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Immune thrombocytopenia (ITP) is a rare autoimmune disorder characterized by low platelet count and skin-mucosal bleeding. In adults it is usually idiopathic and may have a chronic onset, while in children it is usually acute following a viral illness. Dengue has been rarely reported as a cause of ITP. We report a case of a young adult woman that presented with acute ITP following a dengue virus infection.

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Sjögren's syndrome is a systemic autoimmune disorder characterized by salivary insufficiency and lymphocytic infiltration of the exocrine glands. Bronchiolitis and bronchiectasis are common airway manifestations but interstitial pneumonitis, and lymphocytic interstitial pneumonitis may also occur. It rarely presents with pleuritis. We report a woman with primary Sjögren's syndrome who developed pleuritis with moderately large effusions and antibody levels for SS-A and SS-B in the serum without evidence of infection, malignancy or other collagen diseases. After the initial treatment, daily administration of 20 mg of oral prednisone has effectively controlled the serious manifestations of the disease with minimal side effects.

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UNLABELLED: Vancomycin is the mainstay antibiotic used in hemodialysis group due to high prevalence of methicillin resistant Staphylococcus Aureus. For years regimens of vancomycin in high flux hemodialysis (HFHD) patients were designed to achieve a pre-dialysis vancomycin concentration between 5-20 ug/mL. Recent guidelines increased the recommended pre-dialysis level to 15-20 ug/ml for health care associated infections, bacteremia and osteomyelitis. The purpose of this study was to determine if the loading dose (LD) before HFHD and the maintenance dose (MD) of vancomycin achieved a pre-dialysis concentration between 15-20 ug/ml on HFHD in-patients with a suspected infection. The second purpose was to predict an adequate vancomycin dosage to achieve the new recommended levels. MATERIAL AND METHODS: An observational prospective study on hospitalized adult patients on HFHD with evidence of infection treated with 1 gm LD of vancomycin and 500 mg MD. Plasma levels of vancomycin were measured before each HFHD for three consecutive times. Age, gender, weight at admission, blood flow rate, dialyzer flow rate, type of filter and HFHD length were evaluated. RESULTS: Twenty-one patients met the inclusion criteria. All of them were treated with 1 gm LD of vancomycin and 500 mg MD protocol. The mean pre-dialysis concentration #1 was 10.8 ug/mL. The mean pre-dialysis concentration #2 was 13 ug/mL, and the mean pre-dialysis concentration #3 was 12 ug/mL. Only 36% of HFHD sessions achieved an adequate vancomycin level. A liner regression analysis predicted that a loading dose of 23 mg/kg LD and 8 mg/kg MD achieved the recommended pre-dialysis vancomycin concentration. CONCLUSIONS: Current dose regimen of 1 gm LD and 500 mg MD of Vancomycin are not adequate to achieve recommended pre-dialysis level of 15-20 ug/mL for health care associated infections, bacteremia and osteomyelitis in most patients on HFHD. Based on our statistical analysis, we recommended that 23 mg/kg of LD and 8 mg/kg of MD would achieve an adequate vancomycin level.

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An Aspergilloma is a "ball" of fungal mycelia composed of Aspergillus species developing in a pre-existing lung cavity. This uncommon entity may cause hemoptysis and may be a diagnostic challenge. We present imaging and review the literature of a recent case managed in our institution.

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UNLABELLED: Hospitals use a triage system in which health care staff sort's patients into groups. During the long waiting periods after triage, inadvertence of patient's clinical deterioration may occur. OBJECTIVES: To determine whether vital signs and oxygen saturation monitoring and reassessment of medical priority during the waiting period had a positive impact on the clinical outcome of apparently non-critical patients. METHODS: The study was undertaken in a University Hospital Emergency Department (ED). Patients were sorted into experimental (group A) and control (group B) groups. Temperature, respiratory and pulse rates readings of group A patients were constantly generated by electronic devices and displayed in a computer screen. The results were checked every 5-to-10 minutes. Blood pressure (BP) and oxygen (02) saturation were verified every 30 minutes. If critical changes occurred, the patient's chart was discretely moved to the top of the waiting pile. Group B patients were not monitored. Clinical outcome (complications, stability of vital signs, and complete resolution of symptoms at discharge) and the length of hospital stay were compared for both groups. RESULTS: Patients in group A had a shorter hospital stay (p<0.0001), lower rate of complications (p=0.003), and higher rate of vital sign stability (p<0.0001) and of complete resolution of symptoms at discharge (p<0.0001). CONCLUSIONS: Blood pressure monitoring every 30 minutes significantly improved ED waiting patients' clinical outcome and shortened their hospital stay. Observations of oxygen saturation, temperature, pulse, and respiratory rate were not significantly useful.

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BACKGROUND: The knowledge and implementation skills of the DNR (do not resuscitate) order amongst physicians in training appears to be quite variable. METHODS: We constructed, validated and implemented an instrument which evaluates knowledge and implementation skills of medical residents regarding the DNR in the 8 accredited teaching hospitals in Puerto Rico. RESULTS: Participation of 136 residents from 240 approved positions was seen. Most thought (93.3%) the DNR should be written in the medical record. And 88.1% thought appropriate to suggest a DNR to the patient or family for a terminally ill patient. For a patient with an uncertain prognosis who insisted on a DNR, 78.5% believed the attending physician and 21.5% thought the ethics committee was responsible for determining the propriety of the order. When the patient and the treating physicians agreed on the appropriateness of a DNR order most residents in the North of Puerto Rico thought the writing of the order was the purview of the resident while residents in the South-West thought this to be the responsibility of the attending physician. In the absence of a DNR order, more than 77.4% of the residents in the North and South would initiate CPR in a comatose patient with terminal cancer, multiple organ failure and sepsis in contrast to 15% of the residents in the West. CONCLUSIONS: Implementation and knowledge skills of medical residents in the health regions of Puerto Rico differ. Knowledge and implementation of the DNR merits improvement in all training programs.

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The libertarian principles of Personal Autonomy and Personalized Justice which grew mightily in the rapidly spreading young American democracy in the 18th and 19th centuries led to the development of Bioethics in the United States. The bioethical principles of Respect for Autonomy, Beneficence, non-Maleficence and Justice support the elaboration of advance directives (living will and the designation of a proxy to attend health matters) for when the patient is no longer capable to make health decisions. Advance directives can be drafted and signed in Puerto Rico with the help of a lawyer. They can also be legally prepared in a doctor's office or in a hospital if witnessed by a doctor and two persons who will not benefit from the patient's demise or are directly involved in his/her care). We present a model for advance directives which may be executed in a doctor's office or a hospital. The model fulfills the legal requirements of Puerto Rico Law 160 which became effective November 2001. It also fulfills requirements of the Patients Self-Determination Act that became effective in 1991.The document also contains standard options for organ donations. We discuss the fundamental bioethical principles which have given root to the development of the advance directives. We suggest that it may be economically advantageous to health insurance carriers to compensate physicians who help their patients in the execution of a valid document. The existence of this document may help prevent the large expenses associated with inappropriate admissions to intensive care of patients at the end-of-life.

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Pain management is a central issue in the care of cancer patients in hospice services. Morphine is at present the first line opioid recommended. But when morphine is used in large doses, especially in renal patients, an active metabolite of morphine, morphine-6-glucoronide, may cause delirium and myoclonus and sometimes antagonize the analgesic effect of morphine. Both fentanyl and methadone have some potential advantages over morphine since they are longer-acting and have no active metabolites. However, large doses of fentanyl or long-acting morphine are expensive while methadone has an extremely low cost. We present our retroactive comparative observations in 50 cancer patients. Methadone was found to be as effective as morphine, transdermal fentanyl and common combinations of other opioids in controlling the types of cancer pain presented by patients in a hospice in the Northwestern Region of Puerto Rico. The use of methadone on elderly patients with cancer pain as first line therapy is growing in European and North-American hospices. Hospitals should add methadone to their therapeutic armamentarium and physicians should develop skills to use this long acting opioid.

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Calcific uremic arteriolopathy is a rare and devastating disorder characterized by diffuse calcification of medium size arterioles and occasionally affects patients with chronic kidney disease. A 62-year-old woman with diabetes mellitus, arterial hypertension and moderate to severe chronic kidney disease was admitted to the hospital with multiple, non painful, necrotic, hemorrhagic and purulent chronic open wounds ranging from 1 cm to 3 cm of diameter in the medial and posterior aspects of both lower extremities. Sensation to light touch and vibration were absent in the lower extremities. Biopsy of a one of the lesions showed fat necrosis and extensive dystrophic calcific deposits in the subcutaneous fat and the wall of small arterioles, consistent with systemic calcific uremic arteriolopathy. Once the lesions ulcerate and grow proximally survival is unlikely.

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BACKGROUND: Attitudes in regard to end-of life issues are evolving in Western societies. We have sought to trace this evolution in the relatively homogeneous cultural setting of Puerto Rico. METHODS: One hundred fifty-two medical students, 62 medical residents and 84 members of three medical faculties were asked whether in terminally ill patients they: 1) would support a request for euthanasia(E); 2) if legalized, would engage in, would oppose or would not be opposed to others engaging physician-assisted suicide(PAS); 3) would consider ethical to prescribe full doses of drugs needed to alleviate pain, even if they knew it would hasten death; 4) would agree to limit certain resources for the terminally ill. Gender and religious affiliation were also requested. RESULTS: Twenty-eight percent of the students, 26% of the residents and 31% of the faculty supported E. Only 13% of the students, 18% of the residents and 11% of the faculty would engage in PAS. Men were more willing than women to acquiesce to a request for E or PAS. Religious affiliation or its absence did not influence the support or opposition to E and PAS. If it would hasten death, 86% of the residents, but only 65% of the faculty considered ethical to prescribe the dose of drugs needed to alleviate pain. More than 2/3 of the students, residents and faculty favored the limiting of certain resources for the terminally ill. CONCLUSIONS: In our cultural and medical environment, men are more willing than women to engage in E or PAS. The attitude towards E and PAS is not influenced by religious affiliation. If it hastens death, some still consider unethical to prescribe full doses of drugs needed to alleviate pain in the dying patient.

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Prolonged, strenuous exercise is associated with muscle injury; this may become permanent if there is insufficient time to rest between bouts of endurance exercise. We present here the experience of a 36 year old athlete who developed myocardial injury and pulmonary edema during a triathlon. Within 24-hours, after receiving furosemide 40 mg every 8 hours and oxygen, his pulmonary edema disappeared. The serum troponin became transiently elevated as it happens with a myocardial infarction but no electrocardiographic changes occurred. It is concluded that strenuous exercises may cause myocardial injury with a transient decrease of ventricular function and pulmonary edema. The possibility of some permanent damage cannot be excluded.

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Leptospirosis is a zoonosis with protean manifestation caused by the spirochete leptospira. The major presenting symptoms arc fever, jaundice, acute renal failure and thrombocytopenia (1). The fact that this patient owns a small farm where he eats unwashed fruits made us consider this diagnostic possibility. The patient was started on ampicillin therapy, received hemodialysis and marked improverilent of renal function followed. The diagnosis was confirmed by leptospira titers that were rechecked after medical treatment obtaining normal values. The annual incidence of Leptospirosis in the United States ranges from 0.02 to 0.04 cases per 100,000 persons, but in tropical countries it can be the cause of acute renal failure in up to 24% of cases. In Puerto Rico the fever, myalgia, thrombocytopenia may lead to its confusion with dengue (2). In 1966, after hurricane Hortense in Puerto Rico, Sanders did leptospira titers in patients following negative dengue serology and concluded that leptospirosis is an underdiagnosed and misdiagnosed disease.

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There is a long list of prescribed and over the counter oxidizing agents that can induce methemoglobinemia. We report a case of methemoglobinemia in a 46-year-old man with a mayor depression disorder who ingested 30 pills of diphenhydramine, 30 pills of haloperidol, 20 pills of dolagesic, 20 pills of cyclobenzaprine, 20 pills of naproxen, 14 pills of cephalexin, and 48 pills of chlorzoxazone. On admission, he was on mechanical ventilation, and responded only to painful stimuli. Five hours later his face, hands and feet became cyanotic. The pulse oximetry revealed a Sp02 of 85%. The dark chocolate color arterial blood showed a Pa02 of 290.8 mm Hg and oxygen saturation (Sa02) of 99%. The chocolate color arterial blood and unchanged Sp02 suggested the diagnosis of methemoglobinemia. One mg per Klg of intravenous methylene blue was administered in 5 minutes. Twenty minutes later, the cyanosis began to fade and one hour later, it had disappeared and the Sp02 was 99%. Early treatment of methemoglobinernia is crucial in preventing tissue hypoxia. Methylene blue is the treatment of choice in symptomatic patients. The initial dose of methylene blue is 1-2 mg/kg of a 1% solution administered over 5 minutes. Reduction of methemoglobin is usually complete within 1 hour. If methemoglobinernia persists, a second dose not to exceed a total dose of 5-7 mg/kg may be administered. Because headache, nausea, vomiting, diarrhea, and angina may occur with therapeutic doses, methylene blue should only be administered to those patients with symptoms or signs of hypoxia.

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Paralysis due to hypokalemia results from an acute shift of potassium into cells or excessive potassium deficit. In the absence of potassium deficit, it is observed in Familial Hypokalemic Periodic Paralysis and in Thyrotoxic Hypokalemic Periodic Paralysis (TPP). This report describes the initial presentation of hyperthyroidism as sudden quadriplegia associated with hypokalemia. A healthy 25-year-old Puerto Rican policeman came to the emergency room with sudden paralysis in the four extremities of five hours evolution. He woke up in the morning and could not get up. The day before admission his legs felt weak, and it was hard to get out of bed. He arrived home at 7:00 PM, ate pasta and vegetables, and went to sleep at 10:00 PM. He had no diarrhea or weight loss, no history of medications or illicit drugs. He has a cousin and an aunt with the diagnosis of hypo-thyroidism. The admission temperature was 36.0 degrees C, pulse 96 per minute, respiratory rate 18 per minute, blood pressure 160/70 mmHg. He was alert and oriented as to time, place and person. He could talk properly and was in no respiratory distress. He had no exophtalmos or lid lag. The thyroid was not enlarged or tender. No pseudoclubbing or pretibial edema was found. There was flaccid paralysis of all extremities, 0/5 legs and 1/5 arms. Deep tendon reflexes could not be elicited. The cranial nerves and sensory examination were normal. The hemogram was within normal limits as were the renal and liver functions. Serum sodium was 140 mEq/L, potassium 1.48 mEq/L, phosphorus 1.4 mEq/L. A random glucose was 155 mg/dl and the arterial Ph was 7.41. The urine potassium was 7.04 mEq/L, sodium 60.8 mg/dl. TSH levelwas < 0.03 ug/d], TUP 50.69% (24-40%), T4 17.6 ug/dl (4.7-11.4 ug/dl) Free T4 Index 28.23. He was managed with intravenous potassium chloride, 80 mEq in a period of seven hours with cardiac monitor. The serum potassium level, after the infusion was completed, was 6.70 mEq/L. No cardiac arrhythmia was documented. Muscle strength recovery was gradual and it was complete 4 hours after the infusion was initiated. The next day the potassium level was within normal limits but a wide pulse pressure and tachycardia still persisted.

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Renal cell carcinoma is the most feared complication in patients with acquired renal cystic disease. We present a 73-year-old man with end stage renal disease in chronic hemodialysis for eleven years that was admitted to the hospital because of hematuria and right flank pain. Two months before admission the abdominal CT reported atrophic changes of the right kidney with multiple masses. A right laparoscopic nephrectomy demonstrated renal cystic disease associated with multifocal cystic renal cell carcinoma, clear cell, nuclear grade II. There was no extra renal extension or renal pelvis involvement. Patients with end-stage renal disease who have been on hemodialysis for three to five years should undergo yearly screening with ultrasonography. Once the ultrasonogram becomes positive for cysts, the more sensitive contrast enhanced CT scanning should be performed yearly to screen for the possible occurrence of renal cell carcinoma.

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High-grade Non-Hodgkin's lymphomas are very aggressive type of malignancies. We report a high grade small B-cell (Burkitt's like) Non-Hodgkin's lymphoma that initially was considered and treated as ulcerative colitis without improvement or resolution of symptoms for nine months. The clinical presentation of 30 lb weight loss, diarrhea and dyspaurenia as complications of the developing and rapid growth of the mass were highly suggestive of malignancy. Acute lesions of ulcerative colitis begin at the anal verge and involve only the mucosa and submucosa. When induration of the perirectal areas develop a different pathology should be suspected.

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Multiple sclerosis, is an idiopathic inflammatory disease of the central nervous system. Symptoms rarely begin before age 10 or after age 60.The presentation may vary from isolated motor or sensory impairment to seizures or psychotic disturbances. This case report presents a 7-year-old male who complained of double vision, paralysis of the right face and imbalance. At that time the patient had supranuclear facial palsy, mild ataxia, diplopia and horizontal nystagmus. Head CT scan showed nodular densities with low attenuation areas in the white matter of the left frontal and left parietal lobes compatible with multiple sclerosis. At 12 years of age the patient presented dizziness, diplopia, and weakness of right extremities. At 24 years of age he developed seizures and visual and auditory hallucinations. By age 28 the patient was admitted with a sudden onset of paraparesis. Extensive subcortical and periventricular white matter changes were demonstrated by MRI on February 7, 2004. This case, with symptoms beginning at a very young age, demonstrates a wide range of the presentations of multiple sclerosis: motor impairments, seizures and hallucinations.

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Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of the skeletal muscles of the face and extremities. Pregnancy is associated with 19-41% of exacerbations. We present a 19-year-old woman who was seen at the neurology clinic 10 days after her last cesarean section with diplopia and trouble swallowing liquids and solids for the previous 3 months. On examination she had slurred speech, bilateral palpebral ptosis, and mild droop of her shoulders. An arterial blood sample showed a PCO2 of 50 mmHg and a PO2 of 70 mmHg. The tensilon test was positive, Intravenous methylprednisolone and immunoglobulin and oral pyridostigmine effectively relieved her myasthenic signs and symptoms. Five assays for acetylcholine or anti-striational antibodies in her serum were negative. A test for muscle-specific tyrosine kinase antibody was positive. In 10-20% of patients with myasthenia gravis no antibodies to acetylcholine receptors are detectable. Forty percent of this group has an antibody to muscle-specific tyrosine kinase.

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Transient weakness of the legs developed in a 17 year-old male high school student three weeks after the initial injection of a hepatitis B vaccine. Seventeen days after the second injection of the vaccine, low-grade fever, a pruritic maculopapular rash appeared and weakness of the legs recurred. This was associated with elevation of the creatinine kinase to 2,406 U/L. The day after admission he became afebrile and in the subsequent four days the rash improved but leg weakness persisted. One-month later, muscle strength had returned; and the creatinine kinase had returned to normal levels. The only case of dermatomyositis associated with hepatitis B vaccination and the findings in the six reported cases of surface antigen-positive hepatitis associated with polyomyositis or dermatomyositis are briefly reviewed. Hepatitis B vaccination should be encouraged, but it is important to be aware that, rarely, dermatomyositis, polymyositis or neurovascular complications may occur. Polymyositis associated with the administration of the hepatitis B vaccine or with hepatitis B virus infection is a rare occurrence. A Medline Search performed from 1960 to January 2002 associating hepatitis B vaccine or hepatitis B virus with myopathy, myositis, polymyositis and dermatomyositis, showed only one case of dermatomyositis related to the hepatitis B vaccine, and six case reports relating polymyositis to hepatitis B virus infection. We present a case where a causal relationship between polymyositis and hepatitis B vaccination appears quite likely.

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