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Acute Infectious Mononucleosis with Epstein-Barr Virus (EBV)

Patient with clinical and laboratory picture compatible with acute infectious mononucleosis with Epstein-Barr Virus (EBV) receives from the expert wide information regarding the virus, the symptoms and clinical course, the needed follow-up tests etc.

Acute Infectious Mononucleosis with Epstein-Barr Virus (EBV) – further opinion

Patient with clinical and laboratory picture compatible with acute infectious mononucleosis with Epstein-Barr Virus (EBV). Although he still feels weak, his condition is slowly improving. There is a gradual disappearance of the fever episodes and rash, in parallel with gradual normalization of the liver enzymes results, and disappearance of atypical lymphocytes. The reactivation of Herpes labialis can be explained by the stress involved in the EBV infection or the Cortisone treatment.

Autoimmune hepatitis/cholangitis in patient with Crohn’s disease.

18 years old male. 4 months ago the patient was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. He was diagnosed with Crohn’s disease.
Hepatic biopsy, that was performed during this hospitslization, showed evidence of an overlap syndrome picture (cholangitis/hepatitis). He was initially treated with Cortisone and Azathioprine.

ABO-incompatible (ABOI) renal transplantation

The expert answers various questions referred to him regarding ABO-incompatible (ABOI) renal transplantation without splenectomy, using antigen-specific immunoadsorption (IA) and rituximab.

 

Persistent Vertigo

47-year-old female who had the onset of persistent vertigo. The first evaluations revealed right beating nystagmus on gaze straight and to the right, unsteady gait with limb ataxia, and positive head thrust to the left. Improvement seemed to be occurring in that gait deviation with eyes closed was no longer present. Vestibular physical therapy exercises were started. On the next evaluations there was paroxysmal positional vertigo from the left ear and minimal neurosensory hearing loss. An audiogram showed minor neurosensory deafness.

Massive Portal and Mesenteric Vein Thrombosis

47-year-old male presented with un-provoked portal and mesenteric vein thrombosis that caused persistent radiating pains of upper abdominal quadrants. The examinations found heterozygous factor II mutation, and family survey for the factor II mutation was recommended. The patient started anticoagulant therapy. In the expert's opinion, the main risk factors for portal vein thrombosis are: Prothrombotic disorder, abdominal inflammation, cirrhosis, cancer, abdominal intervention and abdominal infection.

Possible Vitamin D/ Parathyroid Hormone Abnormality_1

51-year-old female with vitamin D deficiency and incompatibility between the PTH and vitamin D levels. She reports that as a child she had numerous cavities in her jaw, and her daughter also had multiple tooth fillings. She wonders whether the reason could be genetic abnormality.

 

Myelodysplastic syndrome (MDS), with kariotype del(11)q(11)

A 74 year-old male, that was diagnosed as suffering from myelodysplastic syndrome (MDS) with kariotype del(11)q(11) by a bone marrow biopsy, following a gradual pancytopenia. The patient complains about slowly progressive weakness and being constantly tired.He was offered chemotherapy, but he declined this treatment because of fear that it would worsen his already severe weakness.

Psychomotor retardation due to spinal amyotrophy

10 months old, female. After normal birth (at the 40th week of pregnancy) and neonatal period, started to suffer from gastroesophageal reflux and recurrent respiratory infections, at times with broncospasm. In addition, psychomotor retardation was found and the young patient was assessed by a neurologist. The tests run (EMG and genetics for SMA) pointed to the diagnosis of Spinal Amyotrophy.
After hospitalization due to catarrhal bronchitis, the patient was discharged in good general conditions with recomendations for respiratory physiotherapy and neurological rehabilitation.

Possible Anorexia, Vomiting, Failure to Gain Weight and Linear Growth Retardation

21-month-old female who was born at almost 29 weeks weighing only 650g and with birth height of 31 cm. Her major problems have been poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and subsequently, food administration through a direct gastric tube via a gastrostomy. She gradually gained weight to the extent of being overweight for her height. Laboratory evaluation revealed low absolute numbers of neutrophils low lymphocyte count. Endocrynology and Genetics workup were normal.

Feeding problems, vomiting and short stature in prematurely born child

The patient is a 21 month old female who was born prematurely (at almost 29 weeks) weighing only 650g. She was released after 3 months from NICU, when she was 41 weeks old, weight 2kg. Her parents did not have any problems till she was 5 months old. Her major problems since have been: poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and later, food administration through a direct gastric tube via a gastrostomy.

Facial pain after thyroidectomy

A 47 years old female underwent total thyroidectomy for papillary carcinoma of the thyroid, followed by treatment with radioactive Iodine (I131).
Since then, the patient has been suffering from severe facial pain (left>right), dry mouth and recurrent local infections. She was diagnosed with bilateral sialadenitis, and was repeatedly treated with endoscopy and repeat washing. Medical treatment for neurogenic pain wasn't helpfull, as well as visits to different salivary gland specialists.

MDS – Myelodysplastic Syndrome

74-year-old male with gradual pan-cytopenia with predominant thrombocytopenia underwent a bone marrow biopsy that confirmed the diagnosis of Myelodysplastic syndrome (MDS). He is currently in good general health except for slowly progressive weakness and being constantly tired. In the expert's opinion, there is no indication for therapy at this time, since the counts are satisfactory for every-day living. Nevertheless, the treating options are erythopoietin injections, lenalidomide, Vidaza or Dacogen therapy, or stem cell transplantation.

Long-term results of mandibular bone grafting operations

48-year-old male who had undergone multiple surgical attempts to augment mandibular bone for implant placement ('pins'). The patient received the opinion of a spesialist who spotted severe atrophy in the right mandibular posterolateral area. He reported on the condition of the mucosa with high insertion of frenii in the level of the alveolar ridge. Also the report related to occlusion problem and temporo mandibular dysfunction. In 2007, the patient received a report following a neurophysiological examination of the masseter muscle showing a change in sensation from the lower alveolus.

Motor Neuropathy

52-year-old male with a one year history of lower motor neuropathy affecting the limbs, left upper and lower limbs clinically and all 4 limbs electrically. The neurologic examination showed left lower and left upper limb hyposthenia with mainly distal motor clumsiness, appearance of left upper limb hypotrophy and diffuse fasciculations. The patient was diagnosed with “suspect motor neuron disease" and was treated with IVIG cycles with slight initial improvement, but later lack of response and worsening of the clinical condition.

Right and left lateral tibiotarsal instability

A 50 years old male with generalized ligamentous laxity and long history of distortions (Sprains) of the ankles. On the right ankle the incidence and severity of the sprains had increased significantly in recent months. On MRI imaging of both ankles: in the right ankle the lateral stabilizing ligaments are damaged and incongruent. On the left ankle the picture is similar with an old fracture of the tip of the medial malleolus which is not united, but not significantly displaced. Right ankle instability was diagnosed and  “Brodstrum“ type operation on right ankle has been suggested.

Multiple Sclerosis_2

21-year-old female with an acute onset of a unilateral sixth cranial nerve deficit. Brain MRI showed at least a dozen white matter lesions, one of them contrast-enhancing. Sensory evoked potentials showed a bilateral increase in latency. Multiple sclerosis was diagnosed, and the patient was treated by corticosteroids, followed by improvement of symptoms. The first follow-up revealed no focal neurological signs with a history of a transitory unilateral lower limb hyposthenia. On the second visit, a horizonto-rotatory nystagmus and irregular paraesthesia in the right toes are documented.

Vitamin D Abnormality / Parathyroid Hormone Abnormality

51-year-old female with vitamin D deficiency among other medical problems: high blood pressure, episodes of transient syncope, and sleep apnea. In the expert's opinion frequent changes and discontinuations of drugs as well as big intervals between one dose to another, can be responsible for hypertensive crisis. Therefore the expert recommends to stop too frequent investigations , and instead focus on appropriate treatment, that should be combination of Angiotensin Receptor Blocker and diuretics.

Mild Alzheimer’s disease – additional opinion

78-year-old male was diagnosed with possible mild Alzheimer’s disease. Medical history suggests a condition running a slow but steadily deteriorating course characterized by apathy as well as by impairment of memory, word finding difficulties and reduced vocabulary, impaired ability to make calculation and handle finances and difficulties in managing house work and going outside unsupervised. An episode with characteristics of delirium in the past is described as well. The neuropsychological evaluation describes moderate dementia.

B-cell lymphoma

59-year-old-male underwent biopsy, after founding epigastric mass, and was diagnosed with B-cell lymphoma. He was treated as an aggressive lymphoma with R-CHOP. Because of neurtopenia, the planned 6 cycle regimen was not completed and a radiation course was administered. Since then the patient feels well, but continues to have prolonged and persistent neutropenia with mild thrombocytopenia. The expert suggests differential diagnosis of the bone marrow problem, and recommends additional diagnostic workup.

Respiratory Insufficiency with Tracheotomy_1

72-yaer-old female was hospitalized due to bronchopneumonia complicated by septic shock. Her complicated diagnosis was: acute respiratory insufficiency with recent results of right mediobasal bronchopneumonic foci with respiratory distress, Hypertensive hypertrophic heart disease, Renal insufficiency, Anemia, Drained left PNX, Tracheomalacia, and Gastritis, and various medical procedures were performed, including Tracheostomy.

Back Pain with Partial Sensory Leg Anesthesia

25-year-old male had an outbreak of sharp pain in the loin, and afterwards complained of partial sensory anesthesia in his leg. He has been given prescribed treatment that included blockades, magnetotherapy, and ultrasound massage with hydrocortison. He experienced back pain for the first time after lifting a heavy thing, and got a pain relief after taking a pain-killer and applying Finalgon ointment. After few months the pain reoccurred. The patient then got a MRT test and was prescribed Finalgon and Milgamma pills, but developed an allergy towards Milgamma.

Cerebral Atrophy

A 52 year old began having difficulties with balance. His problems evolved and he had been seen by neurologists providing clinical evidence for a cerebellar motor syndrome. The most recent examination showed ataxia, dysarthria, nystagmus, dysphagia and hyperreflexia. Although the disease has progressed the patient is not severely disabled at this time. 

 

Hyperthyroidism in autoimmune non-nodular thyroiditis

21 years old female who provided us medical report of her endocrinological examination with diagnosis of “Basedow’s Hyperthyroidism in autoimmune non-nodular thyroid (Hashimoto’s thyroiditis). Under therapy with Tapazole at the dosage of 2 tablets daily with FT3 and FT4 values within normal limits and TSH=0.00” . In the light of such values and of the clinical picture, the specialist confirmed the current therapy with Tapazole (2 tablets daily) suggesting therapeutic dosage of 131 Iodine after examination at nuclear medicine department.

Axonal and Demyelinative Sensorimotor Neuropathy

66-year-old male with a 6-year history of sensory symptoms in the feet and hands. He describes a sensation of cold and stinging in the feet; and numbness in the hands, especially at night. Nerve conduction and EMG demonstrated axonal and demyelinative sensorimotor neuropathy with neurogenic changes in muscles. Follow-up nerve conduction testing that was performed 2 years later showed similar findings.

Thrombotic thrombocytopenic purpura (TTP) secondary to Systemic Lupus Erythematosus (SLE)

15 years old patient presented with clinical syndrome of fever, fatigue, and diarrhea. Laboratory findings showed severe anemia with findings of microangiopathic hemolysis (schistocytes, hyperbilirubinemia, elevated LDH) and severe thrombocytopenia. He was later documented to have fluctuating ADAMTS13 activity that appeared to correlate with the hematologic abnormalities. He also had urinary findings of hematuria, moderate proteinuria, and creatinine as high as 1.4 mg/dL.

IgG Multiple Myeloma

57-year-old male who was found to have back pain and hyperglobulinemia approximately. Marrow biopsy was consistent with IgG myeloma. He was treated with steroids and local radiotherapy with improvement in symptoms and a modest reduction in the M-component. He received melphalan-based autologous stem cell transplantation, which was complicated by reversible respiratory failure. Unfortunately, he relapsed and was treated with bortezomib and steroids for 6 cycles followed by thalidomide. The disease has responded to therapy.

Cystic Neoplasms of the Pancreas

The expert shares broad information regarding Cystic neoplasms of the pancreas: categories, symptoms, diagnosis, treatment, risks and outcomes, and qualifications for performing surgery on the pancreas.