Mesenteric rheumatoid nodules masquerading as an intra-abdominal malignancy: a case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Rheumatoid nodules are the most common extra-articular findings in patients with rheumatoid arthritis. They occur most commonly at pressure points such as the extensor surfaces of the forearms, fingers, and occiput, but have also been reported to occur in unusual locations including the central nervous system, pericardium, pleura, and sclera. We present the unusual case of rheumatoid nodules in the small bowel mesentery masquerading as an intra-abdominal malignancy.</p> <p>Case presentation</p> <p>A 65-year-old-male with a known history of longstanding erosive, nodular, seropositive rheumatoid arthritis was incidentally found to have a mesenteric mass on computed tomography (CT) exam of the abdomen. This mass had not been present on prior imaging studies and was worrisome for a malignancy. Attempts at noninvasive biopsy were nondiagnostic but consistent with a "spindle" cell neoplasm. Laparotomy revealed extensive thickening and fibrosis of the small bowel mesentery along with large, firm nodules throughout the mesentery. A limited bowel resection including a large, partially obstructing, nodule was performed. Pathology was consistent with an unusual presentation of rheumatoid nodules in the mesentery of the small bowel.</p> <p>Conclusion</p> <p>Rheumatoid nodules should be considered in the differential diagnosis of a patient who presents with an intra-abdominal mass and a history of rheumatoid arthritis. Currently, no tests or imaging modality can discriminate with sufficient accuracy to rule out a malignancy in this difficult diagnostic delimma. Hopefully, this case will serve as impetus for further study and biomarker discovery to allow for improved diagnostic power.</p

Management of Hypertension: JNC 8 and Beyond

Hypertension is a leading risk factor for cardiovascular disease, the leading cause of death and morbidity in our society and on a global scale. Major components of cardiovascular disease include stroke, coronary artery disease, heart failure, and chronic kidney disease, in all of which hypertension plays a major role. The risk of these complications increases directly and linearly with systolic blood pressure starting at 115 mmHg. Although usually asymptomatic, hypertension is readily detectable on physical examination and is amenable to both lifestyle modification and pharmacologic treatment in most patients. However, large proportions of the hypertensive population remain undetected and undertreated. Numerous guidelines have been issued during the past few decades to promote detection and optimal therapy. Despite the increase in risk with systolic blood pressure greater than 115 mmHg, the generally accepted threshold for diagnosis and treatment has been systolic blood pressure greater than 139 mmHg and diastolic blood pressure greater than 80 mmHg because until recently treatment to lower levels has been associated with an unfavorable relation between clinical benefit and harm. In the past several years, new guidelines, advisories, commentaries, and clinical trials have provided evidence for a potential change in current recommendations for the management of hypertension. In this regard, the long-awaited eighth report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended patients older than 60 years be treated to a systolic blood pressure of less than 150 mmHg, which has generated considerable controversy and caution. The striking findings of the Systolic Blood Pressure Intervention Trial (SPRINT) have received considerable attention because of the demonstration that intensive therapy to a target systolic blood pressure below 120 mmHg decreases cardiovascular mortality and morbidity more than less intensive treatment to a target systolic blood pressure below 140 mmHg, but this approach is not fully generalizable because the trial excluded patients younger than 50 years and those with diabetes and prior stroke. This article addresses major issues in the management of hypertension, including those in the seventh and eight reports of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and subsequent studies, considering maintenance of prior standards as well as the potential application of important new findings

Mechanical Oscillopsia After Lower Eyelid Blepharoplasty With Fat Repositioning

Blepharoplasty with fat repositioning is a technique used to fill the tear trough in the aging lower eyelid. We present a patient who underwent transcutaneous lower eyelid blepharoplasty with fat repositioning and subsequently developed mechanical oscillopsia exacerbated by movement of the face

Mechanical Oscillopsia After Lower Eyelid Blepharoplasty With Fat Repositioning

Blepharoplasty with fat repositioning is a technique used to fill the tear trough in the aging lower eyelid. We describe a patient who underwent transcutaneous lower eyelid blepharoplasty with fat repositioning who subsequently developed mechanical oscillopsia in the right eye exacerbated by facial movement. Surgical exploration revealed cicatrix between the inferior oblique muscle and the anterior superficial musculoaponeurotic system. Excision of the scar bands led to immediate amelioration of symptoms. When performing blepharoplasty with fat repositioning, it is essential to be aware of the anatomic location of the inferior oblique in the anterior inferomedial orbit to avoid incarceration of this muscle

Mesenteric rheumatoid nodules masquerading as an intra-abdominal malignancy: a case report and review of the literature.

BackgroundRheumatoid nodules are the most common extra-articular findings in patients with rheumatoid arthritis. They occur most commonly at pressure points such as the extensor surfaces of the forearms, fingers, and occiput, but have also been reported to occur in unusual locations including the central nervous system, pericardium, pleura, and sclera. We present the unusual case of rheumatoid nodules in the small bowel mesentery masquerading as an intra-abdominal malignancy.Case presentationA 65-year-old-male with a known history of longstanding erosive, nodular, seropositive rheumatoid arthritis was incidentally found to have a mesenteric mass on computed tomography (CT) exam of the abdomen. This mass had not been present on prior imaging studies and was worrisome for a malignancy. Attempts at noninvasive biopsy were nondiagnostic but consistent with a "spindle" cell neoplasm. Laparotomy revealed extensive thickening and fibrosis of the small bowel mesentery along with large, firm nodules throughout the mesentery. A limited bowel resection including a large, partially obstructing, nodule was performed. Pathology was consistent with an unusual presentation of rheumatoid nodules in the mesentery of the small bowel.ConclusionRheumatoid nodules should be considered in the differential diagnosis of a patient who presents with an intra-abdominal mass and a history of rheumatoid arthritis. Currently, no tests or imaging modality can discriminate with sufficient accuracy to rule out a malignancy in this difficult diagnostic delimma. Hopefully, this case will serve as impetus for further study and biomarker discovery to allow for improved diagnostic power

Unintentional secondary exogenous corticosteroid exposure and central serous chorioretinopathy

PurposeThe purpose of this study is to describe a possible association between unintentional secondary exogenous corticosteroid exposure and central serous chorioretinpathy (CSCR).MethodsA retrospective review of three patients diagnosed with CSCR in one or both eyes and a history of possible unintentional secondary corticosteroid exposure. Clinical history, exam findings, optical coherence tomography, fluorescein angiography, and clinical course were reviewed.ResultsThree patients, who did not use corticosteroids, reported suspected unintentional secondary corticosteroid exposure from living with family members or partners using dermatologic corticosteroid cream and/or inhalers frequently. Two of the three patients had a history of recurrent CSCR, one patient involving both eyes. After taking precautions to avoid secondary corticosteroid exposure, all three patients had complete resolution of CSCR without further recurrence during follow-up ranging from 2 to 4 years.ConclusionsPatients with CSCR should be queried for both primary and possible unintentional secondary routes of corticosteroid exposure, which may contribute to this condition