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Background: A reliable and accurate estimation of liver size by physical examination is an important aspect of the clinical assessment of a patient. The scratch test uses auscultation to detect the lower liver edge by using the difference in sound transmission through the abdominal cavity over solid and hollow organs. The test is thought to be particularly useful if the abdomen is tense, distended, obese, or very tender. Although the sign is often taught to medical students and residents, the value of the technique for detecting the liver edge has become controversial. Methods: The study was performed in two parts. In the first part, 18 patients undergoing upper abdominal ultrasound as outpatients were randomly selected and the scratch test was performed by two raters independently, followed by ultrasound (USG) as the reference standard. In the second part of the study, the two raters independently performed the scratch test on separate randomly selected patients (15 patients by rater 1, and 16 patients by rater 2), followed by USG. Results: Agreement between raters on the scratch test was very high, with an intra-class correlation coefficient of 0.97. The agreement between the raters and the USG was 0.37 using Spearman's rho. A Bland -Altman plot indicated that, on average, raters underestimated the distance from the right costal margin to the liver edge by only about 2.4 centimeters compared to USG. This translates into 37% and 54% of raters' estimates falling within 2 and 3 cm of USG estimates. Each unit increase in BMI increased the discrepancy between raters and USG by 0.26 cm (p = 0.012). Conclusion: The scratch test has very high reproducibility and overall agreement between the scratch test and USG was moderate, with a spearman's rho of 0.37. The accuracy may potentially be improved by using the point of initial sound transmission rather than the point of maximal transmission. We conclude that the scratch test deserves further investigation. [ABSTRACT FROM AUTHOR]

Background: A reliable and accurate estimation of liver size by physical examination is an important aspect of the clinical assessment of a patient. The scratch test uses auscultation to detect the lower liver edge by using the difference in sound transmission through the abdominal cavity over solid and hollow organs. The test is thought to be particularly useful if the abdomen is tense, distended, obese, or very tender. Although the sign is often taught to medical students and residents, the value of the technique for detecting the liver edge has become controversial.Methods: The study was performed in two parts. In the first part, 18 patients undergoing upper abdominal ultrasound as outpatients were randomly selected and the scratch test was performed by two raters independently, followed by ultrasound (USG) as the reference standard. In the second part of the study, the two raters independently performed the scratch test on separate randomly selected patients (15 patients by rater 1, and 16 patients by rater 2), followed by USG.Results: Agreement between raters on the scratch test was very high, with an intra-class correlation coefficient of 0.97. The agreement between the raters and the USG was 0.37 using Spearman's rho. A Bland -Altman plot indicated that, on average, raters underestimated the distance from the right costal margin to the liver edge by only about 2.4 centimeters compared to USG. This translates into 37% and 54% of raters' estimates falling within 2 and 3 cm of USG estimates. Each unit increase in BMI increased the discrepancy between raters and USG by 0.26 cm (p = 0.012).Conclusion: The scratch test has very high reproducibility and overall agreement between the scratch test and USG was moderate, with a spearman's rho of 0.37. The accuracy may potentially be improved by using the point of initial sound transmission rather than the point of maximal transmission. We conclude that the scratch test deserves further investigation. [ABSTRACT FROM AUTHOR]

Background Renal transplant recipients are at high risk of developing multiple infections, often concomitantly because of their immunocompromised status. Post renal transplant infections are often elusive and require extensive evaluation for proper diagnosis and treatment. A high index of suspicion is required and an attempt should be made to confirm the microbiological diagnosis from each site involved to rule out multiple infections. Case presentation We report a 50-year-old female, a renal allograft recipient who presented with left hemiplegia, esophageal ulcers and fever 3 months after her transplant. Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions and the whole blood quantitative CMV polymerase chain reaction (PCR) was positive. Neuroimaging showed a brain abscess, stereotactic biopsy from which revealed Scedosporium apiospermum on fungal culture. Her tacrolimus and mycophenolate were stopped and she was managed with intravenous ganciclovir and voriconazole. With these measures, she showed marked improvement in her general and neurological condition. Two months later, she developed recurrence of fever with dry cough. Radiological investigation revealed a cavitating lung lesion, a needle aspiration from which demonstrated acid-fast bacilli. She was started on antituberculous treatment. With these measures, she recovered completely and maintained good graft function despite being on only prednisolone 10 mg once a day. Conclusion Although CMV disease is not uncommon in the first three months post transplant, Scedosporium is a rare cause of brain abscess. On the other hand, tuberculosis is common in transplant recipients, especially in developing countries, like India. However, this is the first case report of occurrence of these three infections in the same patient, demonstrating the importance of a good microbiological work-up from each site involved in immunosuppressed subjects. [ABSTRACT FROM AUTHOR]

Background: Renal transplant recipients are at high risk of developing multiple infections, often concomitantly because of their immunocompromised status. Post renal transplant infections are often elusive and require extensive evaluation for proper diagnosis and treatment. A high index of suspicion is required and an attempt should be made to confirm the microbiological diagnosis from each site involved to rule out multiple infections.Case Presentation: We report a 50-year-old female, a renal allograft recipient who presented with left hemiplegia, esophageal ulcers and fever 3 months after her transplant. Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions and the whole blood quantitative CMV polymerase chain reaction (PCR) was positive. Neuroimaging showed a brain abscess, stereotactic biopsy from which revealed Scedosporium apiospermum on fungal culture. Her tacrolimus and mycophenolate were stopped and she was managed with intravenous ganciclovir and voriconazole. With these measures, she showed marked improvement in her general and neurological condition. Two months later, she developed recurrence of fever with dry cough. Radiological investigation revealed a cavitating lung lesion, a needle aspiration from which demonstrated acid-fast bacilli. She was started on antituberculous treatment. With these measures, she recovered completely and maintained good graft function despite being on only prednisolone 10 mg once a day.Conclusion: Although CMV disease is not uncommon in the first three months post transplant, Scedosporium is a rare cause of brain abscess. On the other hand, tuberculosis is common in transplant recipients, especially in developing countries, like India. However, this is the first case report of occurrence of these three infections in the same patient, demonstrating the importance of a good microbiological work-up from each site involved in immunosuppressed subjects. [ABSTRACT FROM AUTHOR]