Case 2-2012

Abstract

the Departments of Radiology (V.V.M.) and Pathology (M.N.), Massachusetts General Hospital; and the Departments of Radiology (V.V.M.) and Pathology (M.N.), Harvard Medical School -all in Boston. N Engl J Med 2012;366:259-69. (Internal Medicine): A 63-year-old woman was admitted to this hospital because of rapidly progressive respiratory failure.The patient had a history of Poland syndrome (agenesis of the right breast, pectoralis muscle, and the third and fourth costal cartilages) and had received a silicone implant in the right breast 28 years earlier. She had been well until 5 years before admission, when a diagnosis of granulomatous polyangiitis (formerly termed Wegener's granulomatosis) was made, characterized by uveitis and pulmonary hemorrhage with respiratory failure and requiring intubation. Treatment with azathioprine and trimethoprim-sulfamethoxazole resulted in improvement; the titer of antimyeloperoxidase antibodies normalized within 5 months after the start of treatment and remained normal.Nine months before admission, the patient reported pain associated with the right breast implant; it was removed and replaced with a saline implant at another hospital. For 6 weeks after the procedure, there was drainage of sanguinous fluid and local induration at the site. Laboratory-test results are shown in Table 1. The dose of azathioprine was decreased from 75 mg to 50 mg daily. Because of persistent pain at the site, the implant was replaced 7 months before admission and again 3 weeks before admission, with reconstruction of the right chest wall. Five weeks before admission, the patient began to have dyspnea on exertion and intermittent back pain. The platelet count reportedly decreased to 16,000 per cubic millimeter. A specimen from a bone marrow biopsy reportedly revealed an increased number of megakaryocytes, which was suggestive of peripheral destruction of platelets. Azathioprine and trimethoprim-sulfamethoxazole were stopped, and prednisone (40 mg daily) and narcotic analgesia were administered. During the 2 weeks before admission, intravenous immune globulin and a dose of romiplostim were given, without improvement. Testing for antineutrophil cytoplasmic antibodies (ANCA) was negative. The dose of prednisone was tapered to 20 mg daily. The day before admission, dyspnea worsened. The patient came to the emergency department at this hospital.The patient reported a nonproductive cough, pain in the right upper back, but no other chest-wall or breast pain; she reported no fevers, chills, sweats, hemoptysis,

Can clinical case discussions foster clinical reasoning skills in undergraduate medical education? A randomised controlled trial

“…In all experimental groups, the intervention was based on the same three, independent internal medicine cases. Chief complaints in these cases were paraesthesia (first session), fever and respiratory failure (second session) and rapidly progressive respiratory failure (third session) 24–26. Cases were worked through in an iterative approach in different formats: (1) peer-moderated live case discussions in an interactive setting (Live-CCD, n=30), (2) a single-learner format utilising an interactive multimedia platform displaying video recordings of the live case discussions (Video-CCD, n=27) and (3) a single-learner format in which the students worked with the original paper cases of the NEJM (Paper-Cases, n=33).…”

Primary Angiosarcoma of the Breast: A Case Report and Review of Literature

“…This is the only reported case with a history of bilateral reduction mammoplasty, although there are case reports describing an association of augmentation mammoplasty and breast implants with various malignant tumors, including ASB [ 26 - 28 ]. However, a comprehensive review concluded that breast implants are not associated with an increased risk or a delay in detection of breast cancer [ 29 ].…”

Metastatic Angiosarcoma and Kasabach-Merritt Syndrome

“…1,2 They are most frequently of skin and soft tissue origin in the head and neck region, but may also arise from other organs such as the liver, spleen, heart, and breast. In particular, angiosarcomas are known to be associated with radiation, 3,4 chronic lymphedema after breast surgery (Stewart-Treves syndrome), 5 and most recently a possible association with silicone breast implants has also been described.…”

“…Somewhat peculiar to angiosarcoma is that it may present with Kasabach-Merritt syndrome, 2,9-14 a consumptive coagulopathy originally described in association with large benign hemangiomas in infants. 15 Pathogenesis is presumably related to platelet trapping within these highly vascular lesions with secondary consumption of clotting factors and resultant bleeding.…”