Painful hallucinations and somatic delusions in a patient with the possible diagnosis of neuroborreliosis

Neuroborreliosis has become the most frequently recognized tick-borne infection of the nervous system in Europe and the United States. In addition to dermatological, cardiac, articular, and neurologic manifestations, psychiatric disorders such as depression, panic attacks, and schizophrenia-like psychosis can also arise. We report on a 61-year-old woman who developed a severe pain syndrome following several tick bites. She was diagnosed with neuroborreliosis; she received various courses of antibiotics over several years, but without any clinical improvement in her condition. Her eventual admission to a psychiatric ward due to mental symptoms and neuroleptic treatment led to a dramatic improvement of her pain symptoms. However, increasing delusions disclosed a psychotic episode, which ceased over time. We discuss therapeutic difficulties and psychiatric complications in the absence of a clear-cut diagnosis of neuroborreliosis. Although this patient might have suffered from late-onset schizophrenia with painful hallucinations right from the start of her disease, the case highlights psychiatric complications that might be associated with neuroborreliosis.     

Use of metaphors when treating unexplained medical symptoms

The words one chooses to describe personal pain mirror current usage, but may also hold echoes of an individual’s lived experience. They may provide clues to the origin of physical symptoms that are medically hard to explain. The aim of this commentary is to propose, on the basis of the available literature, that verbal metaphors can prove effective in the psychotherapy of such conditions. I provide a case history of a 45 year old woman referred to psychiatry because of extreme ‘burning’ pain in her mouth and tongue. She had been to numerous doctors, had undergone a variety of tests, had tried many medical treatments, and had been prescribed a number of different pharmaceutical agents. She had changed her diet, done her daily dental mouth exercises, drunk a lot of water, but the burning continued and interfered, with her job (she was a teacher), her friendships, and her everyday life. This made her angry and recalcitrant to therapy, but the metaphor ‘burning with rage,’ as applicable to her pain, worked to establish a good alliance that led to a decrease of symptoms. Burning Mouth Syndrome is a medically unexplained condition of complex etiology that psychotherapy alone cannot reverse. The literature bears out, however, that the use of metaphors can help to open avenues of psychological exploration that accelerate adaptation to pain and improve quality life.     

Use of fluorine-18-labelled deoxyglucose positron emission tomography with computed tomography to localize a paraganglioma in pregnancy

A nine-weeks pregnant, 27-year-old female was admitted for hypertension with a blood pressure of 213/110 mm Hg, headaches, palpitations, and anxiety. There was no previous history of hypertension or pre-eclampsia. She had elevated urinary normetanephrine, plasma-free normetanephrine, and plasma-free metanephrine concentrations. Phenoxybenzamine and labetalol were initiated for presumed pheochromocytoma. At thirteen weeks of pregnancy, a noncontrast magnetic resonance imaging (MRI) of the abdomen failed to identify an adrenal or extra-adrenal mass. At 21-weeks gestation, an abdominal [18-F]-fluorodeoxyglucose positron emission tomography with computed tomography demonstrated an extra-adrenal lesion. The patient underwent a laparotomy during the second trimester with successful removal of a benign paraganglioma.     

Guidelines for the diagnosis and treatment of celiac disease in children

Jennifer, age 2 years, is being seen for her regular 2-year well child visit. You note her weight is only at the 5% and has been dropping percentiles over the past year When you ask her mother about Jennifer's diet, she reports Jennifer is a "picky eater" and often complains of a "stomach ache." Her mother reports her stomach looks "bloated. " Steven, age 7 years, is brought into the clinic because of recurrent abdominal pain with occasional constipation or diarrhea. Steven's mother had been told in the past that he probably had "irritable bowel syndrome" but changes in his diet, occasional use of a laxative, and relaxation techniques have not improved his symptoms. Rebecca, age 12 years, is brought into your clinic because her mother has recently learned that two first cousins have been diagnosed with celiac disease. She is wondering if Rebecca should be screened for this condition since she has heard it runs in families.     

Pheochromocytoma in a 49-year-old woman presenting with acute myocardial infarction: A case report

BACKGROUNDPheochromocytoma is a rare endocrine tumor arising from chromaffin cells and having extensive and profound effects on the cardiovascular system by continuously or intermittently releasing catecholamines. The clinical manifestations of pheochromocytoma are diverse, and the typical triad, including episodic headache, palpitations, and sweating, only occurs in 24% of pheochromocytoma patients, which often misleads clinicians into making an incorrect diagnosis. We herein report the case of a patient with intermittent chest pain and elevated myocardial enzymes for 2 years who was diagnosed with pheochromocytoma.CASE SUMMARYA 49-year-old woman presented with intermittent chest pain for 2 years. Two years ago, the patient experienced chest pain and was diagnosed with acute myocardial infarction, with 25% stenosis in the left circumflex. The patient still had intermittent chest pain after discharge. Two hours before admission to our hospital, the patient experienced chest pain with nausea and vomiting, lasting for 20 min. Troponin I and urinary norepinephrine and catecholamine levels were elevated. An electrocardiogram indicated QT prolongation and ST-segment depression in leads II, III, aVF, and V3-V6. A coronary computed tomography angiogram revealed no evidence of coronary artery disease. Echocardiography showed left ventricular enlargement and a decreased posterior inferior wall motion amplitude. Contrast-enhanced computed tomography demonstrated an inhomogeneous right adrenal mass. The patient successfully underwent laparoscopic right adrenalectomy, and histopathology confirmed adrenal pheochromocytoma. During the first-year follow-up visits, the patient was asymptomatic. The abnormal changes on echocardiography and electrocardiogram disappeared. CONCLUSIONClinicians should be aware of pheochromocytoma. A timely and accurate diagnosis of pheochromocytoma is essential for alleviating serious cardiac complications.     

Primary aldosteronism caused by aldosterone-producing adenoma in pregnancy--complicated by EPH gestosis

Pregnancy in conjunction with primary aldosteronism is an unusual occurrence. We report a 28-year-old woman who presented with mild hypertension and hypokalemia as manifestations of primary aldosteronism caused by an aldosterone-producing adenoma in the left adrenal gland during pregnancy. Although the diagnosis was straightforward, the patient refused to undergo the proposed operation during the second trimester of her pregnancy. She was not admitted to hospital until she developed EPH gestosis in the 27th week of gestation, which had an unfavourable outcome for the infant who died nine days after delivery. The patient underwent a laparoscopic adrenalectomy which resulted in normalization of blood pressure and blood potassium levels. In cases of aldosterone-producing adenoma, surgery in the second trimester is the most appropriate option to avoid a poor obstetric outcome.     

Increased phantom limb painas an initial symptom of spinal neoplasia

Phantom limb pain is a common sequela of amputation. Studies suggest that over time,there is a decrease in frequency and intensity of phantom pain. Persistently increased phantom pain has been seen in benign lesions affecting the peripheral and central nervous system. We present a 74-year- old woman who had a left above-knee amputation for leiomyosarcoma of the foot 24 years previously. She had been free of disease and ambulated independently until 1 month before hospitalization, when she noted increasing pain in her phantom foot. At the time of admission, she had developed increasing low back pain and was diagnosed with adenocarcinoma of unknown primary. Work-up confirmed involvement of the L4 vertebral body with epidural and paraspinal disease. We believe this is the first reported case of worsening phantom limb pain resulting from a spinal metastasis. We review the literature on the potential implications of increased phantom pain.     

Thoracic aortic dissection in an 18-year-old woman with no risk factors

Spontaneous aortic dissection is a rare, life-threatening cause of chest pain, and has a higher prevalence when traditional risks such as age, hypertension, dyslipidemia, or connective tissue disorders are present. However, even in the absence of risk factors, non-traumatic rupture of an aortic dissection may occur. Most are found in patients over 40 years of age. Younger victims of this disease often also suffer from other conditions such as cystic medial necrosis, connective tissue disorders such as Marfan's syndrome, or vasculitis. We present the case of an 18-year-old, previously healthy woman who was country line dancing when she began to complain of severe, cramping chest and back pain. She was hemodynamically stable on initial presentation but experienced two seizures while in the emergency department and was intubated. Subsequently, her blood pressure dropped and she developed cardiac arrest, and despite vigorous resuscitation that included blood products and emergency department thoracotomy, she was refractory to all attempts. At autopsy she was found to have a spontaneous, non-traumatic rupture of an aortic dissection. This patient had no discernable risk factors for aortic dissection or discoverable cause on necropsy. We present this case to raise awareness among physicians and review other reported cases in the literature of aortic dissection in patients under age 40 years.     

Pheochromocytoma. The great mimic.

A pheochromocytoma is a tumor of the chromaffin cells of the adrenal gland medulla that produces excessive amounts of norepinephrine. It is difficult to diagnose and complicated to treat because of its variable symptoms and location in the body. The tumor is most likely to cause uncontrolled hypertension, nervousness, diaphoresis, and palpitations, but, at other times, may show no symptoms at all. The diagnosis is established by measuring the plasma levels of the catecholamine hormones, norepinephrine and epinephrine. Although 10% of pheochromocytomas are extra-adrenal, most appear in one adrenal gland. If a tumor can be located by radiological techniques, it can be cured by surgical removal. Since these tumors may recur, it is necessary to reevaluate the patient periodically by measuring catecholamine levels and by radiological studies. We present a case study of one patient with a malignant pheochromocytoma, outlining the diagnosis, treatment, and postadrenalectomy follow-up.     

Exacerbation of a case of myasthenia gravis during therapeutic electric stimulation

In patients with myasthenia gravis, vigorous exercise and electric stimulation produce weakness that is usually reversed by rest. We describe a case of persistent weakness in a 31-year-old woman with myasthenia gravis following therapeutic electric stimulation. She was injured in an automobile accident, with cervical and lumbar muscle strain diagnosed by a local emergency room physician. She consulted a chiropractor two days later because her symptoms had not abated. The chiropractic treatment of short-wave diathermy, high-voltage electric stimulation and spinal manipulation continued thrice weekly for six weeks. She then presented to her neurologist, complaining of persistent fatigue, weakness, increased diplopia, cervical and occipital pain, and disrupted sleep. Neck weakness had developed since her last visit. She was admitted to the hospital for evaluation. Neurologic exam showed no other abnormality of strength, sensation, or reflexes. The exacerbation of myasthenia responded to prednisone and increased pyridostigmine. After two months she required only her preinjury dose of pyridostigmine (60 mg q.d. p.r.n.) to prevent diplopia or fatigue, and her strength was normal. Repeated electrically induced muscle contraction is suspected of causing this exacerbation of myasthenia gravis.     

Vascular disorder in a competitive cyclist: a case report

Abstract

The purpose of this case report was to alert the physical therapist (PT) to the possibility of vascular disorders in endurance athletes with apparent musculoskeletal symptoms. A 33-year-old female injured her knee in a fall and described a history of progressive unilateral lower extremity (LE) pain and weakness, especially with running and cycling. She received LE stretching and strengthening but her symptoms persisted, so she stopped all activity. When she became symptomatic with minimal exertion, she went to a neurologist, but electromyographic (EMG)/nerve conduction velocity (NCV) studies were normal. Eventually, she was referred for vascular studies, which confirmed a diagnosis of external iliac artery endofibrosis. The patient underwent a right common iliac to common femoral artery bypass graft approximately 3 years after onset of initial symptoms. She ran a 5K race 3 weeks after surgery and returned to cycling after 4 weeks. Endofibrosis of the external iliac artery is an uncommon disorder but is most frequently diagnosed in high-performance athletes, especially cyclists. Physical therapists who practice in orthopedic settings should be aware of vascular conditions that mimic musculoskeletal disorders in endurance athletes. Vascular consult or referral may be necessary if PT interventions are ineffective in treating athletes with exercise-induced LE pain and weakness.     

Disseminated fat necrosis: a rehabilitation challenge

Disseminated fat necrosis (DFN) is a rare complication of pancreatic disease characterized by subcutaneous nodules, visceral effusions, osseous intramedullary fat necrosis, and arthritis. The rehabilitation of a 33-year-old patient with DFN is described here. The patient had a history of alcoholic pancreatitis for which she underwent a subtotal pancreatectomy. Three months later she developed subcutaneous nodules and migratory polyarthralgias. The diagnosis of DFN as the etiology of her arthritis was confirmed by synovial fluid analysis; in addition, magnetic resonance imaging of her long bones revealed multiple marrow infarcts. She was nonambulatory and required assistance with transfers because of severe joint pain. Treatment included local ice, prednisone, methadone, instruction on joint preservation and proper body mechanics, and ambulation with weight-bearing as tolerated with an assistive device. At the patient's discharge, her joint inflammation was clinically improved but not resolved, and she was independent in transfers and ambulation with a walker for short distances. Despite ongoing inflammation, functional improvement was accomplished through a rehabilitation program emphasizing partial weight-bearing ambulation rather than strengthening exercises.     

Octreotide reverses shock due to vasoactive intestinal peptide-secreting adrenal pheochromocytoma: A case report and review of literature

Vasoactive intestinal peptide-producing tumors (VIPoma) usually originate in the pancreas and are characterized by diarrhea, hypokalemia, and achlorhydria (WDHA syndrome). In adults, nonpancreatic VIPoma is very rare. Herein, we report an unusual case of VIP-producing pheochromocytoma marked by persistent shock, flushing, and watery diarrhea and high sensitivity to octreotide. A 53-year-old woman was hospitalized for sudden-onset hypertension with convulsions, which then rapidly evolved to persistent shock, flushing, and watery diarrhea. Abdominal computed tomography indicated a left adrenal mass, accompanied by bleeding; and marked elevations of both plasma catecholamine and VIP concentrations were documented via laboratory testing. Surprisingly, all clinical symptoms responded swiftly to octreotide treatment. Once surgically treated, hormonal levels normalized in this patient, and the clinical symptoms dissipated. Postoperative pathological and immunohistopathological studies confirmed a VIP-secreting pheochromocytoma with strong, diffuse positivity for somatostatin receptor type 2. During a 6-mo follow-up period, she seemed in good health and was symptom-free.     

Managing and caring for a patient with a complicated wound

The patient discussed in this care study is a 91-year-old woman admitted to hospital from her own home. She presented with reduced mobility, constipation, increased confusion and reduced oral intake. Her history included small vessel disease and a stroke. On admissions she also had a number of grade two pressure ulcers on her buttocks. The surrounding skin appeared macerated and the patient complained of pain when the skin was cleaned after she was incontinent of both urine and faeces. It was expected that the wound would be fast healing, as it was superficial, but the healing rate proved otherwise. This article will focus on incontinence management as well as ways of aiding in healing a pressure ulcer where skin is macerated and the patient has many risk factors.     

Evaluating patients with mildly elevated transaminase levels

CASE STUDY: S.B. is a 52-year-old woman with recurrent stage IV ovarian cancer. She initially presented three and a half years ago with complaints of abdominal pain, increased abdominal girth, and abdominal bloating. A CA-125 blood test was elevated, and a computed tomography scan of the abdomen and pelvis revealed bilateral ovarian masses highly suspicious for malignancy. She was taken to surgery for a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and suboptimal tumor reduction. Pathology revealed poorly differentiated papillary serous ovarian cancer. Metastatic disease was noted in the rectosigmoid area and vaginal apex. Postoperatively, she received six cycles of paclitaxel and carboplatin. At completion, her CA-125 normalized and imaging studies showed no evidence of disease. However, within three months, her CA-125 was elevated and a palpable mass at the vaginal apex was proven by biopsy to be recurrent disease.     

Vertebral artery dissection in a patient practicing self-manipulation of the neck

OBJECTIVE: The purpose of this case report is to describe a patient who regularly practiced self-manipulation of her neck who presented with shoulder and neck pain and was undergoing a vertebral artery dissection. CLINICAL FEATURES: A 42-year-old female patient sought care for left shoulder pain with a secondary complaint of left lower neck pain. Twelve days prior, she had had "the worst headache of her life," which began in her left lower cervical spine and extended to her left temporal region. The pain was sudden and severe, was described as sharp and burning, and lasted 3 hours. She reported nausea, vomiting, and blurred vision. INTERVENTION AND OUTCOME: Initial history and examination suggested that the patient's head and neck pain was not musculoskeletal in origin, but vascular. She repeatedly requested that an adjustment be performed, but instead was referred to the local emergency department for further evaluation. Magnetic resonance angiogram revealed a dissection of the left vertebral artery from C6 to the C2-C3 interspace and a 3-mm dissecting pseudoaneurysm at the C3 level. She underwent stent-assisted percutaneous transluminal angioplasty combined with antiplatelet therapy (clopidogrel) and experienced a good outcome. CONCLUSION: This case suggests that careful history taking and awareness of the symptoms of VAD are necessary in cases of sudden head and neck pain. More research is needed on the relationship between vertebral artery dissection and self-manipulation of the neck.     

Metoclopramide induced pheochromocytoma crisis

Metoclopramide (MCP) is a commonly used anti-emetic in the emergency department (ED). Its use is generally well tolerated; although infrequent adverse reactions such as extrapyramidal reactions or tardive dyskinesia are reported. However, many ED providers are not familiar with the potentially life-threatening hypertensive emergency that can be precipitated by MCP administration in patients with pheochromocytoma. A previously healthy 36-year-old woman presented to the ED with headache and nausea. She developed acute hypertensive emergency (acute agitation, worsening headache, chest pain and wide complex tachycardia) when her blood pressure (BP) increased to 223/102 mm Hg (initial BP, 134/86 mm Hg) after receiving intravenous MCP. Her hospital course was complicated by multi-organ injury, including acute respiratory distress syndrome requiring venous-venous extracorporeal membrane oxygenation, non-ST elevation myocardial infarction, cardiogenic shock, acute liver failure, and oliguric kidney injury requiring continuous renal replacement therapy. CT scan showed previously undiagnosed large right adrenal mass (5.9 cm). The diagnosis of pheochromocytoma was confirmed after adrenalectomy. Drug-induced acute pheochromocytoma crisis is a rare event. Early recognition and appropriate blood pressure management with clevidipine, nicardipine, or phentolamine is essential.     

Epinephrine-secreting pheochromocytoma in a normotensive woman with adrenal incidentaloma

Pheochromocytomas are rare neuroendocrine tumors that produce, metabolize, and usually secrete catecholamines. Although hypertension is a common presenting feature of pheochromocytoma, the tumors occur (or are present) in only 0.1% of patients with hypertension. The variability of symptoms and rarity of occurrence render these tumors difficult to diagnose; many are discovered incidentally during radiological examination or at autopsy. A patient is presented with a pheochromocytoma that was discovered incidentally when she presented with abdominal pain and a normal blood pressure.     

Advances in metanephrine testing for the diagnosis of pheochromocytoma

Pheochromocytoma is a lethal tumor of chromaffin cells of the adrenal medulla that produces episodes of hypertension with the symptoms of palpitations, severe headaches, and sweating. The diagnosis of pheochromocytoma is a challenging one; autopsy series suggest that many pheochromocytomas are not clinically suspected, and the undiagnosed tumor can be associated with morbid consequences. The testing of catecholamines, metanephrines, and Vanillylymandelic acid commonly is used for screening of pheochromocytoma. The diagnostic value of various biochemical tests,as reported in recent Mayo and National Institutes of Health studies, have been compared and discussed in detail. The recent developments in the methodologies of metanephrines testing also are presented.     

Gabapentin for chronic pain in spinal cord injury: a case report

A 30-year-old white woman with an L1 complete spinal cord injury (SCI) secondary to a gunshot wound in 1985, presented to a chronic pain service for evaluation. She had a 13-year history of chronic lower extremity pain. She described her discomfort as "throbbing, aching, and stabbing." She had tried many different medications, including opioids, Tegretol, and tricyclic antidepressants, without success. During the evaluation process, she admitted to being "angry, frustrated, and anxious." She was diagnosed with central pain after SCI. She was placed on gabapentin 300 mg 3 times daily; within 1 week, her visual analog pain scale fell from 95 mm to 27 mm, and her McGill Short Form pain score fell from 13 to 3. Her mood also vastly improved. This case report suggests that gabapentin should be studied as a therapeutic option for treating central pain post-SCI and should be considered as a viable, well-tolerated, low-toxicity tool.