Little is known about opportunistic fungi causing skin lesions in tropical countries such as Panama. We report an 83-year-old man from Chiriquí, Western Panama, with crusted skin lesions covering tumorous masses resembling Bowen's disease of the skin on the dorsum of his right hand. Fungal cultures were obtained on different nutrient media from disinfected superficial skin scrapings and fragments taken from a deep skin biopsy. Deep skin biopsy showed the presence of globose, dark fungal cells in the upper and lower dermis, sometimes in abscesses or giant cells, indicating chromoblastomycosis. All fungal fragments plated on nutrient media yielded colonies of Chaetomium funicola which was identified based on morphological observations and molecular sequence data of large ribosomal subunit rDNA. Treatment with fluconazole was ineffective. Further treatments could not be applied because of the patient's advanced age, low compliance, and limited resources in a rural, tropical environment. For the first time, C. funicola is confirmed as an opportunistic fungus causing superficial and deep cutaneous lesions. Up to now, the only known clinical record of this species is a tentative identification as an agent of deep mycosis.
Computerized tomography (CT) is the most often used imaging modality in the evaluation of acute clinical stroke. However, the rapidity with which CT density changes occur after acute, severe, focal ischemia cannot be determined clinically. Even if the time of symptom onset is known, clinical stroke severity is highly variable. We studied the time course of CT density change after severe, rapid onset, acute, focal ischemia as documented by stable xenon CT cerebral blood flow (CBF) in monkeys. Eight monkeys (Macaca mulatta) were subjected to transorbital occlusion of the left posterior cerebral, anterior, middle, and internal carotid arteries to induce focal ischemia. CT density Hounsfield units (HU), CBF by stable xenon CT, arterial blood pressure, and blood gases were measured before occlusion, immediately after occlusion, at 30 min, and hourly for up to 6 h. Occlusion of the cerebral arteries decreased CBF to 8 ± 5 ml/100 g/ min within 15 min postocclusion. At 6 h, CBF was unchanged at 9 ± 4 ml/100 g/ min. CT density within the ischemic core fell from 42 to 38 HU immediately after occlusion (P < 0.05), rose transiently, then fell at 2 h (P < 0.01) and plateaued at 36 ± 5 HU for a total decrease of 4-5 HU between 4 and 6 h poststroke. Changes in CT density lag severe focal ischemia by 2 h. Thus, when CT hypodensity is seen in acute stroke, it is likely 2 h old. It also provides an explanation for the phenomenon of clinical CT mismatch with clinical deficits and normal CT.
INTRODUCTION: IgG₄-related disease is a rare autoimmune syndrome that causes fibrosis of glands, most commonly of the pancreas and biliary tract1,3. The overall prevalence is unknown, with an estimated less than 1:100,000 of the general population typically found in middle-aged males2,3. Diagnosis is made with IgG₄ levels at least 2x the upper limit of normal and dense lymphoplasmacytic infiltrate, however, it may be seen with normal IgG₄ levels6. Although rare, it can present similar to GI malignancies and should be considered in the differential for patients with autoimmune disease1,3,4,5. Here we present one of those unusual cases. CASE DESCRIPTION/METHODS: A 65-year-old lady with PMH of DM2 and Sjogren's Syndrome (SS) who presented to the hospital with intractable nausea, vomiting, and failure to thrive for over 1 month. The physical exam, labs that included CMP, LFTs, and serology was unremarkable; previous EGD revealed diffuse thickening of the gastric submucosa. Biopsy via open gastrectomy revealed chronic inflammation with multiple IgG₄ plasma cells and no signs of lymphoma, suspicious for IgG₄-RD. After the partial gastrectomy, serum Na levels were 162, which improved with DDAVP and was later confirmed to be diabetes insipidus (DI). Further workup and imaging were negative and baseline IgG and IgG₄ levels were 1178 and 61, respectively. Treatment included steroid therapy and DDAVP which improved her symptoms and preceded an uneventful hospital course. DISCUSSION: IgG₄-RD is a disease with numerous presentations based on the organs involved. It presents as a GI-specific illness due to its affinity for the pancreas and biliary tract1,2,3. As seen in our patient, although rare, it may also affect the stomach, form mass lesions and cause symptomatology similar to a GI malignancy3,5. In patients with autoimmune diseases, where GI malignancy is considered, it is reasonable to include IgG₄-RD in the differential. IgG₄-RD may mimic symptoms of SS, and therefore case-patients with SS should also be considered for IgG₄-RD. This patient also experienced DI which may be a manifestation of IgG₄-RD, as the syndrome may affect the pituitary4. This case is one of the few instances reported to have pituitary involvement after the onset of multiorgan involvement4. Like other autoimmune disorders, IgG₄-RD is responsive to steroid therapy or rituximab. Therefore, a timely diagnosis can help slow down or prevent symptomatic manifestations, as seen in the case. Clinicians should be aware of this clinical presentation.
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