination especially neurological assessment showed no abnormality. Observation N°2: A 22-year-old man with no special medical history. He complained about same symptoms as the first patient but the attacks occurred without any triggering factor. The neurological examination revealed an incomplete Horner’s syndrome (eyelid ptosis, enophtalmos and a tendency to miosis). The two patients were diagnosed with HS. In the two cases, the etiological investigation was normal. Key message: HS corresponds to a unilateral dysfunction of sympathetic system characterized by hypohidrosis and loss of facial erythrosis to heat, exercise, or emotional factors. This phenomenon is compensated by excessive controlateral sweating and redness. It may be isolated or integrated into other dysautonomic syndromes like Horner’s syndrome. -
Carcinoid Syndrome
Practice Clinical images Carcinoid syndrome Habib ur Rehman MBBS 72-year-old man was admitted to hospital with con- gestive heart failure, weight loss and chronic diar- A rhea. He had flushing of the face and cyanosis, and telangiectasia were present in the cheek area (Figure 1). A contrast-enhanced computed tomography scan of the liver showed multiple masses with ring enhancement that were compatible with metastases (Figure 2). An echocardio- gram showed right-sided dilation of the heart with severe tri- cuspid regurgitation. The patient’s aortic, mitral and pulmonic valves were normal in structure and function. A 24-hour urine collection showed a total output of 5-hydroxyindoleacetic acid of 1515 (normal 0–43) μmol/L. A biopsy of the liver with immunostaining for chromogranin and synaptophysin were strongly positive and confirmed a diagnosis of metasta- tic carcinoid syndrome. The patient died 4 months later. A carcinoid tumour is a rare neuroendocrinologic malig- nancy that commonly originates from enterochromaffin cells in the gastrointestinal tract. The rate of incidence of carcinoid tu- mours has increased from 1.09 cases per 100 000 in 1973 to 5.25 cases per 100 000 in 2004, with a median age at diagnosis of 63 years.1 This increase has likely resulted from improve- ments in the classification of such tumours and from more wide- spread use of certain diagnostic screening tools such as en- doscopy. Carcinoid syndrome occurs when cells from the tumour metastasize to the liver and vasoactive substances enter systemic circulation via the hepatic vein. Flushing involving the face and upper trunk are the most prominent cutaneous signs. -
History & Physical Format
History & Physical Format SUBJECTIVE (History) Identification name, address, tel.#, DOB, informant, referring provider CC (chief complaint) list of symptoms & duration. reason for seeking care HPI (history of present illness) - PQRST Provocative/palliative - precipitating/relieving Quality/quantity - character Region - location/radiation Severity - constant/intermittent Timing - onset/frequency/duration PMH (past medical /surgical history) general health, weight loss, hepatitis, rheumatic fever, mono, flu, arthritis, Ca, gout, asthma/COPD, pneumonia, thyroid dx, blood dyscrasias, ASCVD, HTN, UTIs, DM, seizures, operations, injuries, PUD/GERD, hospitalizations, psych hx Allergies Meds (Rx & OTC) SH (social history) birthplace, residence, education, occupation, marital status, ETOH, smoking, drugs, etc., sexual activity - MEN, WOMEN or BOTH CAGE Review Ever Feel Need to CUT DOWN Ever Felt ANNOYED by criticism of drinking Ever Had GUILTY Feelings Ever Taken Morning EYE OPENER FH (family history) age & cause of death of relatives' family diseases (CAD, CA, DM, psych) SUBJECTIVE (Review of Systems) skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution; lymph nodes - enlargement, pain bones , joints muscles - fractures, pain, stiffness, weakness, atrophy blood - anemia, bruising head - H/A, trauma, vertigo, syncope, seizures, memory eyes- visual loss, diplopia, trauma, inflammation glasses ears - deafness, tinnitis, discharge, pain nose - discharge, obstruction, epistaxis mouth - sores, gingival bleeding, teeth, -
Harlequin Sign Concomitant with Horner Syndrome After Anterior Cervical Discectomy: a Case of Intrusion Into the Cervical Sympathetic System
CASE REPORT J Neurosurg Spine 26:684–687, 2017 Harlequin sign concomitant with Horner syndrome after anterior cervical discectomy: a case of intrusion into the cervical sympathetic system Yannick Fringeli, MD,1 Andrea M. Humm, MD,2 Alexandre Ansorge, MD,1 and Gianluca Maestretti, MD1 1Spine Unit, Department of Orthopaedic Surgery; and 2Unit of Neurology, Department of Internal Medicine, Cantonal Hospital Fribourg, Switzerland Harlequin syndrome is a rare autonomic disorder referring to the sudden development of flushing and sweating limited to one side of the face. Like Horner syndrome, associating miosis, ptosis, and anhidrosis, Harlequin syndrome is caused by disruption of the cervical sympathetic pathways. Authors of this report describe the case of a 55-year-old female who presented with both Harlequin sign and Horner syndrome immediately after anterior cervical discectomy (C6–7) with cage fusion and anterior spondylodesis. They discuss the pathophysiology underlying this striking phenomenon and the benign course of this condition. Familiarity with this unusual complication should be of particular interest for every specialist involved in cervical and thoracic surgery. https://thejns.org/doi/abs/10.3171/2016.11.SPINE16711 KEY WORDS hemifacial flushing; facial anhidrosis; sympathetic pathways; cervical spine surgery HE anterior approach introduced by Cauchoix and Concurrent Harlequin sign and Horner syndrome are Binet3 and Southwick and Robinson11 in 1957 is the extremely rare. We report a case in which both condi- gold standard for surgical access to the lower cervi- tions occur as a complication of cervical spinal surgery Tcal spine. In addition to causing vascular and esophageal and discuss the pathophysiology underlying this striking lesions, this approach can result in iatrogenic peripheral phenomenon. -
Dermatological Indications of Disease - Part II This Patient on Dialysis Is Showing: A
“Cutaneous Manifestations of Disease” ACOI - Las Vegas FR Darrow, DO, MACOI Burrell College of Osteopathic Medicine This 56 year old man has a history of headaches, jaw claudication and recent onset of blindness in his left eye. Sed rate is 110. He has: A. Ergot poisoning. B. Cholesterol emboli. C. Temporal arteritis. D. Scleroderma. E. Mucormycosis. Varicella associated. GCA complex = Cranial arteritis; Aortic arch syndrome; Fever/wasting syndrome (FUO); Polymyalgia rheumatica. This patient missed his vaccine due at age: A. 45 B. 50 C. 55 D. 60 E. 65 He must see a (an): A. neurologist. B. opthalmologist. C. cardiologist. D. gastroenterologist. E. surgeon. Medscape This 60 y/o male patient would most likely have which of the following as a pathogen? A. Pseudomonas B. Group B streptococcus* C. Listeria D. Pneumococcus E. Staphylococcus epidermidis This skin condition, erysipelas, may rarely lead to septicemia, thrombophlebitis, septic arthritis, osteomyelitis, and endocarditis. Involves the lymphatics with scarring and chronic lymphedema. *more likely pyogenes/beta hemolytic Streptococcus This patient is susceptible to: A. psoriasis. B. rheumatic fever. C. vasculitis. D. Celiac disease E. membranoproliferative glomerulonephritis. Also susceptible to PSGN and scarlet fever and reactive arthritis. Culture if MRSA suspected. This patient has antithyroid antibodies. This is: • A. alopecia areata. • B. psoriasis. • C. tinea. • D. lichen planus. • E. syphilis. Search for Hashimoto’s or Addison’s or other B8, Q2, Q3, DRB1, DR3, DR4, DR8 diseases. This patient who works in the electronics industry presents with paresthesias, abdominal pain, fingernail changes, and the below findings. He may well have poisoning from : A. lead. B.