A 56-year-old woman began to have pain and redness of the left leg the day after a six-hour car ride. Two days later she was found to have erythema and tenderness on the medial aspect of the left knee and moderate pitting edema of the left ankle. The remainder of the examination was unremarkable. She had no history of deep venous thrombosis.
Both her parents, however, had a history of deep venous thrombosis. Despite treatment with warm compresses, aspirin, and elevation of the leg, the pain and erythema increased. A palpable, ropelike cord was present from the left medial malleolus to the groin. Duplex Doppler ultrasonography revealed thrombosis of the greater saphenous vein, with no extension into the deep venous system. Despite anticoagulation with heparin, a vague, substernal chest pain developed that was unrelieved by nitroglycerin.
Cardiac enzymes, electrocardiographic findings, and arterial blood gas levels remained normal. The results of ventilation–perfusion scanning were indeterminate for pulmonary embolism, and a pulmonary arteriogram was negative. Repeated duplex Doppler ultrasonography 5, 10, and 25 days after presentation showed no extension of the thrombus into the deep venous system. Studies revealed that the patient had lupus anticoagulant, and a diagnosis of primary antiphospholipid-antibody syndrome was made. Other studies for thrombophilic tendencies, including tests for factor V Leiden and protein C and S deficiencies, were negative.
Two weeks after the initiation of treatment with warfarin, the international normalized ratio was 3.4 and the patient's symptoms had resolved. Follow-up at three months showed no recurrence.
Michael A. Lucia, M.D.
University of Nevada School of
Medicine, Reno, NV 89520-0111
E. Wesley Ely, M.D., M.P.H.
Vanderbilt University Medical Center, Nashville, TN 37232-8300
Source: nejm.org *The current state of Tuberculosis infections:*
1. In 2013, nearly nine million people contracted TB around the world
2. In 2013 around 1.5 million TB-related deaths occurred worldwide
3. TB is the leading killer of HIV-infected people. In South Africa, 73% of TB patients are HIV positive
4. In South Africa alone, there was an estimated 500 000 cases of active TB in 2011, the highest stats after India and China
5. TB is the leading cause of death in SA (40 000 - 60 000 deaths a year)), a figure which is slowly decreasing as several interventions are being put in place to tackle the disease.
6. There are two types of TB – latent and active. People with latent TB are not contagious and often show none of the symptoms associated with TB, whereas people with active TB are contagious and may have many of the TB symptoms
7. Across the world 1 in 3 people is infected with latent TB. In South Africa 80% of the population is infected with latent TB and the majority of these people are in the age group 30-39 years old living in townships and informal settlements.
8. 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in the world in 2013. In 2012, South Africa reported 14,161 laboratory-confirmed cumulative cases of MDR-TB and 701 laboratory-confirmed cumulative cases of extensively drug-resistant TB (XDR-TB) cases.
9. For the past six years, an estimated three million people are missed every year by the health systems in their country
10. People ill with TB can infect up to 10-15 other people through close contact over the course of a year.
11. The estimated number of people falling ill with TB each year is declining, although very slowly, which means that the world is on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015.
12. The global TB death rate dropped 45% between 1990 and 2013.
13. An estimated 37 million lives were saved through TB diagnosis and treatment between 2000 and 2013.
14. South Africa is one of the three countries (together with India and Ukraine) with the largest increases in multidrug-resistant (MDR-TB) between 2011 and 2012
15. People infected with TB bacteria have a lifetime risk of falling ill with TB of 10%. Psoriasis is a common condition where the skin gets red and scaly; psoriasis can cause itching, discomfort, and sometimes pain.
Psoriasis affects 2% to 4% of the world’s population. While it can begin at any age, psoriasis has 2 peaks of onset, the first at age 20 to 30 years and the second at age 50 to 60 years. It affects men and women equally but is more common in non-Hispanic whites. Some patients are more prone to developing psoriasis, especially if there is a family member with psoriasis. External factors such as infection, smoking, and certain medications can make psoriasis worse in some patients.
Psoriasis is associated with a number of medical conditions. One-third of patients with psoriasis develop psoriatic arthritis, a progressive joint disease that can limit movement if untreated. Patients with severe psoriasis are also at higher risk than the general population for high blood pressure, diabetes, heart attacks, strokes, obesity, and depression.