Differential Diagnosis of Charcot Neuroarthropathy in Subacute and Chronic Phases: Unusual Diseases

Charcot Neuroarthropaty (CN) is a complication of diabetes with devastating consequences as it produces severe deformities in the foot developing in recurrent ulcers that rise the probability of amputation. There are several diseases mentioned in the literature that have to be considered for the differential diagnosis of CN, often related to the acute phase (gout, ankle sprain, inflammatory arthritis, cellulitis, venous thrombosis) but there is paucity of information related to the differential diagnosis in later stages (coalescence, remodeling) when there is deformity of the foot. Clinicians and diabetologists are not familiarized with orthopedic pathology and do not have in mind certain diseases that could mimic CN in the subacute or chronic phases and this can develop in a wrong diagnosis. It is important to make a correct diagnosis in patients with suspected CN not only in the acute phase but also in the chronic phase to establish an accurate treatment. This article is a review of the differential diagnosis of CN in subacute and chronic phases showing similarities and differences that can help clinicians and diabetologists to make an accurate diagnosis and treatment. We describe unusual diseases like tendon and muscles disorders, Frieberg's disease, complex pain regional syndrome, transient regional osteoporosis and osteomyelitis superimposed to CN and the main features of each one that could help in making a differential diagnosis

Endoscopic Submucosal Dissection for Resolution of a Symptomatic Pancreatic Rest in a Pediatric Patient: A Case Report and Literature Review

The pancreatic rest, aberrant, or heterotopic pancreas is a normal function pancreas found in the submucosal layer of the greater curvature of the gastric antrum and occasionally in the duodenum. Most of the patients are asymptomatic and the finding is usually incidental. We describe the case of a child with abdominal pain and history of recurrent ulcers that necessitated esophagogastroduodenoscopy and further evaluation with endoscopic ultrasound that confirmed a submucosal lesion consistent with a pancreatic rest. Endoscopic submucosal dissection was performed without complication, and complete symptom resolution was achieved after dissection of the pancreatic rest.

Complications, Indication and Tolerance of Foam Sclerotherapy in Varicose Vein Management Done in A Tertiary Care Centre in South India

INTRODUCTION: Foam sclerotherapy is used for treating varicose veins in our institution for patients who are not willing for surgery, debilitated patients, recurrent ulcers, cosmetic & in SFV (Sapheno Femoral Vein) <6 mm size. AIM: The aim of this study was to find and assess the rate and pattern of post–sclerotherapy complications in our institution compared with international standards. MATERIALS AND METHOD: The present study was retrospective in nature and case records of patients who underwent foam sclerotherapy [2009-2013, lower limb-Ultrasound (USG) guided and blind] in our hospital [10% Sodiumtetradecylsulfate (STS), Tessari technique] were assessed to look for indication, tolerance to the procedure and immediate outcomes. A pre-tested and pre-validated questionnaire was used and physical examination were done to assess post-procedural complications. Statistical significance was p< 0.05. RESULTS: Among 112 patients, 62.5 % were aged >50 years and 69% were males. It was observed that 22% had indication as recurrence; 43% had mild pain during procedure and 36.6% developed post-foam sclerotherapy complications. 47.6% of patients whose age were <50 years had CEAP(Clinical Etiological Anatomical Pathological) criteria C2(p=0.007). 48.8% with complications had multiple criteria(p=0.012) and 57.7% C2 had least complication (p=0.000). Cosmetic indication showed least tolerance. Use of 10% STS was found to have lesser complication rate (36%), compared to study which had 76% success with STS 3% and complication-64%. CONCLUSION: Foam sclerotherapy is less invasive and its efficacy could be improved by performing under USG guidance, selection of sclerosant, appropriate candidate (age>50 years, multiple CEAP criteria, without pre-existing co-morbidities).

A 9-year retrospective evaluation of 102 pressure ulcer reconstructions

• Objective: Several pressure ulcer (PU) risk factors including paralysis and age greater than 70 have been identified, while others such as nutrition are debated. The object of this study is to identify perioperative risk factors that may predict improved outcomes and reduced complications in primary and recurrent PU reconstructions. • Method: A retrospective chart review of patients treated surgically for PUs from 2004 to 2013 at the University of Toledo Medical Center, Toledo, Ohio, US, was completed. Data collected included ulcer and medical history, as well as risk factors, complications and postoperative outcome. Data were statistically analysed for perioperative variances between primary and recurrent ulcers and closure status. • Results: A total of 49 patients with 102 reconstructions were reviewed. Spinal cord injured patients accounted for 90% receiving flap coverage of ulcers. Numerous differences between primary and recurrent ulcers were identified, including ulcer location, patient nutritional status, wound infection, postoperative course and recurrence. Multivariate analysis revealed a flap reconstruction prediction model using creatinine, haematocrit, haemoglobin, and prealbumin that is able to successfully predict closure outcome in 83.6% of cases. • Conclusion: Many factors play a role in the development, course and treatment of PUs. It is vital to understand the role of patient risk factors in the development of PUs, to direct subsequent management and reconstruction, and to prevent future recurrences.

Dose HLA-B5, 7, 8, 27, and 51 Antigens Associated to Behcet's disease? A Study in Southwestern Iran

Background: Behcet's disease is a potentially life threatening autoimmune disease with recurrent ulcers and unknown pathogenesis. Gender and human leukocyte antigen-B51 seem to have an effective role in the clinical features of the disease. Objective: The aim of this study is to evaluate the frequency of HLA-B5, 7, 8, 27 and 51 in behçet's disease in southwestern Iranian patients who visited the rheumatology clinic and to find the association between these HLA types and the disease. Methods: 63 patients with behcet's disease participated in this study and peripheral blood samples were collected from them. The expression of each HLA antigen was evaluated by standard lymphocytotoxicity technique. Results: Compared to other studied antigens, the expression of HLA-B5 and HLA-B51 was more prevalent among our patients. According to the results, 25% and 21% of patients were positive for HLA-B5 and HLA-B51, respectively. Conclusions: HLA-B5 and HLA-B51 are dominant positive HLA antigens among behcet's disease patients in the southwest of Iran; however, we cannot conclude that these antigens are valuable diagnostic or prognostic biomarkers due to our study limitations. We suggest studying the association between HLA-B antigens and inflammation severity in patients to determine the possible prognostic value of HLA-B antigens in Iranian population in the southwest and this region needs more studies in HLA subject among BD patients because of the frequency of BD to evaluate the value of HLA typing in BD prognosis.

SAT-232 Pheochromocytoma Presenting Rare Skin Findings: Livedoid Vasculopathy and Raynaud’s Phenomenon

BACKGROUND: Oversecreted catecholamines from pheochromocytoma (PCC) is responsible for a large variety of clinical signs and symptoms, including skin lesions, due to their effects on hemodynamics and metabolism, as well as the putative effects on the blood coagulation system. Livedo reticularis had been reported as the skin complications of PCC, but there was no pathological evidence. Livedoid vasculopathy, a subtype of livedo reticularis is a noninflammatory thrombotic condition. Here we firstly showed that livedo reticularis accompanying PCC. Case: A 36-year-old female with hypertension, hyperglycemia, and right adrenal mass had referred to our hospital. She had violaceous reticular lesions on bilateral lower limbs, a three-year history of recurrent ulcers around her right ankle with severe pain. She also had frequent Raynaud’s phenomenon. On admission, the blood examination showed that her hemoglobin concentration was 16.3g/dl and her platelet count was 408,000/ml. Plasma catecholamines and the metabolite levels were elevated. The abdominal CT scan showed the right adrenal mass, approximately 6.5cm in diameter, and MRI showed a heterogeneous mass with high signal intensity on T2-weighted images. MIBG scintigraphy showed uptake in the mass. We diagnosed her as PCC. A skin biopsy revealed occlusions of the lumen of small vessels in the mid dermis without vasculitis. Administration of doxazosin revealed the improvement of the clinical parameters including the pain and the ulcer of the right ankle. The laparoscopic right adrenalectomy was performed. Histopathological study of the adrenal tumor was consistent with PCC. Genetic testing and MLPA analysis for RET, VHL, SDHx, SDH-AF2, MAX, and TMEM127 showed no mutations or copy number alterations. Postoperatively, hypertension and hyperglycemia improved, and Raynaud’s phenomenon and reticular macules disappeared. Discussion: Among the various clinical signs of PCC, skin disorders are relatively rare. Limited reports showed that the livedo reticularis was a complication of PCC, but its mechanism had not been elucidated. Livedoid vasculopathy is a rare cutaneous disease manifesting as recurrent ulcers on the lower extremities, which is a noninflammatory thrombotic condition associated with hypercoagulation. The catecholamine excess could induce arterial vasospasm in addition to relative hypercoagulation tendency, which could result in livedoid vasculopathy. Conclusion: The present study showed first pathological evidence of that the livedo reticularis accompanying PCC was livedoid vasculopathy.

Reccurent trauma-induced aphthous stomatitis in adjustment disorder patients

Background: Adjustment disorder is a temporary psychological condition related to emotional responses or behaviour in reaction to stress resulting from certain changes in a specific period of an individual’s life yet which does not significantly affect his/her daily life. Recurrent aphthous stomatitis (RAS) constitutes recurrent inflammation of the oral mucosa, in the form of an ulcer, frequently associated with psychological stress. Occasionally, a patient does not realise that she/he is suffering from a psychological disorder until the emergence of clinical symptoms, among them recurrent ulcers the causes of which are unknown. Purpose: This article presents a case of adjustment disorder diagnosed from symptoms observable in the oral cavity. Case: The case involved a 21-year-old student who presented with the symptoms of large, painful ulcers on her tongue, the inside of her cheek, and the floor of her mouth. These symptoms had been observable for one month but remained untreated. The patient only ate once a day or even once every two days. An introverted personality, she did not associate with other people. Case management: The procedure covered anamnesis, clinical examination, blood laboratory tests, total immunoglobulin E (IgE), an Antinuclear Antibody (ANA) test, bacterial and fungal culture in ulcus, questionnaire screening on psychological disorders, cortisol level examination and referral to a psychiatrist. Symptomatic therapy administered to the patient led to recovery of the ulcer in 29 days. Conclusion: RAS can be triggered by psychological stress which induces changes in the immune system and oral mucosa tissue.