Pregnant patients with coccidioidomycosis develop dissemination and serious disease more frequently than do the general population. To assist in prognosis and management, we analyzed the significance of erythema nodosum in pregnant patients with coccidioidomycosis. Sixty-one pregnant patients (mean age { SD, 26.4 { 6.3 years) were evaluated. Seventy percent of the patients were Hispanic; 15%, African American; 13%, Caucasian; and 2%, unknown race. Of the 30 patients (49%) who developed erythema nodosum, 0 had disseminated disease (P Å .001), 1 (3%) with pulmonary involvement required therapy for ú1 year, and 29 (97%) recovered (P Å .0008). Of the 31 patients (51%) without erythema nodosum, 11 (35%) had disseminated disease, 12 (39%) required therapy for ú1 year, 17 (55%) recovered, 1 (3%) died, and 1 (3%) had an outcome that was unknown. Erythema nodosum appears to be a salient marker of a positive outcome for pregnant patients, more so than for the general population.
We present a case of a 65-year-old Hispanic man with a history of disseminated cutaneous coccidioidomycosis who presented to the emergency room for progressively worsening abdominal pain associated with shortness of breath. The patient was found to have pleural effusion and moderate ascites on physical examination. Abdominal ultrasound and computed tomography scan were consistent with moderate ascites and portal hypertension but negative for both liver cirrhosis and for venous or arterial thrombosis. Cytology of ascitic fluid was suggestive of portal hypertension and was negative for infection. Subsequent, thoracentesis was suggestive of exudative effusion and also negative for infection. Liver biopsy confirmed the absence of cirrhosis. Complete blood count indicated pancytopenia, whereas bone marrow biopsy and flow cytometry were suggestive of marginal zone lymphoma (MZL). Clinically, the patient’s shortness of breath was resolved by thoracentesis and paracentesis; however, his abdominal pain persisted. A diagnosis of idiopathic noncirrhotic portal hypertension in the setting of splenic MZL was made. The patient was transferred to a higher level of care for splenectomy; however, he missed multiple appointments. Since discharge, the patient has been seen in the outpatient setting and states that he is controlling his disease with diet and exercise; however, he continues to complain of intermittent shortness of breath with exertion.
The diagnosis of acute pancreatitis in a patient requires the presence of two of the following three criteria: (I) acute onset of persistent, severe; (II) epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal; (III) characteristic radiographic evidence hypertriglyceridemia is a potential cause of acute pancreatitis when levels are greater than 1,000 mg/dL. Very severe hypertriglyceridemia is classified as levels above 2,000 mg/dL. Management includes targeting pancreatitis with intravenous fluids, pain control, and nutritional support. While apheresis with therapeutic plasma exchange is a known option for severe hypertriglyceridemia, we present a rare case with management with intravenous fluids, subcutaneous insulin, statins, and fibrates in a patient with a triglyceride level of 12,234 mg/dL who presented with severe epigastric pain radiating to her back.
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