Search

A patient presented with acute solar retinopathy after gazing directly at the sun. Best-corrected visual acuities were 6/12 and 6/18 in the left and right eyes, respectively. Optical coherence tomography (OCT) demonstrates full-thickness hyperreflective areas (A and B) corresponding to the hypopigmented areas observed on examination (C and D). At 3 months follow-up, the patient’s vision had improved to 6/9 in both eyes. The hypopigmented areas on the maculae had faded (E and F), and OCT shows hyporeflectivity in the outer retinal layers (G and H).

To the Editor.— Two patients with pustulosis palmaris et plantaris (PPP) followed by purpuric pustules, fever, and severe intestinal symptoms are described in the context of systemic pustular vasculitis. Report of Cases.—Case 1.— A 43-year-old man with PPP of 14 years' duration developed tender, purpuric, 2- to 40-mm macules and pustules on the dorsa of his feet, legs, and palms (Fig 1), sore throat, and intersternocostoclavicular (ISCC) pain after acute pharyngitis. Laboratory studies disclosed the following values or results: leukocytes, 14.0×10 9 /L (neutrophils, 0.7); IgA, 7.21 g/L (normal, 0.90 to 4.50 g/L); erythrocyte sedimentation rate, 70 mm/h; C-reactive protein, 5+; CH 50 , 66.9 U/mL (normal, 30 to 40 U/mL); and proteinuria and microhematuria. A throat culture yielded Streptococcus pyogenes . Bone scintigraphy with technetium Tc 99m MDP ( m ethylene d i p hosphonate) indicated incipient ISCC ossification. Pustules were not induced by trauma. Severe colicky abdominal pain

In Reply . — I appreciate Krane's interest in the subject of microscopic hematuria. My study was essentially stimulated by my lack of discovery of bladder neoplasms in female patients whom I evaluated for asymptomatic microscopic hematuria. I wish to make it clear that all of the subjects of the study were evaluated by their internists prior to being referred to me. None of these patients had any evidence of proteinuria, red blood cell casts, or abnormality in renal function. As a consequence, it was felt by the referring physician that the patient might harbor significant underlying urologic disease, ie, either a bladder or a renal neoplasm. The thrust of my study was to emphasize that I was unable to discover any urologic neoplasms either of the bladder or of the kidney. In essence, I was suggesting that an abbreviated urologic evaluation for female asymptomatic microhematuria might be considered that would

An adult with cutaneous diphtheria was admitted with bilateral purulent conjunctivitis and a perforated eye with most of the cornea absent due to Corynebacterium diphtheriae. At the time of admission of grayish patch of corneal epithelium was noted in the other eye, and in the next 24 hours there developed a large corneal perforation with dissolution of much of the cornea. Involvement of the external eye in diphtheria is rare but it is usually associated with cutaneous forms of the disease. Cutaneous diphtheria has been prominent in several recent outbreaks in the United States. Prompt recognition, early antibiotic treatment, and neutralization of the toxin with antitoxin are required for successful therapy.

DISTORTED hearing deserves early recognition and careful evaluation. Diplacusis and poor pitch discrimination frequently produce disturbing emotional reactions in patients unaware of their own defective harmonics. Culpepper 1 discovered that a congenital form of diplacusis was the main cause of "off-key" singers. He was able to obtain consistent diplacusis curves in repeated testing of these "tone-deaf" children 10 years of age with normal audiograms. Musicians are the first ones to recognize malfunction of their finely-tuned ears. Inability to register proper pitch made one vocal soloist stop a performance. This patient had a temporary diplacusis for six weeks following a stapedectomy. An emotional upset of a Catholic sister resulted when she was unable to play her violin without discord or direct a choir harmoniously. An acute cochlear hydrops due to a sudden descent of a jet-airliner resulted in a severe diplacusis of more than one octave in another patient. Diplacusis Testing

WHILE a graduate student and National Research Fellow in Physics, from 1920 to 1923, at the University of Chicago, I had the opportunity to cooperate with Dr. J. Gordon Wilson of Northwestern University Medical School in studying various types of deafness. Many of our studies were presented to physicians and physical therapeutists. I have maintained my interest in diseases of the ear and their effects on hearing during the intervening years. The subject of diplacusis is one rarely met with and little discussed. Dr. Wilson and I reported on 1 case. 1 It is felt that the following discussion involving my case of diplacusis may prove of interest to the otologist and add to our early statement of 1923. Dr. R. S. Yancey of Dallas has been interested in the case and has made the medical treatments involved. REPORT OF A CASE History .—On Dec. 5, 1944, I was visiting one of

The finding of diplacusis in a case of deafness is a valuable diagnostic aid in localizing the pathologic condition, since diplacusis can be caused only by a lesion of the organ of Corti. This statement is based on theoretic considerations, which I shall discuss, and on clinical observations, which I shall describe. If it is true, some practical applications follow for the diagnosis and treatment of certain cases of deafness and of Meniere's syndrome. INTRODUCTORY OBSERVATIONS Definition .—diplacusis is the hearing of one sound as two. There are three varieties of diplacusis: Diplacusis binauralis echotica, in which a sound is heard a fraction of a second later by one ear than by the other, as a distinct echo, is comparatively rare. I have observed it but once (case 8). Diplacusis monauralis dysharmonica, in which a pure tone is heard by the affected ear as a double tone of two different pitches

The determination of the etiology of deafness due to obstruction to the conduction of sound is a comparatively simple matter to one skilled in the use of the differential tuning fork tests and experienced in the clinical course and diagnosis of the conditions which may cause deafness based on poor conduction. On the one hand are the cases of catarrhal or suppurative otitis media in which the defect in hearing is not progressive except during the active stage, i. e., an acute tubal occlusion with fluid in the middle ear or a purulent discharge from a perforation in the drum membrane. On the other hand are the cases of spongification of the labyrinthine capsule (otosclerosis) with primary fixation of the stapes and progressive deafness in which the drum membrane is entirely normal or shows slight scarring or thickening, the residues of otitis media in childhood unrelated to the present

MANIPULATION of the stapes in the oval window is not without risk to the integrity of the cochlea. Even greater risks are imposed when the stapes is removed and replaced with either viable grafts or nonviable materials such as absorbable gelatin, metal, or plastic. Great advances in audiosurgery in recent years have brought to the otosclerotic patient well-founded hope for dramatically improved hearing with the promise of lasting results. They have, however, brought also the realization of the vulnerability of the cochlea to the numerous procedures and implants to which it is subjected. Shambaugh1has pointed out, "At the same time there has been a distressingly higher incidence of irreversible cochlear pathology producing further impaired and often useless ears." Postoperative serous labyrinthitis following fenestration surgery had been previously noted by Shambaugh. Impaired hearing, diplacusis, reduced speech discrimination, vertigo, and nystagmus developed several hours postoperatively and persisted several days. Similar

The diplacusis described in this paper was my own case and presented an unusual opportunity for study. During an acute attack of purulent rhinitis of the ordinary "head cold" variety, bilateral eustachian catarrh, stuffiness in the ears, impaired hearing, a "sea-shell" tinnitus, transitory spells of dizziness and diplacusis developed. The dulness of hearing, diplacusis and tinnitus were Fig. 1.—B 488 Koenig fork (which was interpreted as D 581 in the left ear by reason of false impression). The fork was struck a standard blow by a swing pleximeter, and was timed by a stop watch from the time struck. The normal for this fork is thirty seconds bone conduction, and fifty-five seconds air conduction. The dampening factor expressed in sensation units per second is 2.0, the factor K for reducing the loss of hearing to percentage is

DIPLACUSIS may be congenital as seen in "tone-deaf" people, or acquired when due to allergy, trauma, infection, toxin, and neoplasm. Provocative food testing will often elicit diplacusis which can be improved by a strict allergic regimen. Trauma may vary from the din of a discotheque to a direct blow to the head or to iatrogenic injury. Infection may be indirect as with a focus in septic tonsils or direct pressure on the oval or round windows in a suppurative otitis media. Toxic factors include: aspirin, quinine, streptomycin, kanamycin, carbon monoxide, and excessive sodium intake. Leukemia, with associated cochlear hemorrhage or acoustic neurinoma, with initial "coagulum" effect, are neoplastic causes of diplacusis. Cochlear dysharmonics result from physical, chemical and bioelectric effects of anoxia, vasopasm, edema, abnormal capillary permeability, hemorrhage, exudate, and viscosity changes. Capillary fragility can be easily tested using the vacuum-cup method with graduated suction of 10 to 20 or

How many RBCs per high-power field in a routine urinalysis are notable and warrant further investigation? Periodic review of a subject frequently taken for granted, eg, microhematuria, is not only appropriate but essential. With improvement of techniques and better understanding of various disease processes, it is important to update the clinical implications of microhematuria. Carson et al (p 149) indicate that 81% of their patients with microhematuria followed up for two years had substantial genitourinary pathological conditions. Approximately 20 years ago, one of the authors, Laurence F. Green, MD, recorded only 10% of patients with microhematuria who had a substantive pathological condition. Thirteen percent of the present group of patients who were followed up for the two years had a malignant neoplasm of the genitourinary tract. The same evaluation 20 years ago showed only 2.2% of patients with microhematuria to have a malignant neoplasm of the urinary tract. The authors

To the Editor.— Dysacusis is a hearing disturbance that refers to malfunction of the sense organ or to an abnormal brain function such as auditory agnosia, phonemic regression, and psychogenic "deafness."1(p85)Paracusis refers to the ability to hear better in noisy places,1(p89)and diplacusis ("hearing double") is a form of dysacusis in which a given pure tone has different pitches in the two ears.1(p96) Recently I had the opportunity to examine a patient with the curious clinical sign called echoacousia, occurring in association with the controversial Gerstmann syndrome without aphasia (acalculia, finger agnosia, left-to-right disorientation).2-4 The patient was a 70-year-old right-handed woman with a history of extracranial vascular disease and compensated hypothyroidism who required admission to the hospital because of uncontrolled hypertension of sudden onset associated with a clinical presentation of right-side dysesthesias ("water running on my right side"). The neurological examination disclosed marked discalculia, finger

A 32-year-old man presented with relapsing polychondritis (RP) and microhematuria. A renal biopsy specimen disclosed focal segmental glomerulonephritis with occasional crescents. Immunofluorescent and electron micrographic studies suggested immune complex—mediated glomerular injury. Initially, life-threatening upper airway obstruction responded to high-dose corticosteroid therapy. Subsequently, progressive renal insufficiency and proteinuria caused by increasingly active glomerulonephritis were treated by adding cyclophosphamide, with sustained improvement. This case supports the concept that RP is an immunologically mediated disease and suggests that a regimen of prednisone and cyclophosphamide warrants consideration for use in cases of RP with glomerulonephritis. ( JAMA 1981;245:847-848)

• Behcet's syndrome is a multisystem disease complex, the major manifestations of which are oral and genital ulcers, arthritis, uveitis, and skin eruptions. Less frequently, CNS disturbances, colitis, thrombophlebitis, large-vessel vasculitis, and myocarditis occur. If renal involvement does occur, it is usually manifested by asymptomatic microhematuria and/or proteinuria. Recently, renal amyloidosis and focal necrotizing glomerulonephritis with immune complex deposition have been described. We describe a patient with Behcet's syndrome who experienced diffuse proliferative glomerulonephritis with epithelial cell crescent formation in 75% of glomeruli examined. Immune complexes were not identified. Renal function, impaired on admission, improved with no therapy. (Arch Intern Med140:713-714, 1980)

Asymptomatic microhematuria is a common finding, occurring in 13% of adult men and postmenopausal women in Rochester, Minn. Previous recommendations to perform cystoscopic and excretory urographic examinations on all patients with this finding were based on findings in referred patients. In the present population-based study, the frequency of serious urologic disease in patients with asymptomatic microhematuria was 2.3%; only 0.5% had bladder or renal cell carcinoma. Urologic malignant lesions occurred more frequently in the elderly. There was a trend toward more serious diseases in those with higher grades of hematuria. Complete urologic investigation of all patients with any degree of asymptomatic microhematuria cannot be recommended. The presence of other risk factors should be considered in opting for further evaluation.

In Reply.— One of the difficulties in ascertaining the ability of asymptomatic microhematuria to predict the existence of renal or uroepithelial cancer is that the gold standard of diagnosis, excretory urography and cystoscopy, entails risks. The ethics of studies in man would generally preclude performances of these tests on all asymptomatic adults with one or more red blood cells per high-power field on urinalyses. However, the results of such tests on a high-risk subgroup, such as patients whom physicians have referred to urologists, cannot be applied to the general population. Thus, one must study a defined general population by observing the appearance of disease after an abnormal urinalysis result. Dr Heller must have overlooked our reporting on page 227 of patients who had urologic tests in the month after their urinalysis, but this does not resolve his legitimate concern that hematuria may be a clue to the preclinical phase of

We have studied ten normotensive patients (nine male and one female, aged between 28 and 51 years) who each had a solitary functioning kidney and proteinuria. Six had undergone unilateral nephrectomy, and four unilateral renal agenesis. In each case, intravenous pyelography revealed only one functioning kidney with compensating hypertrophy. Mild to moderate chronic renal failure was present in six, and microhematuria in two. Proteinuria ranged from 1.10 to 4.10 g/24 hr, being in the nephrotic range in three patients. In seven patients, a renal biopsy showed focal glomerulosclerosis. Immunofluorescence studies demonstrated granular deposits of IgM in three and C3 in six cases, over the sclerotic areas. We suggest that the appearance of proteinuria and focal glomerulosclerosis in a patient with a solitary kidney could be due to chronic glomerular hyperfiltration.

• A prospective study of 177 women with asymptomatic microhematuria was carried out over a ten-year period. The implications of asymptomatic microhematuria in this population indicate that endoscopic evaluation of the bladder may be unnecessary, as no vesical neoplasms were discovered. It seems that cytologic examination of the urine may be a simpler, more cost-effective method for screening the female population with microhematuria. ( Arch Intern Med 1988;148:2629-2632)

• Funduscopic examination of two young adults complaining of blurred vision revealed small symmetrical macular lesions suggestive of solar retinopathy. Although both patients had recently looked at the sun for less than one minute, it is common to look at the sun for longer periods (ie, sunsets) without incurring visual symptoms of retinal lesions. Our biophysical analysis revealed the important parameters of solar retinopathy and the minimum exposure to the sun that would produce such lesions. Under ideal optical conditions, solar retinopathy can occur following extremely short observations of the sun.

To the Editor.— I read with interest the article by Mohr et al 1 and admire their extensive review of patient records and the literature. Unfortunately, they do not present hard evidence to support their conclusion that complete urologic evaluation of all adult patients with asymptomatic microscopic hematuria is not necessary. They claim "complete follow-up" for 677 of 781 cases of asymptomatic hematuria. The 55 autopsy cases certainly do represent complete follow-up. Among the 656 living patients, however, "complete follow-up" was simply defined as at least one physician contact three or more years after first finding microhematuria. The percent-age of patients undergoing urologic evaluation, such as excretory urography, cystoscopy, renal function studies, and urine cultures, is not given. The fact that one is alive and asymptomatic three years later does not mean one has no urologic disease. Even "moderately serious" and "serious" diseases (the authors' words), such as neoplasms, stones

To evaluate the etiology of microhematuria, the cases of 200 consecutive patients with asymptomatic microhematuria who had undergone complete urologic examination and two-year follow-up were reviewed. Most patients were 50 to 59 years old. Highly significant urologic lesions were found in 20% of patients. Thirteen percent of these patients had a genitourinary malignant neoplasm. No urologic lesion could be identified in 19% of patients in this group. The results suggest that present diagnostic modalities have substantially refined and improved the urologist's diagnostic abilities. The urologic examination of patients with asymptomatic microhematuria, particularly in those older than 40 years, is justified. ( JAMA 241:149-150, 1979)

SEATTLE-KING County has experienced an outbreak of diphtheria since 1972. 1 It has been characterized mainly by cutaneous diphtheria among alcohol-using indigent adults in Seattle's Skid Road area. During this period, 749 cases and carriers of diphtheria were identified, and one, described here, was an unusual case of chronic intermittent cutaneous diphtheria. Methods For three years the patient was often seen at one of five health facilities: Harborview Medical Center (HMC), Seattle-King County Health Department Communicable Disease Control Clinic, Seattle City Jail, Seattle Indian Health Clinic, and Pioneer Square Neighborhood Health Center. There, the patient's skin lesions were swabbed with a sterile cotton-tipped applicator, and the material was either directly inoculated onto blood agar, tellurite, and Loeffler's blood culture media, or, in several of the facilities, Amies transport medium without charcoal was used initially. Nasopharyngeal and throat cultures were also obtained when the patient was examined at the Health Department.

Chronic ulcerative diphtheria of the skin occurs sporadically in Palestine in persons weakened by infectious disease or with lowered nutrition. In the dermatologic department of the Hadassah Policlinic in Haifa, there was 1 case of the disease in 2,000 cases of dermatologic diseases. The lesions were almost invariably located on the legs. Epidemic ulcers affected members of the British Army in Palestine during World War I.1Craig in 1916 found Corynebacterium diphtheriae in a great part of them. I do not know whether at the same time civilians also suffered from acute diphtheritic ulcers. In 1940 an outbreak of cutaneous diphtheria occurred in the army in northern Palestine. Two years later, in August 1942, a small epidemic of diphtheritic ulcers occurred among the civilian population.2During a period of four months 22 cases were observed, and eight months later there were 17 new cases. GENERAL DESCRIPTION In

HISTORICAL REVIEW Diphtheritic infection of the skin, a rarity in civilian dermatologic practice, has been noted with considerable frequency among the armed forces of various countries during the present war, and may be considered a not uncommon military dermatosis in certain geographic areas where diphtheria is more or less endemic and climatic conditions are favorable. These areas include the south of Europe, the Near and Middle East, India and the coasts of Africa. This increase of cutaneous diphtheria in the current conflict parallels in a most interesting fashion a similar outbreak during World War I, when Scott 1 and Manson-Bahr 2 separately noted a sharp rise in the number of cases of so-called veld or desert sore among British troops, resulting in a considerable amount of disability in Egypt, the Near East and at Gallipoli. The latter author pointed out that at least in 1 instance the

That the Klebs-Loeffler bacillus may produce cutaneous eruptions is well known. Dermatitis diphtheritica may be primary, or, which is usual, may result from contamination from mucous membrane lesions. These secondary eruptions were, until the introduction and wide spread use of diphtheria antitoxin, not uncommon. On the other hand, primary cutaneous diphtheria is either very rare or, because not very often diagnosed, commoner than is generally thought. This undoubt

CUTANEOUS diphtheria is rarely seen in the temperate zone, but it is a common cause of disability among soldiers serving in the tropics. 1 Abrasions, blisters, insect bites, gunshot wounds and dermatophytic fissures, to mention only a few of the common lesions of the skin, are frequently secondarily infected with virulent Corynebacterium diphtheriae. These infections develop into the chronic ulcers of cutaneous diphtheria, which have been called variously desert sores, septic sores, barcoo rot and veldt sores. In the fighting around Myitkyina during the North Burma campaign a small epidemic of cutaneous diphtheria occurred among American soldiers. One hundred and forty cases of this condition were studied at the Twentieth General Hospital: In 61, or 43 per cent, of this group multiple neuritis developed as a complication. The purpose of this report is to analyze and record the observations in these cases of neuritis. Articles covering the dermatologic, bacteriologic and

TROPICAL ulcers, of diphtheritic or other origin, have been treated by a variety of methods, with varying degrees of success. With the advent of penicillin, more satisfactory results have been observed. 1 This report concerns itself with the bacteriologic findings and the results of several plans of penicillin therapy in 56 patients with tropical ulcers or ulcerated dermatitides. In 8 of the patients the ulcerated lesions harbored virulent Corynebacterium diphtheriae. MATERIALS AND METHODS Plan of Study.— The patients were admitted to special wards with isolation facilities. Schick tests were performed on admission, and the results were read on the third and fifth days, to minimize the number of falsely positive and combined reactions. Each patient was given three days of preliminary cleansing treatments, during which time material for cultures was taken daily from the nose, throat and all active lesions of the skin (ulcerations, fissures, vesicles, pustules and other lesions

Diphtheria of the skin was first recognized by Chomel 1 in 1759, and by Samuel Bard 1 in an epidemic in New York in 1771. Although the diphtheria bacillus was not discovered until 1883 by Klebs 1 and 1884 by Loeffler 1 of Greifswald, working independently, as early as 1830 Trousseau 1 wrote extensively of cutaneous diphtheria. It was not, however, until 1891 that the integumentary outbreak of this affection was studied not only clinically but also bacteriologically by Neisser. 2 The invasion of the skin by the Klebs-Loeffler bacillus is of infrequent occurrence, as shown by the report of the St. Anne's Children's Hospital of Vienna. 2 From 1894 to 1902, out of 2,217 clinical and bacteriologic cases of diphtheria the cutaneous surface was attacked in but twenty-three instances, and the most of these were of the false-membrane type. Mallory 1 has found in a series of 251 cases

The following report describes a rather infrequent cutaneous complication in a patient suffering from congenital syphilis. Cutaneous diphtheria is a rare but not entirely uncommon manifestation, and congenital syphilis is found only too frequently in every hospital and clinic, but their occurrence in the same patient is unusual. In a search of the literature I was unable to find the description of a similar case. It is known that both Spirochaeta pallida and the Klebs-Loffler bacillus have a special affinity for the nasal passages, and it is interesting to note what happens when these two destructive forces invade the same nose. REPORT OF CASE History.— In January 1933, a girl, aged 11 years, came to the York Hospital Dispensary with an obvious chief complaint. Her nose was swollen and reddened, and a marked, odoriferous, mucopurulent discharge was present. Surrounding the alae for about 1 inch (2.5 cm.) was a crusted