The correct answer is 5. The clue is in the whitish lesions of the jugal mucosa corresponding to Koplik's spots, which are pathognomonic of measles, although as an observation I would say that they usually appear in the prodromal phase of the disease and are often no longer seen when the exanthema appears. In this case you are describing measles complicated by pneumonia. Very timely question at the present time.

[HIDDEN] The clue is in the whitish lesions of the jugal mucosa corresponding to Koplik's spots, which are pathognomonic of measles, although as an observation I would say that they usually appear in the prodromal phase of the disease and are often no longer seen when the exanthema appears. In this case you are describing measles complicated by pneumonia. Very timely question at the present time.

A 7-month-old infant comes to the emergency department referred by his pediatrician for suspected Kawasaki disease. He reports a fever of up to 39.5ºC of 5 days evolution that does not subside despite treatment with amoxicillin prescribed 72 hours ago for suspected acute pharyngotonsillitis. During the last 24 hours he has had erythematous and pruritic exanthema of cephalocaudal evolution and during the last few days his parents have noticed a cough and intense conjunctivitis. No rhinorrhea was reported. Clinical examination showed subcrepitant in both lung bases without tachypnea or signs of respiratory distress. On oropharyngeal examination there are whitish spots in the jugal mucosa. What is the most probable diagnosis?

Measles

Diagnosis Typically, clinical diagnosis begins with the onset of fever and malaise about 10 days after exposure to the measles virus, followed by the emergence of cough, coryza, and conjunctivitis that worsen in severity over 4 days of appearing. Observation of Koplik's spots is also diagnostic. Other possible condition that can result in these symptoms include parvovirus, dengue fever, Kawasaki disease, and scarlet fever. Laboratory confirmation is however strongly recommended.

[Adult Kawasaki disease].

Kawasaki disease is an acute vasculitis seen rarely in adults. Diagnosis is based on fever lasting at least 5 days and four or five major clinical criteria in the absence of any other potential pathological causes. A 50-year-old woman taking no new medications immediately beforehand was seen with a febrile maculopapular exanthema present for 3 days, as well as gradual onset of enanthema, cheilitis, odynophagia, adenopathy, peripheral oedema and bilateral conjunctivitis. Fever and markers of inflammation persisted despite 3 days of antibiotic therapy. The diagnosis of Kawasaki disease was made on the basis of the presence of all the major diagnostic criteria of Kawasaki disease. A favourable outcome was achieved 48 hours after the start of intravenous immunoglobulin and aspirin. Our case is of interest because of the presence of all the diagnostic clinical criteria as well as the favourable outcome achieved rapidly with treatment. In adults, the rarity of this disease, which frequently presents in the incomplete forms, with lack of specific clinical signs and the unavailability of diagnostic laboratory tests mean that diagnosis is usually delayed. It is recommended that treatment be initiated before the disease has progressed for 10 days.

Measles

Signs and symptoms Symptoms typically begin 10–14 days after exposure. The classic symptoms include a four-day fever (the 4 D's) and the three C's—cough, coryza (head cold, fever, sneezing), and conjunctivitis (red eyes)—along with a maculopapular rash. Fever is common and typically lasts for about one week; the fever seen with measles is often as high as . Koplik's spots seen inside the mouth are diagnostic for measles, but are temporary and therefore rarely seen. Koplik spots are small white spots that are commonly seen on the inside of the cheeks opposite the molars. They appear as "grains of salt on a reddish background." Recognizing these spots before a person reaches their maximum infectiousness can help reduce the spread of the disease.

Acute bronchitis

Prognosis Acute bronchitis usually lasts a few days or weeks. It may accompany or closely follow a cold or the flu, or may occur on its own. Bronchitis usually begins with a dry cough, including waking the sufferer at night. After a few days, it progresses to a wetter or productive cough, which may be accompanied by fever, fatigue, and headache. The fever, fatigue, and malaise may last only a few days, but the wet cough may last up to several weeks. Epidemiology Acute bronchitis is one of the most common diseases. About 5% of adults are affected and about 6% of children have at least one episode a year. It occurs more often in the winter. In infants under one year of age, acute bronchitis was the most common reason for admission to the hospital after an emergency department visit in the US in 2011. References External links Acute Bronchitis FamilyDoctor.org (American Academy of Family Physicians)

COVID-19 surveillance

Syndromic surveillance is done based on the symptoms of an individual who corresponds to COVID-19. As of March 2020, the WHO recommends the following case definitions: Suspect case: "a patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath), and a history of travel to or residence in a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset" OR " a patient with any acute respiratory illness and having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset" OR "a patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g. cough, shortness of breath; and requiring hospitalization) and in the absence of an alternative diagnosis that fully explains the clinical presentation"

InternalMed_Harrison

The differential diagnosis of measles includes other causes of fever, rash, and conjunctivitis, including rubella, Kawasaki disease, infectious mononucleosis, roseola, scarlet fever, Rocky Mountain spotted fever, entero virus or adenovirus infection, and drug sensitivity. Rubella is a milder illness without cough and with distinctive lymphadenopathy. The rash of roseola (exanthem subitum) (see Fig. 25e-5) appears after fever has subsided. The atypical lymphocytosis in infectious mononucleosis contrasts with the leukopenia commonly observed in children with measles.

Measles -- History and Physical

The WHO clinical case definition of measles is "any person with fever, generalized maculopapular rash, cough, coryza, or conjunctivitis." Measles is an acute febrile exanthema that is characterized by the three “Cs”: cough, coryza, and conjunctivitis. Koplik spots, small white papules on the buccal mucosa, are pathognomonic for measles and appear a day or two before the rash, although they are not always seen. The fever precedes the rash. The rash appears first on the face and spreads caudally to become generalized. Uncomplicated measles typically resolves a week after the rash onset. [11]

Acute bronchitis

Diagnosis A physical examination will often reveal decreased intensity of breath sounds, wheezing, rhonchi, and prolonged expiration. During examination for physicians rely on history and the presence of persistent or acute onset of cough, followed by a URTI with no traces of pneumonia. Acute bronchitis is typically a clinical diagnosis that relies on patients history and exam, and should be suspected in patients with an acute onset of cough, which often follows a URTI without traces of pneumonia. Although there is no universally-accepted clinical definition for acute bronchitis, there is a proposed set of practical criteria (Macfarlane, 2001) that include: An acute illness of less than three weeks. Cough as the predominant symptom. At least one other lower respiratory tract symptom, such as sputum production, wheezing, chest pain. No alternative explanation for the symptoms.

Rubeola (Measles) -- Differential Diagnosis

Measles should be distinguished from similar presenting exanthemic diseases of childhood, autoimmune processes, and adverse drug reactions. Rubella causes a rash similar to measles with head to caudal distribution, mild respiratory symptoms, the absence of conjunctivitis. Still, it is accompanied by the presence of adenopathies - which is characteristic of this disease. Roseola is characterized by an illness beginning with a high fever, which subsides after a few days, accompanied by the appearance of a rash in the central part of the body, without the presence of Koplik's points. Mononucleosis is a febrile viral disease, a characteristic course with few symptoms during childhood, contrary to what happens in more advanced ages.  Mononucleosis manifests itself by pharyngeal compromise, polyadenopathy, and hepatosplenomegaly, and the rash can have different forms of presentation. In Kawasaki disease, there is an ocular compromise with the presence of conjunctivitis without exudate, and the respiratory compromise is not part of this pathology. Group A Streptococcus (particularly Scarlet fever) may present with a similar rash (a coarse, sandpaper-like, blanching, erythematous) to measles in association with pharyngitis. [5] [14]

Kawasaki disease

The first day of fever is considered the first day of the illness, and its duration is typically one to two weeks; in the absence of treatment, it may extend for three to four weeks. Prolonged fever is associated with a higher incidence of cardiac involvement. It responds partially to antipyretic drugs and does not cease with the introduction of antibiotics. However, when appropriate therapy is started – intravenous immunoglobulin and aspirin – the fever subsides after two days. Bilateral conjunctival inflammation has been reported to be the most common symptom after fever. It typically involves the bulbar conjunctivae, is not accompanied by suppuration, and is not painful. This usually begins shortly after the onset of fever during the acute stage of the disease. Anterior uveitis may be present under slit-lamp examination. Iritis can occur, too. Keratic precipitates are another eye manifestation (detectable by a slit lamp, but are usually too small to be seen by the unaided eye).

Bronchiolitis -- History and Physical

Once RSV is acquired, the symptoms of an upper respiratory tract infection appear and include a cough, fever, and rhinorrhea. Within 48 to 72 hours, the acute infection involving the lower airways will become evident. During the acute stage, the infant may develop small airway obstruction that leads to symptoms of respiratory distress. The physical exam will reveal crackles, wheezing, and rhonchi. The severity of respiratory distress may vary from infant to infant. Some infants may have mild disease with only tachypnea, but others may show severe retractions, grunting, and cyanosis. The course of the illness may last 7 to 10 days, and the infant may become irritable and not feed. However, most infants improve within 14 to 21 days, as long as they are well hydrated.

Bronchiolitis

Signs and symptoms Bronchiolitis typically presents in children under two years old and is characterized by a constellation of respiratory symptoms that consists of fever, rhinorrhea, cough, wheeze, tachypnea and increased work of breathing such as nasal flaring or grunting that develops over one to three days. Crackles or wheeze are typical findings on listening to the chest with a stethoscope. The child may also experience apnea, or brief pauses in breathing. After the acute illness, it is common for the airways to remain sensitive for several weeks, leading to recurrent cough and wheeze. Some signs of severe disease include: poor feeding (less than half of usual fluid intake in preceding 24 hours) significantly decreased activity history of stopping breathing respiratory rate >70/min presence of nasal flaring and/or grunting severe chest wall recession (Hoover's sign) bluish skin Causes

A 2-Month-Old with Kawasaki Disease with Coronary Artery Dilation in the Pre-COVID-19 Era.

BACKGROUND Kawasaki disease (KD) is an acute inflammatory vasculitis, which occurs mostly in childhood, predominantly between the ages of 6 months and 5 years. The incidence of coronary artery abnormalities associated with KD has decreased from 25% to 4% as a result of timely diagnosis and treatment with intravenous immunoglobulin (IVIG). Infants ≤6 months of age are the most likely to develop prolonged fever without the other clinical criteria for KD, and diagnosis can sometimes be challenging or delayed. They are therefore at particularly high risk of developing coronary artery abnormalities. CASE REPORT A 2-month-old male infant with no significant medical history initially presented with a history of nasal congestion, right conjunctivitis, red lips, and 1 loose stool in the pre-COVID-19 era. He was diagnosed with otitis media and was started on oral amoxicillin. By day 7 of fever, he had developed symptoms and signs and laboratory findings consistent with Kawasaki disease, which is rare in this age group. His echocardiogram showed dilated proximal left anterior descending and right coronary arteries. He was successfully treated, and his most recent echocardiogram, performed 17 months after his treatment, showed remarkable improvement in the coronary arteries. CONCLUSIONS Kawasaki disease in children less than 6 months of age is still rare, and the presentation can sometimes make the diagnosis somewhat challenging. Increased clinical suspicion is required for recognition in the youngest patients, as they are more likely to present with few features of KD. Early diagnosis and treatment are needed to prevent or minimize the risk of significant coronary artery abnormalities.

Kawasaki disease triggered by parvovirus infection: an atypical case report of two siblings.

There are reports of the familial occurrence of Kawasaki disease but only a few reports described Kawasaki disease in siblings. However, the familial cases were not simultaneous. In these patients the idea of infective agents as trigger must be considered. We describe two siblings with atypical presentations of Kawasaki disease; the sister was first diagnosed as having parvovirus infection with anemia and the brother was diagnosed as having myocarditis. The first patient was a 9-month-old Caucasian girl with fever, conjunctivitis, rash, and pharyngitis, and later she had cervical adenopathy, diarrhea and vomiting, leukocytosis, and anemia, which were explained by positive immunoglobulin M against parvovirus. However, coronary artery lesions with aneurysms were documented at day 26 after fever onset. An infusion of intravenous immunoglobulin and high doses of steroids were not efficacious to resolve the coronary lesions. She was treated with anakinra, despite a laboratory test not showing inflammation, with prompt and progressive improvement of coronary lesions. Her 7-year-old Caucasian brother presented vomiting and fever at the same time as she was unwell, which spontaneously resolved after 4 days. Four days later, he again presented with fever with abdominal pain, associated with tachypnea, stasis at the pulmonary bases, tachycardia, gallop rhythm, hypotension, secondary anuria, and hepatomegaly. An echocardiogram revealed a severe hypokinesia, with a severe reduction of the ejection fraction (20%). He had an increase of immunoglobulin M anti-parvovirus, tested for the index case of his sister, confirming the suspicion of viral myocarditis. He received dopamine, dobutamine, furosemide plus steroids, with a progressive increase of the ejection fraction to 50%. However, evaluating his sister's history, the brother showed a myocardial dysfunction secondary to Kawasaki shock syndrome. We report on familial Kawasaki disease in two siblings which had the same infectious trigger (a documented parvovirus infection). The brother was diagnosed as having post-viral myocarditis. However, in view of the two different and simultaneous evolutions, the girl showed Kawasaki disease with late coronary artery lesions and aneurysms, whereas the brother showed Kawasaki shock syndrome with myocardial dysfunction. We stress the effectiveness of anakinra in non-responder Kawasaki disease and the efficacy on coronary aneurysms.

Wheezing -- Introduction

The presence of wheezing does not always mean that the patient has asthma, and a proper history and physical exam are required to make the diagnosis. [1] [2] [3] [4]

Pharmacology_Katzung

A 45-year-old man is brought to the local hospital emer-gency department by ambulance. His wife reports that he had been in his normal state of health until 3 days ago when he developed a fever and a productive cough. Dur-ing the last 24 hours he has complained of a headache and is increasingly confused. His wife reports that his medical history is significant only for hypertension, for which he takes hydrochlorothiazide and lisinopril, and that he is allergic to amoxicillin. She says that he developed a rash many years ago when prescribed amoxicillin for bron-chitis. In the emergency department, the man is febrile (38.7°C [101.7°F]), hypotensive (90/54 mmHg), tachypneic (36/min), and tachycardic (110/min). He has no signs of meningismus but is oriented only to person. A stat chest x-ray shows a left lower lung consolidation consistent with pneumonia. A CT scan is not concerning for lesions or elevated intracranial pressure. The plan is to start empiric antibiotics and perform a

Paramyxovirus -- History and Physical

Measles : Typically, measles presents with the classic three “C”s: cough, coryza (inflammation of the mucous membranes lining the nasal cavity) and conjunctivitis. Fevers are common, along with a generalized maculopapular rash. The three “C”s usually appear the first 10 – 12 days after infection, followed by the rash. On physical exam, the Koplik spots, tiny grains of white papules surrounded by red halo on the buccal mucosa, can be noted a day or two prior to the maculopapular rash on the skin. The rash spreads on the face first, then caudally. The disease usually resolves on its own within a week after the onset of rash. [4]

Persistent cough in an adolescent.

Jessica, a 14-year-old girl with a history of asthma, went to her pediatrician's office because of a persistent cough. She had been coughing for at least 3 months with occasional cough-free periods of less than a few days. The cough was nonproductive and was not accompanied by fever, rhinorrhea, or facial or chest pain. Jessica and her mother observed that the cough increased with exercise and typically was not present during sleep. She has used two metered-dose inhalers--albuterol and cromolyn--without any change in the cough pattern. For the past 5 years, Jessica has had mild asthma responsive to albuterol. She enjoys running on the cross-country team, soccer, and dancing. She is an average student and denies any change in academic performance. She has never been hospitalized or had an emergency department visit for asthma or pneumonia. There has been no recent travel or exposure to a person with a chronic productive cough, tobacco smoke, or a live-in pet. Jessica lives with her mother and younger sister in a 10-year-old, carpeted apartment without any evidence of mold or recent renovation. In the process of taking the history, the pediatrician noticed that Jessica coughed intermittently, with two or three coughs during each episode. At times, the cough was harsh; at other times, it was a quiet cough, as if she were clearing her throat. She was cooperative, without overt anxiety or respiratory distress. After a complete physical examination with normal findings, the pediatrician interviewed Jessica and her mother alone. Jessica's parents had been divorced for the past 6 years. She lived with her mother but visited her father, and his new family with two young children, every weekend. She spoke about this arrangement comfortably and said that she loved her father and mother but didn't like the tension she experienced at her father's home. "I don't like adults arguing when kids are around." When asked why she thought the cough persisted so long, she commented in a neutral tone, "I don't know. It's never been like this before." Jessica's pediatrician prescribed an inhaled steroid with the albuterol. When the cough did not respond after 1 week, he ordered a chest radiograph (normal) and a tuberculin skin test (purified protein derivative-negative), and he added montelukast (a leukotriene inhibitor) and monitored airway resistance with a peak flow meter. The cough persisted, and the peak flow recording showed normal airway resistance. At this time, Jessica's pediatrician suspected a conversion reaction and contemplated the next best therapeutic strategy.

Acute Bronchitis -- History and Physical

Following an episode of acute bronchitis, the cough typically persists for 10 to 20 days, with a median duration of 18 days. [20] Occasionally, bronchitis cough may extend beyond 4 weeks. Paroxysms of cough accompanied by an inspiratory whoop or posttussive emesis should raise concerns for pertussis infection.

InternalMed_Harrison

In children, adenoviruses cause a variety of clinical syndromes. The most common is an acute upper respiratory tract infection, with prominent rhinitis. On occasion, lower respiratory tract disease, including bronchiolitis and pneumonia, also develops. Adenoviruses, particularly types 3 and 7, cause pharyngoconjunctival fever, a characteristic acute febrile illness of children that occurs in outbreaks, most often in summer camps. The syndrome is marked by bilateral conjunctivitis in which the bulbar and palpebral conjunctivae have a granular appearance. Low-grade fever is frequently present for the first 3–5 days, and rhinitis, sore throat, and cervical adenopathy develop. The illness generally lasts for 1–2 weeks and resolves spontaneously. Febrile pharyngitis without conjunctivitis has also been associated with adenovirus infection. Adenoviruses have been isolated from cases of whooping cough with or without Bordetella pertussis; the significance of adenovirus in that disease is

Adult Kawasaki's disease with myocarditis, splenomegaly, and highly elevated serum ferritin levels.

Kawasaki's disease is a disease of unknown cause. The characteristic clinical features of Kawasaki's disease are fever> or =102 degrees F for> or =5 days accompanied by a bilateral bulbar conjunctivitis/conjunctival suffusion, erythematous rash, cervical adenopathy, pharyngeal erythema, and swelling of the dorsum of the hands/feet. Kawasaki's disease primarily affects children and is rare in adults. In children, Kawasaki's disease is more likely to be associated with aseptic meningitis, coronary artery aneurysms, and thrombocytosis. In adult Kawasaki's disease, unilateral cervical adenopathy, arthritis, conjunctival suffusion/conjunctivitis, and elevated serum transaminases (serum glutamic oxaloacetic transaminase [SGOT]/serum glutamate pyruvate transaminase [SGPT]) are more likely. Kawasaki's disease in adults may be mimicked by other acute infections with fever and rash, that is, group A streptococcal scarlet fever, toxic shock syndrome (TSS), and Rocky Mountain Spotted Fever (RMSF). Because there are no specific tests for Kawasaki's disease, diagnosis is based on clinical criteria and the syndromic approach. In addition to rash and fever, scarlet fever is characterized by circumoral pallor, oropharyngeal edema, Pastia's lines, and peripheral eosinophilia, but not conjunctival suffusion, splenomegaly, swelling of the dorsum of the hands/feet, thrombocytosis, or an elevated SGOT/SGPT. In TSS, in addition to rash and fever, there is conjunctival suffusion, oropharyngeal erythema, and edema of the dorsum of the hands/feet, an elevated SGOT/SGPT, and thrombocytopenia. Patients with TSS do not have cervical adenopathy or splenomegaly. RMSF presents with fever and a maculopapular rash that becomes petechial, first appearing on the wrists/ankles after 3 to 5 days. RMSF is accompanied by a prominent headache, periorbital edema, conjunctival suffusion, splenomegaly, thrombocytopenia, an elevated SGOT/SGPT, swelling of the dorsum of the hands/feet, but not oropharyngeal erythema. We present a case of adult Kawasaki's disease with myocarditis and splenomegaly. The patient's myocarditis rapidly resolved, and he did not develop coronary artery aneurysms. In addition to splenomegaly, this case of adult Kawasaki's disease is remarkable because the patient had highly elevated serum ferritin levels of 944-1303 ng/mL; (normal<189 ng/mL). To the best of our knowledge, this is the first report of adult Kawasaki's disease with highly elevated serum ferritin levels. This is also the first report of splenomegaly in adult Kawasaki's disease. We conclude that Kawasaki's disease should be considered in the differential diagnosis in adult patients with rash/fever for> or =5 days with conjunctival suffusion, cervical adenopathy, swelling of the dorsum of the hands/feet, thrombocytosis and otherwise unexplained highly elevated ferritin levels.

Elisha Bartlett

During his tenure he was faced with the challenges of the Lowell Mill Girls strike in 1836, and the Panic of 1837. Writings An Address of the Birth of Spurzheim (1838) The history, diagnosis, and treatment of typhoid and of typhus fever, with an essay on the diagnosis of bilious remittent and of yellow fever (1842). An sssay on the philosophy of medical science, (1844). The history, diagnosis, and treatment of the fevers of the United States, (1847). An inquiry into the degree of certainty in medicine: and into the nature and extent of its power over disease, (1848). The history, diagnosis, and treatment of edematous laryngitis, (1850). References Bibliography

Acute Appendicitis Associated With Kawasaki Disease: Case Report and Review of the Literature.

Acute appendicitis is a rare complication of Kawasaki disease in the setting of the absence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We experienced a rare case of acute appendicitis associated with Kawasaki disease. The patient is a six-year-old male who was brought to the emergency department by his mother with a pruritic rash, nausea, vomiting, and abdominal pain. Given fever, tenderness in the right lower quadrant on physical examination, leukocytosis with bandemia, and a non-compressible and dilated appendix on ultrasound, he was diagnosed with acute appendicitis and was treated with a laparoscopic appendectomy. He developed persistent fevers after surgery with new lip swelling, mucositis, and bilateral conjunctival injection. Kawasaki disease was suspected and intravenous gammaglobulin and aspirin were administrated. He made a full recovery. This case suggests that careful examination is needed for accurate diagnosis, especially in patients with postoperative persistent fever without signs of intra-abdominal complications. We performed a PubMed literature search and reviewed eight cases of appendicitis associated with Kawasaki disease. Of note, this case was seen in 2018 before the SARS-CoV-2 pandemic and the description of multisystem inflammatory syndrome in children (MIS-C).

Eduard Bloch

Hitler family doctor The first member of the Hitler family Bloch was to see was Adolf Hitler. In 1904, Hitler had become seriously ill and was bedridden due to a serious lung ailment. Due to this, he was allowed to abandon his school career and return home. However, after checking Hitler's files, Bloch later maintained that he had treated the youth for only minor ailments, cold or tonsilitis and that Hitler had been neither robust nor sickly. He also stated that Hitler did not have any illness whatsoever, let alone a lung disease.

A 16-Year-Old Boy With Cough and Fever in the Era of COVID-19.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.

Édouard Rist

Selected works Études bactériologiques sur les infections d'origine otique, 1898 – Bacteriological studies on the origin of otic infections. Précis de pathologie exotique, (with Édouard Jeanselme), 1909 – Specifics of exotic pathology. La tuberculose, 1927 – Tuberculosis. Séméiologie élémentaire de l'appareil respiratoire, 1934 – Elementary respiratory symptomatology. Les Symptômes de la tuberculose pulmonaire (clinique, physiologie, pathologique, thérapeutique), 1943 – Symptoms of pulmonary tuberculosis. 25 portraits de médecins français, 1900-1950, (1955) – 25 portraits of French doctors, 1900-1950. References 1871 births 1956 deaths People from Strasbourg French military doctors Tuberculosis researchers French pulmonologists

Severe desquamation in Kawasaki disease: Is it somehow protective?

Kawasaki disease is a common vasculitis that typically affects children between one and five years of age. We report a 12-year-old boy who presented following a presumed diagnosis of pharyngitis associated with nondesquamating skin rash and conjunctivitis. Despite treatment with amoxicillin for seven days his fever persisted for ten days and then remitted. Two weeks later, he developed full thickness extensive desquamation of his palms and soles that mandated a visit to emergency department in our tertiary health centre. Physical examination revealed full thickness desquamation of his palms and soles with absence of erythema or swelling and he had unremarkable systemic examination. Laboratory tests showed thrombocytosis and high erythrocytes sedimentation rate. Throat culture and Anti-streptolysin-O titer were negative. Aspirin, anti-platelets dose, was initiated. Echocardiography was performed in the first visit and repeated three times later: at four weeks, six weeks and at three months of the illness revealing normal coronary arteries. Follow up complete blood count and sedimentation rate were normal after six weeks, therefore, aspirin was discontinued. Full thickness desquamation, not as it would be expected, might be somehow protective against the involvement of coronary arteries in Kawasaki disease.

During a physical examination, lung auscultation may reveal the presence of wheezing. In some instances, the detection of rhonchi may improve or clear with coughing, suggesting that the airway secretions or obstruction causing the sound can be alleviated through coughing efforts.

[The probability of Kawasaki diseases in young patients with cardiac disorders--retrospective studies].

Kawasaki disease (KD) is the leading cause of acquired heart disease in children in some countries. In Poland the diagnosis of KD is still rarely reported. KD is an acute systemic febrile illness of unknown aetiology, predominantly affecting children under five years of age. Delay in diagnosis and treatment is associated with an increased risk of coronary artery aneurysms and late cardiac complications. The aim of this study was to find out whether Kawasaki disease in childhood was the cause of cardiac disorders in young patients. We retrospectively studied 50 patients (ranging in age from 20 to 47 years; 34 males and 16 females) diagnosed in 1 Cardiac Department within one year. The patients were divided into three groups: group I--patients with ischemic heart disease, myocardial infarction and congestive heart failure; group II--patients with cardiac arrhythmia and conduction abnormalities; group III--patients with congestive cardiomyopathy. Eighteen patients had rubella in childhood and in this group one person was under 5 years of age. Nineteen patients suffered from measles and in this group there were two persons under 5 years of age. Twenty-three persons in the study group confirmed acute febrile illness under 5 years of age lasting over 5 days. No cardiac symptoms occurred during the childhood febrile or exanthema illnesses. Five criteria (symptoms of Kawasaki disease) were fulfilled by 4 persons, 4 criteria--by 4 persons, 3 criteria--by 1 person, 2 criteria--by 3 persons, 1 criterion--by 6 persons. Nobody in the study population had signs of measles, rubella or scarlet fever. Nobody had coronary artery abnormalities detected by echocardiography. Twenty-six of 50 persons had coronary angiography--no coronary artery aneurysms or ectasia were detected. Completing a more precise past history with the help of patient's parents was often impossible (death, distant place of residence). The verification of diagnosis on the basis of the obtained data is impossible. The most reliable data about diseases affecting children under 5 years of age would have been produced by additional investigations. They would have facilitated the retrospective recognition of the Kawasaki disease.

Health of Frédéric Chopin

On 17 October 1849, at 2 a.m., after a sudden coughing fit, Chopin died at the age of 39. His physician, Jean Cruveilhier, confirmed his death by holding a mirror to Chopin's mouth and by illuminating his pupils with light from a candle. Pursuant to Chopin's will, Dr. Cruveilhier, a renowned professor of pathology, carried out an autopsy. The postmortem findings were also communicated to Chopin's sister Ludwika, Adolphe Gutmann and Jane Stirling. The postmortem report was destroyed either in the Paris fire of 1871 or during World War II. The death certificate stated the cause of Chopin's death as tuberculosis of the lungs and larynx. However, Wojciech Grzymała, in a letter to Auguste Leo dated October 1849, wrote that the autopsy had not confirmed tubercular pulmonary changes and that his actual disease was unknown to contemporary medicine.

InternalMed_Harrison

The most common clinical manifestations of rhinovirus infections are those of the common cold. Illness usually begins with rhinorrhea and sneezing accompanied by nasal congestion. The throat is frequently sore, and in some cases sore throat is the initial complaint. Systemic signs and symptoms, such as malaise and headache, are mild or absent, and fever is unusual in adults but may occur in up to one-third of children. Illness generally lasts for 4–9 days and resolves spontaneously without sequelae. In children, bronchitis, bronchiolitis, and bronchopneumonia have been reported; nevertheless, it appears that rhinoviruses are not major causes of lower respiratory tract disease in children. Rhinoviruses may cause exacerbations of asthma and chronic pulmonary disease in adults. The vast majority of rhinovirus infections resolve without sequelae, but complications related to obstruction of the eustachian tubes or sinus ostia, including otitis media or acute sinusitis, can develop. In

Cough -- Etiology

Pertussis, also known as whooping cough, is an illness with a classic clinical finding of paroxysmal episodes of intense coughing lasting up to several minutes followed by a loud gasp for air. It is an infection of the respiratory tract by Bordetella pertussis, where the bacterium induces mucopurulent sanguineous exudate formation within the respiratory tract. The overall course of pertussis infection lasts up to six weeks and is characterized by three stages: a catarrhal phase, a paroxysmal phase, and a convalescent phase. The catarrhal phase is characterized by rhinorrhea, sneezing, low fever, tearing, and nasal congestion. The paroxysmal phase occurs within two weeks of colonization and is characterized by classic coughing episodes followed by post-tussive vomiting. The convalescent phase is a condition of chronic coughing that may last for weeks. This illness is a serious diagnosis that requires prompt attention as it remains one of the highest causes of infant morbidity and mortality. [2]


The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation. This nerve injury produces hypoesthesia and weakness along its distribution. Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh. Therefore, answer 1 is correct. The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee, so it would not explain the motor problem of gait and 2 is false. The obturator nerve (L2-L4) is a mixed nerve. At the motor level, it invests the obturator externus, pectineus, short approximator, the approximators (adductors) and gracilis. At the sensory level the capsule of the coxofemoral joint, medial aspect of the thigh above the knee. Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is false. A lesion of the sciatic nerve at motor level affects to the flexion of the knee not to its extension and at distal level to this one (they do not count anything of distal clinic) and at sensitive level also it is distal in the external face of the leg and in the foot reason why 4 also is false.

The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation. This nerve injury produces hypoesthesia and weakness along its distribution. Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh. Therefore, answer 1 is [HIDDEN]. The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee, so it would not explain the motor problem of gait and 2 is [HIDDEN]. The obturator nerve (L2-L4) is a mixed nerve. At the motor level, it invests the obturator externus, pectineus, short approximator, the approximators (adductors) and gracilis. At the sensory level the capsule of the coxofemoral joint, medial aspect of the thigh above the knee. Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is [HIDDEN]. A lesion of the sciatic nerve at motor level affects to the flexion of the knee not to its extension and at distal level to this one (they do not count anything of distal clinic) and at sensitive level also it is distal in the external face of the leg and in the foot reason why 4 also is [HIDDEN].

A woman presenting with difficulty walking after gynecologic surgery. She has mild thigh pain and leg failure on support. On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh. What is the most probable diagnosis of suspicion:

Meralgia paresthetica of the femoral cutaneous nerve.

Femoral nerve dysfunction

Those with femoral nerve dysfunction may present problems of difficulties in movement and a loss of sensation. The patient, in terms of motor skills, may have problems such as quadriceps wasting, loss of knee extension and a lesser extent of hip flexion given the femoral nerve involvement of the iliacus and pectineus muscles. One may experience numbness and tingling in any part of the leg, typically in the front and the inside of one’s thighs and down to the feet. They may also experience a dull ache in the genital region given that the inguinal ligament is actually divided into the femoral and genital branches. Feelings of the patient’s leg and knees giving out may also be prevalent due to lower extremity muscle weakness and quadriceps weakness. In terms of sensory skills, patients may observe a decrease in sensation over the front and medial sections of the thigh and medial aspects of the lower legs and feet due to their involvement of the anterior and medial cutaneous nerves of the

Femoral nerve dysfunction

The diagnosis of femoral neuropathy can be done through physical examinations, several imaging techniques and electrodiagnostic studies. Provided patients do not suffer from haemorrhage, physical examinations is the first line of diagnosis. These examinations are carried out in order to evaluate whether nerves of the lower back, lower limbs and hips are functioning well. They can also help determine whether it is strictly an injury in the femoral nerve or a systemic disorder. Other than questioning about possible recent injuries, surgeries, and medical history, inspection of asymmetry or atrophy of the quadriceps muscles, muscle stretch reflexes, and sensory testing through pinpricks and light touches are conducted. By looking at the asymmetry or atrophy of the quadriceps muscles, weaknesses in knee extension or hip flexion can be observed. Furthermore, physicians palpate over the inguinal ligament to inspect the anterior and medial leg, anterior thigh, and quadriceps reflex. In

Femoral nerve dysfunction

in knee extension or hip flexion can be observed. Furthermore, physicians palpate over the inguinal ligament to inspect the anterior and medial leg, anterior thigh, and quadriceps reflex. In addition, comparison of quadriceps strength to adductor strength help point towards femoral neuropathy. However, given that the diagnosis of femoral neuropathy through physical examination is subject to how severe the injury is, additional imaging testing such as computed tomography, magnetic resonance imaging, ultrasounds and nerve conduction studies and electromyography are also done.

Hip arthroscopy

Damage to nerves around the hip joint can occur, sometimes because of direct damage with the surgical instruments, or as a result of the traction needed to gain access to the joint. For this reason, surgeons prefer to apply as little traction as possible, for as short a time as possible, in order to gain safe access to the joint. The most common nerve to be injured is the lateral cutaneous nerve of the thigh. This nerve supplies feeling to the upper, outer thigh. Other nerves that may be affected are the sciatic (leading to a weakness lifting the foot – 'foot-drop'), femoral (weak thigh muscles), obturator (numbness in the inner thigh and weakness of those muscles), and pudendal nerves. The pudendal nerves supply feeling to the reproductive organs.

Ultrasound-Guided Diagnosis and Treatment of Meralgia Paresthetica.

Meralgia paresthetica refers to the entrapment of the lateral femoral cutaneous nerve at the level of the inguinal ligament. The lateral femoral cutaneous nerve - a purely sensory nerve - arises from the L2 and L3 spinal nerve roots, travels downward lateral to the psoas muscle, and then crosses the iliacus muscle. Close to the anterior superior iliac spine, the nerve courses in contact with the lateral aspect of the inguinal ligament and eventually innervates the lateral thigh. The entrapment syndrome is usually idiopathic but can also ensue due to trauma/overuse, pelvic and retroperitoneal tumors, stretching of the nerve due to prolonged leg/trunk hyperextension, leg length discrepancies, prolonged standing, external compression by belts, weight gain, and tight clothing. The diagnosis of Meralgia paresthetica is usually clinical, i.e., based on the following symptoms: paresthesia, numbness, burning sensation, dysesthesia, and pain over the anterolateral aspects of the thigh. These complaints may be worsened by walking or prolonged standing and typically disappear after weight loss, abdominal muscle strengthening, or elimination of the underlying cause. Although there are several reports on the confirmatory role of electrodiagnostic studies in the diagnosis of Meralgia paresthetica, electromyographers would usually prefer/suggest not to perform nerve conduction studies in daily clinical practice. Herewith, due to its several advantages, ultrasound imaging has been proposed as an alternative diagnostic method in the recent literature. It not only confirms the entrapment morphologically, but also uncovers a likely underlying cause and provides immediate interventional guidance. The pertinent sonographic findings would be hypoechoic and swollen lateral femoral cutaneous nerve.

Meralgia paresthetica caused by hip-huggers in a patient with aberrant course of the lateral femoral cutaneous nerve.

"Hip-huggers" may be a precipitating factor for meralgia paresthetica (MP), especially in thin persons with an aberrant pathway of the lateral femoral cutaneous nerve (LFCN). We describe a 25-year-old woman with a long-standing history of MP caused by an abnormal course of the LFCN and tight trousers, specifically hip-huggers. Ultrasonography was useful for detecting the lesion site and the abnormal pathway of the LFCN. After neurectomy of the LFCN, most of the symptoms of MP were relieved, but mild hypesthesia remained in the lateral thigh.

InternalMed_Harrison

2692 LATERAL FEMORAL CUTANEOUS NEUROPATHY (MERALGIA PARESTHETICA) The lateral femoral cutaneous nerve arises from the upper lumbar plexus (spinal levels L2/3), crosses through the inguinal ligament near its attachment to the iliac bone, and supplies sensation to the anterior lateral thigh. The neuropathy affecting this nerve is also known as meralgia paresthetica. Symptoms and signs consist of paresthesias, numbness, and occasionally pain in the lateral thigh. Symptoms are increased by standing or walking and are relieved by sitting. There is normal strength, and knee reflexes are intact. The diagnosis is clinical, and further tests usually are not performed. EDx is only needed to rule out lumbar plexopathy, radiculopathy, or femoral neuropathy. If the symptoms and signs are classic, EMG is not necessary. Symptoms often resolve spontaneously over weeks or months, but the patient may be left with permanent numbness. Treatment consists of weight loss and avoiding tight belts. Analgesics

[A Case of Meralgia Paresthetica Treated with Neurolysis].

A 60-year-old woman presented with a 1-year history of pain and numbness in the left anterolateral thigh. The symptoms aggravated on walking and standing. Her visual analogue scale(VAS)score was 7.1/10. Tinel's like sign was positive over the lateral femoral cutaneous nerve(LFCN), in the inguinal ligament region. LFCN block at the trigger point, in the inguinal ligament, resulted in relief of the symptoms and we diagnosed meralgia paresthetica(MP), which is the entrapment neuropathy of the LFCN. Initially, we performed observation therapy with oral medication and LFCN blocks. However, these treatments failed to relieve the symptoms. Therefore, we performed neurolysis with a microscope under local anesthesia. The symptoms improved immediately after surgery and her VAS score of thigh symptom improved from 7.1 to 1.9 after 3 months. Conservative and surgical treatment for MP generally yield good outcome and we should pay attention to the MP as a differential diagnosis for thigh numbness and pain.

Bilateral femoral neuropathy after vaginal hysterectomy.

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.

Clinically, patients will have quadriceps wasting, loss of knee extension, and to a lesser extent, hip flexion due to the involvement of the iliacus and pectineus muscles. On the sensory side, there will be a loss of sensation over the anterior and medial thigh due to the involvement of the anterior and medial cutaneous nerves of the thigh. Furthermore, loss of sensation will occur over the medial aspect of the lower leg and foot due to the involvement of the saphenous nerve. Although the prognosis in most cases is satisfactory, some cases necessitate nerve repair or grafting, and some cases cause permanent residual neurologic deficits.

InternalMed_Harrison

Sciatic neuropathies commonly complicate hip arthroplasty, pelvic procedures in which patients are placed in a prolonged lithotomy position, trauma, hematomas, tumor infiltration, and vasculitis. In addition, many sciatic neuropathies are idiopathic. Weakness may involve all motions of the ankles and toes as well as flexion of the leg at the knee; abduction and extension of the thigh at the hip are spared. Sensory loss occurs in the entire foot and the distal lateral leg. The ankle jerk and on occasion the internal hamstring reflex are diminished or more typically absent on the affected side. The peroneal subdivision of the sciatic nerve is typically involved disproportionately to the tibial counterpart. Thus, patients may have only ankle dorsiflexion and eversion weakness with sparing of knee flexion, ankle inversion, and plantar flexion; these features can lead to misdiagnosis of a common peroneal neuropathy.

List of neuromuscular disorders

Lower extremity deep peroneal mononeuropathy at the fibular neck common fibular mononeuropathy at the hip deep fibular mononeuropathy at the ankle superficial fibular mononeuropathy sciatic mononeuroapthy at the hip or thigh piriformis syndrome proximal tibial mononeuropathy tarsal tunnel syndrome interdigital neuropathy (Morton's Neuroma) sural mononeuropathy femoral mononeuropathy saphenous mononeuropathy lateral femoral cutaneous neuropathy ilioinguinal neuropathy iliohypogastric neuropathy genitofemoral neuropathy posterior femoral cutaneous neuropathy obturator neuropathy neuropathy of gluteal nerves

InternalMed_Harrison

The symptoms of lateral femoral cutaneous nerve entrapment, commonly known as “meralgia paresthetica,” include sensory loss, pain, and dysesthesia in part of the area supplied by the nerve (Fig. 463e-3E). There is no motor component to the nerve, and therefore weakness is not a part of this syndrome. Symptoms often are worsened by standing or walking. Compression of the nerve occurs where it enters the leg near the inguinal ligament, usually in the setting of tight-fitting belts, pants, corsets, or recent weight gain, including that of pregnancy. The differential diagnosis of these symptoms includes hip problems such as trochanteric bursitis.

Clinical Presentations of Lumbar Disc Degeneration and Lumbosacral Nerve Lesions.

Lumbar disc degeneration is defined as the wear and tear of lumbar intervertebral disc, and it is mainly occurring at L3-L4 and L4-S1 vertebrae. Lumbar disc degeneration may lead to disc bulging, osteophytes, loss of disc space, and compression and irritation of the adjacent nerve root. Clinical presentations associated with lumbar disc degeneration and lumbosacral nerve lesion are discogenic pain, radical pain, muscular weakness, and cutaneous. Discogenic pain is usually felt in the lumbar region, or sometimes, it may feel in the buttocks, down to the upper thighs, and it is typically presented with sudden forced flexion and/or rotational moment. Radical pain, muscular weakness, and sensory defects associated with lumbosacral nerve lesions are distributed on lower extremities, the buttock, lower abdomen, and groin region. A lumbosacral plexus lesion presents different symptoms in the territories of the lumbar and sacral nerves. Patients with lumbar plexus lesion clinically present with weakness of hip flexion, knee extension, thigh adduction, and sensory loss in the lower abdomen, inguinal region, and over the entire medial, lateral, and anterior surfaces of the thigh and the medial lower leg, while sacral plexus lesion presents clinical symptoms at nerve fibers destined for the sciatic nerve, common peroneal nerve, and pudendal nerve. Weakness of ankle inversion, plantar flexion, and foot drop are the main clinical manifestations of the sacral plexus lesion area. Numbness and decreased sensation are also present along the anterolateral calf and dorsum of the foot. On examination, foot eversion is usually stronger than foot dorsiflexion. The patients may also present with pain and difficulty of bowel movements, sexual dysfunction assessments, and loss of cutaneous sensation in the areas of the anal canal, anus, labia major, labia minor, clitoris, penis, and scrotum.

Local anesthetic nerve block

3-in-1 nerve block is indicated for pain relief for hip fractures. The femoral nerve block is indicated for femur, anterior thigh, and knee surgery. It is performed slightly inferior to the inguinal ligament, and the nerve is under the fascia iliaca. The sciatic nerve block is done for surgeries at or below the knee. The nerve is located in the gluteus maximus muscle. The popliteal block is done for ankle, achilles tendon, and foot surgery. It is done above the knee on the posterior leg where the sciatic nerve starts splitting into the common peroneal and tibial nerves. The saphenous nerve block is often done in combination with the popliteal block for surgeries below the knee. The saphenous nerve is numbed at the medial part of the lower thigh under the sartorius muscle.

Iliopsoas

It is a typical posture muscle dominated by slow-twitch red type 1 fibers. Since it originates from the lumbar vertebrae and discs and then inserts onto the femur, any structure from the lumbar spine to the femur can be affected directly. A short and tight iliopsoas often presents as externally rotated legs and feet. It can cause pain in the low or mid back, SI joint, hip, groin, thigh, knee, or any combination. The iliopsoas gets innervation from the L2-4 nerve roots of the lumbar plexus which also send branches to the superficial lumbar muscles. The femoral nerve passes through the muscle and innervates the quadriceps, pectineus, and sartorius muscles. It also comprises the intermediate femoral cutaneous and medial femoral cutaneous nerves which are responsible for sensation over the anterior and medial aspects of the thigh, medial shin, and arch of the foot nerves. The obturator nerve also passes through the muscle which is responsible for the sensory innervation of the skin of

Foot Drop in Obstetrics -- Evaluation -- Tests for Obturator Internus Neuropathy

The patient lies supine with the thigh flexed at the hip and the leg flexed at the knee. The examiner has one hand on the medial side of the knee and the other on the ankle. The patient then adducts the thigh against resistance to determine weakness or pain due to what appears to be an obturator neuropathy. The other side is tested for comparison purposes.

Hip dislocation

Posterior dislocation For posterior dislocation, the affected limb will be in a position of flexion, adduction, and internal rotation. This is to say, the affected leg will be bent upwards at the hip, while being shifted and pointed towards the middle of the body. Sciatic nerve injury is also present in 8%-20% of cases, conferring numbness and weakness to aspects of the lower leg. Anterior dislocation For anterior dislocation, the affected limb will be in a position of abduction and external rotation. The degree of flexion depends on whether it is a superior or inferior dislocation, with the former resulting in hip extension and the latter, hip flexion. This is to say that with superior and inferior anterior dislocations, the affected leg will be bent at the hip backwards and upwards respectively, while being shifted and pointed away from the body. Femoral nerve palsies can also be present, conferring leg numbness and weakness, however are uncommon. Diagnosis

InternalMed_Harrison

Lesions of the proximal femoral nerve are relatively uncommon but may present dramatically with weakness of hip flexion, quadriceps atrophy, weakness of knee extension (often manifesting with leg-buckling falls), and an absent patellar reflex. Adduction of the thigh is spared as these muscles are supplied by the obturator nerve, thereby distinguishing a femoral neuropathy from a more proximal lumbosacral plexus lesion. The sensory loss found is in the distribution of the femoral nerve sensory branches including the anterior part of the thigh (Fig. 463e-3D). Compressive lesions from retroperitoneal hematomas or masses are common, and a CT of the pelvis should be obtained in all cases of femoral neuropathy to exclude these conditions. Bleeding into the pelvis resulting in hematoma can occur spontaneously, following trauma, or after intrapelvic surgeries such as renal transplantation. In intoxicated or comatose patients, stretch injuries to the femoral nerve are seen following prolonged,

A cook with 'burning in the thigh' and a 'hotspot' in the groin!

Meralgia paresthetica (MP) is a condition characterised by abnormal sensations on the anterolateral aspect of the thigh due to the dysfunction of the lateral femoral cutaneous nerve. Here, I present a case of a 64-year-old female cook who attended the General Medicine clinic with 2 months of persistent numbness and 'burning' sensation over the right anterolateral thigh. Subsequent physical examination revealed the diagnosis of meralgia paresthetica. The significance of good history taking and thorough physical examination in reaching the diagnosis of meralgia paresthetica cannot be overemphasized. In most typical presentations, advanced imaging and neurodiagnostic testing do not add value to confirm the diagnosis. If the clinical diagnosis is doubtful, nerve conduction study and magnetic resonance imaging may still be performed to exclude other mimicking pathologies. Increasing awareness of MP among doctors unfamiliar with this condition will prevent the ordering of excessive investigations.

Femoral nerve dysfunction

a decrease in sensation over the front and medial sections of the thigh and medial aspects of the lower legs and feet due to their involvement of the anterior and medial cutaneous nerves of the thigh and the saphenous nerve respectively.

Neurology_Adams

This nerve is formed from the second, third, and fourth lumbar roots. Within the pelvis it passes along the lateral border of the psoas muscle and enters the thigh beneath the Poupart ligament, lateral to the femoral artery. Branches arising within the pelvis supply the iliacus and psoas muscles. Just below the Poupart ligament the nerve splits into anterior and posterior divisions. The former supplies the pectineus and sartorius muscles and carries sensation from the anteromedial surface of the thigh; the posterior division provides the motor innervation to the quadriceps and the cutaneous innervation to the medial side of the leg from the knee to the internal malleolus. The distinction between femoral neuropathy and a third lumbar root lesion is made by detecting weakness of the hip adductor (innervated by the obturator nerve) in the case of the root lesion.

Meralgia paraesthetica

The nerve may become painful over a period of time as weight gain makes underwear, belting or the waistband of pants gradually exert higher levels of pressure. Pain may be acute and radiate into the rib cage, and into the groin, thigh, and knee. Alternately, weight loss or aging may remove protective fat layers under the skin, so the nerve can compress against underwear, outer clothing, and—most commonly— by belting. Long periods of standing or leg exercise that increases tension on the inguinal ligament may also cause pressure. The lateral cutaneous nerve of the thigh can occasionally be damaged during laparoscopic hernia repair, or scarring from the operation can lead to meralgia paraesthetica. Diagnosis Diagnosis is largely based on patient description and relevant details about recent surgeries, hip injuries, or repetitive activities that could irritate the nerve. Examination checks for sensory differences between the affected leg and the other leg.

Neurology_Adams

The most common cause of femoral neuropathy is diabetes. The nerve may also be involved by pelvic tumors. Not uncommon is injury to the nerve during pelvic operations. Usually this is the result of improper placement of retractors, which may compress the nerve directly or indirectly by undue pressure on the psoas muscle. Bleeding into the iliacus muscle or the retroperitoneum, observed in patients receiving anticoagulants and in hemophilia patients, is a relatively common cause of isolated femoral neuropathy (Goodfellow et al). The presenting symptom of iliacus hematoma is pain in the groin spreading to the lumbar region or thigh, in response to which the patient assumes a characteristic posture of flexion and lateral rotation of the hip. A palpable mass in the iliac fossa and the signs of femoral nerve compression (quadriceps weakness and loss of knee jerk) follow in a day or two. Infarction of the nerve may occur in the course of diabetes mellitus and polyarteritis nodosa. Not

Anatomy, Bony Pelvis and Lower Limb: Thigh Femoral Nerve -- Clinical Significance -- Femoral Neuropathy in Obstetric Patients Undergoing Vaginal Delivery

Femoral neuropathies may occur during vaginal delivery. Commonly, patients are put in the dorsal lithotomy position, in which the thigh is flexed at the hip, and the leg is flexed at the knee. This position compresses the femoral nerve against the inguinal ligament, compromising the blood supply to the nerve. At the end of the delivery, the patient attempts to stand and falls to the floor because the quadriceps femoris muscle is not functional due to the loss of its innervation by the femoral nerve. The quadriceps femoris muscle inserts onto the patella. The patellar ligament attaches to the tibial tuberosity. When the quadriceps femoris muscle contracts, it extends the leg at the knee. This action is crucial to prevent the leg from buckling. Thus, if one is assisting the patient in arising from a gurney after delivery, one must be able to catch the patient if she falls due to femoral neuropathy. [17]

InternalMed_Harrison

Femoral neuropathies can arise as complications of retroperitoneal hematoma, lithotomy positioning, hip arthroplasty or dislocation, iliac artery occlusion, femoral arterial procedures, infiltration by hematogenous malignancy, penetrating groin trauma, pelvic surgery including hysterectomy and renal transplantation, and diabetes (a partial form of lumbosacral diabetic plexopathy); some cases are idiopathic. Patients with femoral neuropathy have difficulty extending their knee and flexing the hip. Sensory symptoms occurring either on the anterior thigh and/or medial leg occur in only half of reported cases. A prominent painful component is the exception rather than the rule, may be delayed, and is often self-limited in nature. The quadriceps (patellar) reflex is diminished.

Lateral cutaneous nerve of thigh

Nerve block The lateral cutaneous nerve of the thigh can be blocked with local anaesthetic. Ultrasound is used to guide needle insertion. This is used for procedures in the supplied area of skin, such as surgical incisions over the outer thigh, and skin grafts. Meralgia paraesthetica Entrapment of the lateral cutaneous nerve of the thigh is caused by compression of the nerve near the anterior superior iliac spine and the inguinal ligament. This causes meralgia paraesthetica (Bernhardt-Roth syndrome). This may be diagnosed with ultrasound, which changes the morphology of the nerve. Changes can include general enlargement, and a hypoechoic appearance. In patients who only have meralgia paraesthetica on one side, ultrasound scans are performed on both thighs to compare the appearance of the nerve. History The lateral cutaneous nerve of the thigh may also be known as the lateral femoral cutaneous nerve. Additional images

Meralgia paraesthetica

Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh. This chronic neurological disorder involves a single nerve—the lateral cutaneous nerve of the thigh, which is also called the lateral femoral cutaneous nerve (and hence the syndrome lateral femoral cutaneous neuropathy). The term "meralgia paraesthetica" combines four Greek roots to mean "thigh pain with anomalous perception". The disorder has also been nicknamed bikini brief syndrome and skinny pants syndrome, because it can be caused by wearing tight clothing.

Meralgia paresthetica: clinical and electrophysiological diagnosis in 120 cases.

We report the results of clinical and electrophysiological examinations in 131 cases of meralgia paresthetica (MP) among 120 unselected patients, 69 men and 51 women, aged 15-81 years. All patients experienced permanent or intermittent pain, and all but one had permanent sensory impairment of the thigh. The lateral aspect of the thigh was solely involved in 88 cases and the anterior aspect was also or exclusively involved in 32 cases. The right thigh was involved 62 times and the left 58 times. Symptom duration varied from 2 weeks to 20 years. The initial diagnosis was meralgia paresthetica in 47 cases (39%), root disease in 35 cases, and osteoarthritis in 6 cases; no diagnosis was proposed in the 32 remaining cases. Two cases had undergone previous spine surgery for disk herniation, with no benefit. A precise cause could explain the lateral femoral cutaneous nerve (LFCN) lesion in 46 cases, the other 74 cases being considered idiopathic (25% of patients were obese). Only one case required surgery to relieve symptoms. LFCN conduction was studied orthodromically, distally from the anterior superior iliac spine. The side-to-side amplitude ratio (ssRatio) was greater than 2.3 in 118 of 120 patients (98.3%) and was a better index to confirm a lesion of the LFCN than SNAP amplitude, which was abnormal (less than 3 microV) in 88 cases (73.3%). Only two of the 11 bilateral cases had an ssRatio lower than 2.3 (they were both 2.0). An ssRatio of 2.3 or more and a SNAP amplitude lower than 3 microV provided a specificity of 98.75% or more. The mean axonal loss was 88%. These clinical and electrophysiological data highlight the central role the neurophysiologist should play in diagnosing MP by means of an LFCN conduction study.

Furcal nerve

It gives branches to the femoral nerve, lumbosacral trunk, and obturator nerve. Clinical significance The furcal nerve is found at various locations and can give problems in the diagnosis of a radiculopathy or sciatic pain. It is the main cause of atypical symptoms of sciatic and radicular pain, that are often due to lumbar disc herniation. A study found evidence of double-rooted abnormality in most of the cases looked at. References Nerves of the lower limb and lower torso

Postoperative femoral motor neuropathy: diagnosis and treatment without neurologic consultation or testing.

To review the diagnosis and treatment of postoperative femoral motor neuropathy without neurologic consultation or testing. A retrospective review of 6 consecutive patients with postoperative femoral motor neuropathy following gynecologic surgery. Diagnosis was made on clinical evaluation: history of falling during postoperative ambulation, quadriceps weakness, straight leg raise weakness, diminished knee jerk response, and no evidence of psoas hematoma or abscess. Neurologic consultation, electromyography, nerve conduction study and radiologic imaging, such as computed tomography, were not obtained. Instead, a physical therapy consultation was obtained for a knee orthotic and rehabilitation. Four postoperative femoral motor neuropathies developed following 3,014 cases of major gynecologic surgery (0.1%). Two additional cases were seen in consultation. The median age was 57 years. All patients fell while attempting ambulation on postoperative day 1. Recovery occurred at a median of 3 months (1-4). At a median follow-up of 4 years, no patient had developed additional neurologic sequelae. A history of prior postoperative femoral motor neuropathy was noted in 2 of 6 patients (33%). This was the first study of diagnosis and treatment of postoperative femoral motor neuropathy following gynecologic surgery without neurologic consultation or testing. Because of the significant expense of neurologic consultation and testing, patients with postoperative femoral motor neuropathy can have the condition diagnosed by the gynecologist and be referred directly to physical therapy without adversely affecting outcome. This also was the first study to elicit a prior history offemoral neuropathy in 33% of patients. Thus, a prior history may be a risk factor for recurrence.

Meralgia Paresthetica Caused by Surgery in the Park-Bench Position.

Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). We report a rare case of MP after microvascular decompression (MVD) surgery in the park-bench position in a patient with hemifacial spasm. The patient was a nondiabetic 46-year-old woman (height: 155 cm, weight: 42 kg) who consumed alcohol infrequently. After a first MVD for right hemifacial spasm, the symptom recurred and she underwent a second MVD procedure in the park-bench position, after which hemifacial spasm resolved. However, she reported right anterolateral thigh pain and dysesthesia without motor weakness. The pain was limited to the LFCN area, and a pelvic compression test elicited a positive Tinel-like sign. Our preliminary diagnosis was MP. Because conservative therapy was ineffective, she underwent LFCN block 9 months after the second MVD procedure. Her pain improved dramatically and we made a definitive diagnosis of MP. There has been no recurrence after 30 months of observation, although she reported persistent mild dysesthesia in the LFCN area. MP is a rare complication after MVD surgery in the park-bench position. LFCN block can resolve symptoms and hasten diagnosis.