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Severe Abdominal Pain in a Young Girl After a Hug on 2009-06-15
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The CT scan of the abdomen reveals a fluid-filled cystic mass with an irregular margin in the fourth segment of the liver. The mass communicates with the gallbladder and is associated with a small amount of free fluid around the liver and in the peritoneal cavity. These imaging findings in the setting of eosinophilia, an associated allergic reaction, and a history of acutely worsening abdominal pain with sudden pressure applied to the abdomen, are consistent with a ruptured hydatid cyst.
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After humans ingest the eggs, they hatch into embryos in the small intestine. The embryos penetrate the intestinal mucosa, enter the portal circulation, and are carried to the liver.
[3,4] Some are destroyed in the liver while others form into hydatid cysts. A small percentage of the eggs may pass through the liver and form cysts in other parts of the body, including the lungs, central nervous system (CNS), spleen, and pancreas.
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Surgery is the traditional treatment of choice for hydatid cysts; however, a number of cysts are now treated with PAIR (percutaneous aspiration, infusion of scolicidal agents, and reaspiration). PAIR may be a reasonable approach for treating patients with inoperable disease, and it is typically performed while patients are on antihelminthic therapy to decrease the risk of cyst dissemination.
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PAIR is contraindicated for superficially located cysts, cysts communicating with the biliary tree, and cysts with multiple internal septal divisions. Surgery is still preferred for complicated cysts under these conditions. Care must be made to remove cysts without contaminating the surrounding tissues, as anaphylaxis and dissemination of infectious protoscolices may result.
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Albendazole and mebendazole are used for the medical treatment of echinococcosis in patients with contraindications for surgery.
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Albendazole is the preferred agent because of its greater absorption from the gastrointestinal tract, which results in higher serum levels.
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NEJM -- Case 11-2009 -- A 47-Year-Old Man with Fever, Headache, Rash, and Vomiting on 2009-04-10
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fever, headache, rash, and vomiting.
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Four years earlier, his partner had received a diagnosis of HIV infection and did not take antiretroviral medications, reportedly because of a low viral load and normal CD4 count.
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NEJM -- Myocarditis on 2009-04-10
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Dilated cardiomyopathy with chronic heart failure is the major long-term sequela of myocarditis
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NEJM -- Kerley's A, B, and C Lines on 2009-04-10
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hypertension and diabetic nephropathy
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hypertension (blood pressure, 225/122 mm Hg), tachycardia (heart rate, 112 bpm), tachypnea (24 breaths per minute), and hypoxemia
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elevated jugular venous pressure, bilateral rales, and edema of the legs. The level of brain natriuretic peptide was elevated (780.8 pg per milliliter; normal level, <18.4)
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enlarged cardiac silhouette
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Kerley's A lines (arrows) are linear opacities extending from the periphery to the hila; they are caused by distention of anastomotic channels between peripheral and central lymphatics. Kerley's B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base; they represent edema of the interlobular septa. Kerley's C lines (black arrowheads) are reticular opacities at the lung base, representing Kerley's B lines en face.
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cardiogenic pulmonary edema
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NEJM -- Falciform-Ligament Sign of Pneumoperitoneum on 2009-04-10
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Rigler sign (also known as the double-wall sign), indicating the presence of gas on both sides of the bowel wall (arrowheads)
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falciform ligament (Panel B, arrow), outlined by intraperitoneal free air. Pneumoperitoneum was diagnosed.
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NEJM -- Asthma on 2009-03-30
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approximately 7% of Americans have current asthma
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slightly more boys than girls affected and, after puberty, more women than men.
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airway smooth-muscle constriction and inflammation of the bronchi
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cellular infiltration, particularly by
eosinophils (and in some cases, neutrophils) and activated helper
T lymphocytes
9 as well as mast cells that (unlike mast cells
in other eosinophilic airway diseases) infiltrate smooth-muscle
bundles
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increased airway secretions, including secreted mucus, desquamated lining cells, and intraluminal eosinophils; capillary engorgement; hyperplasia of smooth muscle; and deposition of excess collagen, particularly immediately beneath the basement membrane of the epitheliu
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quick relief or long-term control
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NEJM -- Penile Papules on 2009-03-29
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pearly penile papules was made
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The lesions are typically localized to the corona of the glans penis but can also affect the glans or the shaft of the penis or both.
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their histologic features are characteristic of angiofibroma, and the lesions are free of papillomavirus.
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NEJM -- Case 10-2009 -- A 23-Year-Old Woman with an Abnormal Papanicolaou Smear on 2009-03-29
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high-grade squamous intraepithelial lesion
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Menarche had occurred at the age of 13 years
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sexually active since the age of 21 and had had 18 male partner
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menses had been monthly and regular
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used oral contraceptives for 3 months
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consistent condom use for both contraception and protection against sexually transmitted infections, except on three occasions
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She had had multiple atypical nevi, and one of two previous excisions had reportedly shown dysplastic changes. She had had an adenoidectomy at the age of 10 years.
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reported several episodes of blackouts while drinking
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Her mother had a history of vitiligo and alcohol abuse; her father and two sisters had irregular nevi.
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She was allergic to codeine. Her only medication was lorazepam, as needed for anxiety during airplane flights.
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multiple nevi on the trunk, arms, and legs
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The patient was counseled about her level of alcohol consumption
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The next week, review of the Pap smear revealed a high-grade squamous intraepithelial lesion. All other laboratory-test results were normal, and tests for infectious diseases were negative.
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Pathological examination revealed moderate-to-severe squamous dysplasia with koilocytosis.
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atypical glandular epithelium.
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In women, having sex during menses, having early coitarche, and being subject to coercive sex are also important risk factors; using alcohol, tobacco, marijuana, or oral contraceptives and having a new partner, especially if he is known for less than 8 months before initiation of sexual activity, are predictive of an incident HPV infection.
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The presence of another sexually transmitted infection, such as vulvar warts or HSV infection, is an additional biologic risk factor for HPV infection in this age group.
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This patient had multiple new sexual partners during a short time and reported that on at least three occasions she failed to use condoms. We can thus assume that she was at high risk for an incident HPV infection.
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Current guidelines recommend initiation of cervical-cancer screening within 3 years after first intercourse or by the age of 21 years, whichever occurs first.
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which are cells with the classic features of a productive viral infection, were indicative of the presence of low-grade squamous intraepithelial lesions.
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However, coexisting with the koilocytes were cells representative of a high-grade squamous intraepithelial lesion, which is a true neoplastic precursor lesion capable of progression to invasive carcinoma
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The presence of a high-grade squamous intraepithelial lesion typically correlates with the presence of severe dysplasia or carcinoma in situ, known as grade 3 cervical intraepithelial neoplasia (CIN 3) on biopsy specimens.
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time of progression from persistent HPV infection to high-grade squamous intraepithelial lesions has been thought to be 5 to 15 years
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cumulative 36-month progression rates to grade 2 or 3 CIN (CIN 2/3) from 7 to 20%, with the highest rates reported for HPV type 16 (HPV-16)
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Thus, this patient's diagnosis of high-grade squamous intraepithelial lesions within 2 years after becoming sexually active may not be as unusual as we might have thought.
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Invasive cervical cancer is rare in adolescents and young women aged 13 to 20 years
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Thus, although high-grade squamous intraepithelial lesions in adolescents and young women is unlikely to regress, it does not appear to progress rapidly to invasive cancer.
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Because of the low risk of invasive cancer in this population, diagnostic excisional procedures are avoided in adolescents, unless high-grade squamous intraepithelial lesions persist for a total of 24 months.
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after two normal Pap smears, the patient can return to routine screening.
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Nonetheless, for this patient, the benefit of vaccination would include protection against the development of new HPV infection with other high-risk strains, as well as against genital warts.
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In this patient, completion of vaccination with the quadrivalent vaccine would be appropriate, despite the likelihood that she is already infected with at least one of the four HPV types in the vaccine.
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We do not know why a high-grade lesion developed in this patient, which occurs in less than 1% of all adolescent girls and young women.
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NEJM -- Mediastinal Extension of a Goiter on 2009-03-29
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6-month history of dyspnea and dysphagia
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but the lower poles of the thyroid were not palpable. The serum thyrotropin and free thyroxine levels were normal.
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showed tracheal deviation
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large goiter (8 by 6 by 10 cm) extending from the laryngeal cartilage into the mediastinum, displacing vascular structures
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compression and deviation of the trachea
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NEJM -- "Popcorn" Calcifications in a Pulmonary Chondroid Hamartoma on 2009-03-29
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nonsmoker, had no pulmonary symptoms, and was otherwise well
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linear, nodular, irregular shape, known as "popcorn" calcifications
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pulmonary chondroid hamartoma
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Pulmonary hamartoma is a benign lung tumor that should be considered when an incidental solitary pulmonary nodule is identified. Popcorn calcifications within a well-circumscribed pulmonary nodule are highly suggestive of pulmonary chondroid hamartoma.
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