Page 55 - DIFDUF

677
zine, and low-dose prednisone. A chest
failing to improve with infliximab, mesala-
mg/kg prednisone and vedolizumab after
that time, she was being treated with 0.5
clavicle, with sternoclavicular joint pain. At
thematous nodule located on the proximal
IBD, presented with a firm, tender, ery-
A 24 year old woman with newly diagnosed
pATIEnT DESCRIpTIOn
characteristic of PG.
The duration spent on investigations is important and may
wall AA concomitantly with necrotic ulcers
unique combination of an extensive chest
a patient with IBD who presented with a
icking bacterial abscess [2]. We describe
collections of neutrophils, clinically mim-
condition characterized by deep sterile
aseptic abscess (AA) is an inflammatory
myelogenous leukemia) [1]. Similarly,
hematologic disease (i.e., acute and chronic
matory bowel disease (IBD), arthritis, and
systemic disease, most commonly inflam-
ent, coincident, or subsequent associated
50% of patients with PG have an anteced-
necrotic undermined border. More than
ents as a rapidly expanding ulcer with a
P neutrophilic dermatosis, which pres-
yoderma gangrenosum (PG) is a rare
gangrenosum (PG)
dermatosis, neutrophils, pyoderma
In our study, 52 patients (44.1%) underwent percutaneous
bowel disease (IBD), neutrophilic
aseptic abscess, inflammatory
KEY WORDS:
2
1
2,3,4
2
1
Original articles Original articles negative results. Am J Gastroenterol 2004; 99 (2): 249-54. FNA for mediastinal lymphadenopathy: an emphasis on clinical impact and false 2009; 20 (2): 81-6. and neck clinic: a clinically beneficial and cost-effective service. Cytopathology 2006; 34 (2): 130-4. superficial lymphadenopathy: a 5-year Brazilian experience. Diagn Cytopathol Surg Engl 2008; 90 (3): 221-5. lymph nodes of the neck, axilla and groin: rhyme, reas
#
nosis, including more instances of physical assault. The authors HOlOCAuST AnD HOARDIng pARADIgM Detection of Disseminated Aspergillosis on FDG PET/CT
highlighted an important association between hoarding and The scientific literature was searched using the terms Holocaust,
certain traumatic events prior to symptom onset [9]. hoarding, and Holocaust and hoarding, with a specific inter- in a Patient with Acute Lymphoblastic Leukemia
est in the number of publications, by year, from 1990 to 2018.
pTSD AMOng JEwISH HOlOCAuST SuRVIVORS The number of publications on hoarding increased in 2006 Nir Hod MD MHA , Reut Anconina MD , Daniel Levin MD , Ekaterina Tiktinsky MD , Dina Ezroh Kazap MD , Itai Levi MD ,
1
1
1
1
2
1
In the initial years following the end of World War II, Jewish and again in 2013 when hoarding was added as a standalone Maria Zektser MD , Vered Stavi MD , Gilbert Sebbag MD and Sophie Lantsberg MD 1
2
2
3
Holocaust survivors were not assessed or treated for PTSD for disorder rather than a subcomponent of other diagnoses, such
3
2
several reasons. First, these individuals experienced PTSD dur- as OCD [Figure 1]. Although PTSD and hoarding associations 1 Institute of Nuclear Medicine and Molecular Imaging and Departments of Hematology and Surgery Soroka University Medical Center and Faculty of Health Sciences,
ing a time in history when the disorder was not codified into are documented in published work [12], and PTSD has been Ben-Gurion University of the Negev, Beer Sheva, Israel
a distinct diagnosis with a treatment strategy. When present- investigated in Jewish Holocaust survivors, no publications
ing with symptoms, affected individuals did not get the proper were found linking hoarding and Jewish Holocaust survivors.
treatment [3,4]. Second, many survivors did not want to talk Because of the established correlations between PTSD and
about their experiences and the world did not want to listen – a hoarding, as well as PTSD and the Holocaust, we propose a uptake in activated granulocytes is based developed neutropenia and fever, which
phenomenon termed: a collusion of silence [4]. However, paradigm linking the Jewish Holocaust survivor population KEY WORDS: 18 F-fluorodeoxyglucose positron- on the fact that these cells use glucose as were not responsive to antibacterial ther-
research published in the 1970s [10] identified PTSD among with hoarding [Figure 2]. As this paradigm is highly plausible, emission tomography/computed an energy source after activation during the apy. A contrast-enhanced CT scan showed
Holocaust survivors, despite the fact that most had achieved it should be investigated. tomography ( 18 F-FDG PET/CT), metabolic burst. several nonspecific hypodense lesions
productive lives. disseminated aspergillosis, FDG PET/CT is becoming more relevant in the liver and spleen. The patient was
Furthermore, as Jewish Holocaust survivors age, their psy- hematological malignancy, for the diagnosis of several infectious and referred for FDG PET/CT to determine
chopathological symptoms exceed those of PTSD and some figure 2. Holocaust and hoarding paradigm immunosuppression, invasive inflammatory diseases as well as therapy more accurately the nature of the lesions
suggest that the latter diagnosis is insufficient to provide a basis Illustration of the novel paradigm linking Holocaust fungal infection (IFI) monitoring. Research results describe the and to identify any other lesions not
for treatment [4]. For years, these untreated individuals coped the Jewish Holocaust survivor population IMAJ 2018; 20: 717–719 usefulness of FDG PET/CT in the diagno- detected by CT.
with PTSD symptoms by engaging in occupational and family with hoarding, as proposed by the authors sis, management, and follow-up of patients FDG PET/CT images showed intensely
responsibilities. Most were disconnected from their families of PTSD for editorial see page 707 with sarcoidosis, spondylodiscitis, periph- increased FDG uptake in multiple lesions,
origin and developed strong social circles with other survivors eral bone osteomyelitis, fever of unknown including the liver and spleen but also
[3]. However, with aging, individuals retired from their profes- nvasive fungal infection (IFI) is an origin, and vasculitis [2]. However, for in renal, lung (not seen), and multifo-
sions, children became independent adults, and social circles Hoarding I uncommon but serious life-threatening fungal infections, hard evidence is lacking. cal intramuscular lesions [Figure 1]. It is
contracted as friends died [11]. As Holocaust survivors age, PTSD = post-traumatic stress disorder disease, which mostly affects immuno- Preliminary case reports note that FDG of interest that several hypermetabolic
largely untreated PTSD symptoms, which are unique, require suppressed patients. Recently, due to the PET/CT could be a useful tool. lesions were not demonstrated on the cor- 131118-COHANIM - 131118-COHANIM | 2 - B | 18-11-13 | 11:24:13 | SR:-- | Magenta
adjustments in diagnosis and treatment approach [11]. increase in the number of immunosup- We present a case of invasive aspergil- responding CT images of the study. Initial 131118-COHANIM - 131118-COHANIM | 2 - B | 18-11-13 | 11:24:13 | SR:-- | Yellow #131118-COHANIM - 131118-COHANIM | 2 - B | 18-11-13 | 11:24:13 | SR:-- | Black 131118-COHANIM - 131118-COHANIM | 2 - B | 18-11-13 | 11:24:13 | SR:-- | Cyan
COnCluSIOnS pressed patients, Aspergillus has become one losis in a young patient presenting with a percutaneous tissue and microbiological
HOARDIng AMOng JEwISH HOlOCAuST SuRVIVORS Holocaust survivors may present with unique PTSD and of the most common pathogens responsible hematological malignancy that developed investigations from the liver were not
We did not find any articles in the literature that directly hoarding symptoms owing to the horrors they endured. for fatal IFI [1]. Diagnosis of such infections disseminated multi-organ involvement, diagnostic and did not confirm infection
assessed PTSD among Jewish Holocaust survivors, although Unfortunately, man’s inhumanity to man will continue and may be difficult. However, early recognition including pulmonary, hepatosplenic, renal, or malignancy. Therefore, the patient was
hoarding and PTSD were found to be correlated [12]. However, future survivors of those atrocities will need caregivers who of disseminated aspergillosis may reduce and multiple intramuscular lesions, follow- referred for open liver biopsy guided by
emerging anecdotal reports and related literature suggest a con- fully understand their unique needs and treatments. morbidity and mortality caused by this ing chemotherapy. We pay special attention FDG PET/CT from the most prominent
nection in this population. Heritable possibility should be further examined for pathogen, which is more difficult to treat to the potential role of FDG PET/CT in the hypermetabolic lesions seen in the right
In a review of literature on hoarding in elderly populations, Holocaust survivors and their progeny to allow further under- than other fungi, such as Candida. diagnosis and therapy monitoring of IFI, hepatic lobe. Biopsy ruled out malignant
Roane and co-authors [13] concluded that hoarding onset standing of implications over the next generations 18 F-fluorodeoxyglucose positron-emis- which supports the results obtained in involvement, and microbiological investi-
begins around 40 years of age, increases in severity after middle sion tomography/computed tomography preliminary studies. gation was compatible with the diagnosis
age, and is correlated with social isolation, co-morbid anxiety, Acknowledgement ( 18 F-FDG PET/CT) is a well-known useful of invasive aspergillosis infection. The
and depression. Furthermore, Cath and colleagues [14] found The authors thank the Australasian Jewish Medical Federation and B’nai imaging technique, which is mostly used patient was treated with Amphotericin B
that hoarding prevalence and severity increases by 20% with B’rith Victoria, Melbourne, Australia, for financial support of the post- to detect neoplastic diseases. The technique pATIEnT DESCRIpTIOn antifungal therapy.
every 5 years of life. Hoarding incidence is estimated at 2–4% fellowship training (B. P-K). fuses metabolic imaging of FDG uptake A 46 year old man presented with pancyto- Despite antifungal therapy, the patient’s
of the general population, but as high as 6% in people over 55 Correspondence with excellent anatomical resolution of penia. A bone marrow biopsy was compat- clinical condition was not resolved and
years of age [15]. Dr. B. porat-Katz CT. FDG is a glucose analog combined ible with the diagnosis of B-cell acute lym- he underwent a series of follow-up FDG
Scientists have linked genetic heritability of PTSD [16] Faculty of Agriculture, Food and Environment, School of Nutritional with positron emitting radionuclide, phoblastic leukemia (B-ALL) with negative PET/CT scans that revealed persistence
and hoarding [17-19]. Similar to PTSD, hoarding may not be Sciences, the Hebrew University of Jerusalem, Rehovot 76100, Israel which merely detects glucose metabolism. Philadelphia chromosome; negative 12, 21 of the hepatosplenic fungal infection with
diagnosed for years (up to a decade) after onset of symptoms. fax: (972-8) 946-1888 It is able to concentrate not only in neo- translocation; and with some copies of the some of the lesions showing significantly
email: b7pk@walla.co.il
This complicates efforts to characterize and treat the problem. plastic diseases but also in cells involved AML-1 gene. higher FDG uptake compared with the
Furthermore, hoarding in the elderly is characterized as a form References in infection and inflammation, especially The patient started chemotherapy treat- baseline PET images. The anatomical size
of elder neglect or abuse and speaks to the severe impairment 1. Hoarding disorder. Anxiety and Depression Association of America, ADAA in neutrophils and macrophages, which ment according to the GMALL protocol. of many lesions did not show significant PERFECTOR
hoarding places on this vulnerable population [14]. online site. [Available at https://www.adaa.org]. [Accessed 13 June 2018]. are able to concentrate FDG. The high During his chemotherapy treatment, he change on the corresponding CT images.
672 717