The top medical cases of July 2018

Centipedes, chemotherapy, and lamb casserole were the subjects of July’s most engaging medical cases on the Figure 1 platform.

Healthcare professionals and institutions around the world use Figure 1 to learn from real medical cases shared by their colleagues. We identified these five cases as the month’s most engaging based on:

Community Metrics: The number of times they were viewed, discussed, and shared by the more than 2M healthcare professionals on the platform.

Clinical Value: Our medical and community teams assess the quality, complexity, and educational merit of our top cases to highlight the most credible and clinically useful material. July’s top cases showcase the depth and breadth of medicine as it was discussed around the world, offering a unique window on healthcare as it happens.

1. “It is indeed a space scenario”

Physicians on Figure 1 can get feedback on what they’re seeing — or on something they may never see. In this case, Dr. Keith Brandt of the Johnson Space Center asked the community about “barrier creams for an extreme survival setting.” As he phrased it:

“We are dealing with a very unusual situation where the subject may be in contact with fecal material for up to 6 days. The subjects would be in an extreme survival setting where they would be confined to a survival suit for up to 144 hours before rescue. The current idea is to have an adhesive fecal bag applied before donning the survival suit. The perianal region would potentially be exposed to feces for the duration of the emergency. We are looking at barrier creams to protect this exposed skin. Due to constraints of the survival suit, we can’t use petroleum products and shy away from most ‘natural’ product as they are difficult to quantify the exact contents and thus difficult to determine compatibility with survival systems. We’ve currently narrowed the field to Proshield Plus or Selan + Zinc Oxide. I’m looking for experience with these products, or other ideas for skin protection in this extreme scenario.”

Despite the unusual request — or perhaps because of it — the healthcare professionals on Figure 1 were enthusiastic in their answers.

Some suggestions offered by healthcare professionals:

“Consider whether a polyvinyl alcohol coating such as is used in teat dips for dairy cattle might be suitable. They are effective in minimizing mastitis in cattle who lie in mud contaminated with feces.” “In lieu of spray on skin (although sounds like the most easily applicable), I’d postulate that a physical barrier to potential bacteria (plus an antibacterial gauze or application material to surface) would be the most reliable.” “I agree with the comment that applying a cream type barrier is going to pose an appliance adherence issue. I’d look at a coating barrier that dries and lasts 6 days.”

All of which were of interest to Dr. Brandt, who came back to say:

“I appreciate the ‘thinking out of the box’ suggestions we’ve had so far and are looking at several of the suggestions. We are still quite interested in looking at further options. Thanks for the comments and interest!”

2.”It fits clinically.”

A patient undergoing chemotherapy for testicular cancer presents with fever and a rash. He has an absolute neutrophil count (ANC) of zero, putting him at high risk of infection. He owns a cat.

This detailed, well-structured case hits the perfect note for the physicians on Figure 1, The internal medicine resident who shared the case was able to talk through his thinking with a fellow resident:

“Blood + urine Cx [culture]. Chest X-ray. Filgrastim. Cefepime + Vanc (want MRSA 👀 @ lesion). Looks kind of ecthyma-ey (pseudomonas vs strep) may consider an amikacin for a dose while wait for culture. Cat is interesting - dunno if he has much contact with it. I think of bartonella, toxoplasma, pasteurella, & capnocytophaga — doesn’t look classic for those but 🤷‍♂️ with ANC =0. Any livestock contact?” “This is very excellent discussion. Thanks for your time. Blood cultures now growing GNR. We are thinking about pseudomonas bacteremia which can be associated with #ecthyma gangrenosum. He’s on vancomycin and pip/tazo. I will keep you posted.”

And a dermatologist was able to offer her feedback on the results of the tests:

“Ecthyma?” “That’s what we are thinking about especially the setting of gram-negative rods in the blood.” “Perfect. It fits clinically.”

3. “Florida providers should be able to solve this one easily”

The Braden Clinic, a hospital in south Florida, shared this case to test healthcare professionals.

“A 32-year-old female presents with the above pictured mark on her posterior right shoulder. She denies injury and reports she awoke from sleep to this.”

The answer:

“This mark is produced by a burn from a millipede commonly found in and around FL. The burn is caused by prolonged contact to the millipede and the subsequent release of: “millipede toxin” which contains hydrochloric acid, hydrogen cyanide, organic acid, cresols, benzoquinones, hydroquinones (sometimes) and phenols. Unknowingly to the patient, her mattress was infested.”

4. “Ice gloves while infusing chemo”

This case from one of July’s top dermatologists also used a Q-and-A formar to test the community’s knowledge.

“This is chemotherapy induced. What is the agent and how can it be prevented?”

The answer, as correctly identified by a family medicine physician:

“Taxanes (paclitaxel and docetaxel) are often used for breast and gynecological cancers. They are derived from the yewtree and disrupt mitosis by inhibiting microtubule assembly. Taxane toxicity affects rapidly growing cells of hair causing hair loss as well as damage to skin damage (sunburn-like reaction) and nails. Damage to cells of the nail matrix result in these changes. Cooling the hands during chemotherapy infusion may decrease perfusion and minimize toxicity.”

5. “A sharp, painful sensation in her throat following ingestion of a lamb casserole.”

BMJ Case Reports shared this case featuring a patient who ingested a foreign body.

“A 38-year-old female presented to an emergency department after feeling a sharp, painful sensation in her throat following ingestion of a lamb casserole. The pain was worse on swallowing and radiated to the right chest and between her shoulder blades. Examination was unremarkable, the patient’s voice remained unchanged, and there was no abnormality on fiberoptic nasendoscopy. A diagnosis of an ingested foreign body was proposed. A chest and lateral neck x-ray showed no evidence of a foreign body but a CT showed a bony foreign body within the thoracic oesophagus at the level of the azygos vein located 2 mm from the aortic arch. It measured 20×21 mm and was stretching the lumen of the oesophagus but there was no evidence of perforation or vascular injury. A rigid oesophagoscopy was performed under general anaesthesia with support from on-site cardiothoracic surgeons and a cardiac anaesthetist given the possibility of severe haemorrhage. A 40-cm rigid oesophagoscope was passed into the upper oesophagus atraumatically where the bone was visualised at 22 cm from the upper incisors. No recent or active bleeding was seen. Grasping forceps were used under direct vision and the bone was gently dislodged from the wall of the oesophagus and removed in its entirety without excessive traction required. A small mucosal tear on removal of the bone occurred with a small amount of blood.”

A surgeon on Figure 1 was among those applauding the care team on this case.

“Nicely done. I have had similar cases in the past in both adults and children. I was often able to use flexible endoscope instead of the rigid one that we used to use many years ago. After the procedure it is crucial to do a serial chest x-ray for two or three days to look for delayed perforation. Thank you for sharing this case.”