Unbounded Medicine

The brachial artery is the major artery that transverses the antecubital fossa; injury to the brachial artery will cause radiating pain, decreased skin temperature, decreased pulses, and pallor of the distal arm and may result in Volkmann contracture.

The Volmann’s ischemic contracture is a contracture of the flexor muscles and median and ulnar nerve palsies. a long-term sequelae of compartimental syndrome and posterior elbow dislocation.

It could be prevented by early microvascular repair of brachial artery injuries.

Introduction
Leprosy has a rich history dating to biblical times.

“Leper” is an ancient term used to identify patients with leprosy who were severely stigmatized by the deformity that resulted from Mycobacterium leprae infection.

In the clinical context, the term Hansen’s disease should be used instead of leprosy. Gerhard Henrick Armauer Hansen, a Norwegian physician, discovered the microbe in 1874 just before Koch’s discovery of Mycobacterium tuberculosis.

Epidemiology
In Mexico, in the last 16 years the prevalence of Hansen’s disease has been reduced about 95%, from 16,694 reported cases in 1990 to 820 reported cases in 2006. The World Health Organization (WHO) established the goal of eliminating leprosy as a public health problem by the year 2000, with “elimination” defined as a reduction in prevalence to <1 case per 10,000 population in all endemic countries. The six countries with the highest rates of endemic leprosy in 2001 are: Brazil, India, Madagascar, Mozambique, Myanmar, and Nepal

Transmision
This disease is probably spread by the respiratory route, like tuberculosis.

Risk Factors
Close contact
Older persons
Impaired cell mediated immunity

Clinical manifestations
The cardinal manifestations of leprosy are infiltrative skin lesions, hypoesthesia, and peripheral neuropathy
The clinical manifestations of leprosy are closely related to the polarity of the cellular immune response to M. leprae in the patient.
The history of a patient with suspected leprosy should include whether the person has resided in an area with high prevalence and whether the person has been previously diagnosed or treated for leprosy. Certain patients may deny knowledge of a prior diagnosis or may report that skin lesions or neuropathy or both are acute, as they wish to avoid the stigma of a diagnosis of leprosy, even in emigrants to developed countries.

If lepromatous leprosy is left untreated, it can progress to “leonine” facies as seen in the following images.

Diagnosis
This includes physical exam and skin biopsy.

Treatment
Once monthly: Rifampin, Dapzone and Clofazimine for two years and then stop.
Daily: Sulfone and Clofazimine for two years and then stop.

Results of treatment

Intussusception is the invagination of a part of the intestine into itself, in other words is the prolapse of one part of the intestine into the lumen of an immediately adjoining part. It is the most common abdominal emergency in early childhood.

Epidemiology: Most episodes of intussusception occur in otherwise healthy and well-nourished children. Approximately 60% of children are younger than one year old, and 80 percent are younger than two. Is the most common cause of intestinal obstruction in children between 3 months and 6 years old. It appears to have a slight male predominance with a male:female ratio of approximately 3:2.

Etiology: The vast majority of cases is unknow. Another causes are Meckel’s diverticulum, polips, intestinal tumors, Henoch-Schönlein purpura, strange bodies, etc.
The most common form of this disease is the ileo-colic and ileo-ileo-colic invaginations. It could be associated with the rotavirus vaccine.

Clinical picture: Acute onset of intermittent, severe, crampy, progressive abdominal pain, accompanied by inconsolable crying and drawing up of the legs toward the abdomen. This painfull episodes occurs at 15 – 20 minute intervals and then become more frequent and severe. Vomiting may follow episodes of abdominal pain.

This episodes can be followed by vomiting and the passage of “currant jelly” stool (a mixture of blood and mucous). A sausage-shaped abdominal mass may be felt in the right side of abdomen. The prevalence of blood in the stool is as high as 70% if occult blood is included.

Diagnosis: It is based on index of suspicion, frequently the diagnosis is stablished with contrast studies (wich could be also therapeutic).

The abdominal plain film (see below) may be helpful because they may show frank intestinal obstruction or massively distended loops of bowel with absence of colonic gas.

The ultrasound can be useful also, with a sensitivity and specificity approach 100%. The classic finding is a “bull’s eye” or “coiled spring” lesion (see below) representing layers of the intestine within the intestine.

Treatment: Nonoperative reduction using barium or air contrast techniques is successful in approximately in 75 – 90% (in the first 24 hours) of patients with ileo-colic intussusception.
Surgery is indicated when nonoperative reduction is incomplete or when a persistent filling defect, indicating a mass lesion is noted. Broad-spectrum intravenous antibiotics should be given before surgery. Manual reduction at operation is attempted in most cases, but resection with primary anastomosis needs to be performed if manual reduction is not possible or if a lead point is seen.

Regards,
Jon Mikel Iñarritu, M.D.

Purpura fulminans

It is a severe condition due to meningococcal sepsis, it occurs in 15 to 25% of those patients with meningococcemia.

The clinical picture is as follows: acute onset of cutaneous hemorrhage and necrosis secondary to vascular thrombosis and disseminated intravascular coagulation. Often there is pain followed by petechiae. Ecchymoses develop and evolve into painful indurated, well-demarcated purple papules with erythematous borders (as you can see in the image this lesions are coalescent). Then this lesions progress to necrosis with formation of bullae and vesicles. Gangrenous necrosis can follow with extension into the subcutaneous tissue and occasionally involves muscle and bone.

To prevent this complication of meningococcemia you have to be prompt and agressive with IV antibiotics and support of vascular perfusion. The use of Xigris (drotrecogin alfa activated) have shown promising results once the process has instaled. Often this patients require surgical debridement, skin grafting or limb amputation.

Regards,

Jon Mikel Iñarritu, M.D.