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During a 2-week trip to El Salvador, the patient drank bottled water and stayed in clean habitation but was in a rural environment. In this article, we describe an uncommon case that demonstrates the possibility of misdiagnosis resulting in a delay in appropriate treatment. Patricia Chang,Tyson Meaux Current Fungal Infection Reports.
May 22, 2012By Saeed Ahmed, MBBS, Saira Rashid, MBBS, Daych Chongnarungsin, MD, Wisit Cheungpasitporn, MD, Edward Bischof, MD, and Michael Bauer, MD. A 71-year-old man was referred to the pulmonary clinic for evaluation of the sudden onset of exertional dyspnea. The patient was a healthy-appearing man in minimal distress on presentation to the pulmonary clinic. Hard X-rays can penetrate solid objects, and their largest use is to take images of the inside of objects in diagnostic radiography and crystallography. The roentgen (R) is an obsolete traditional unit of exposure, which represented the amount of radiation required to create one electrostatic unit of charge of each polarity in one cubic centimeter of dry air. The rad is the (obsolete) corresponding traditional unit, equal to 10 millijoules of energy deposited per kilogram. The sievert (Sv) is the SI unit of equivalent dose, which for X-rays is numerically equal to the gray (Gy). X-rays are generated by an X-ray tube, a vacuum tube that uses a high voltage to accelerate the electrons released by a hot cathode to a high velocity. In crystallography, a copper target is most common, with cobalt often being used when fluorescence from iron content in the sample might otherwise present a problem.
X-ray fluorescence: If the electron has enough energy it can knock an orbital electron out of the inner electron shell of a metal atom, and as a result electrons from higher energy levels then fill up the vacancy and X-ray photons are emitted. So the resulting output of a tube consists of a continuous bremsstrahlung spectrum falling off to zero at the tube voltage, plus several spikes at the characteristic lines. In medical diagnostic applications, the low energy (soft) X-rays are unwanted, since they are totally absorbed by the body, increasing the dose.
To generate an image of the cardiovascular system, including the arteries and veins (angiography) an initial image is taken of the anatomical region of interest.
A specialized source of X-rays which is becoming widely used in research is synchrotron radiation, which is generated by particle accelerators. The most commonly known methods are photographic plates, photographic film in cassettes, and rare earth screens. Before the advent of the digital computer and before invention of digital imaging, photographic plates were used to produce most radiographic images. Since photographic plates are sensitive to X-rays, they provide a means of recording the image, but they also required much X-ray exposure (to the patient), hence intensifying screens were devised.
Areas where the X-rays strike darken when developed, causing bones to appear lighter than the surrounding soft tissue. Contrast compounds containing barium or iodine, which are radiopaque, can be ingested in the gastrointestinal tract (barium) or injected in the artery or veins to highlight these vessels.
An increasingly common method is the use of photostimulated luminescence (PSL), pioneered by Fuji in the 1980s. The PSP plate can be reused, and existing X-ray equipment requires no modification to use them. For many applications, counters are not sealed but are constantly fed with purified gas, thus reducing problems of contamination or gas aging. Some materials such as sodium iodide (NaI) can "convert" an X-ray photon to a visible photon; an electronic detector can be built by adding a photomultiplier.
She was well until 9 days after she returned, when she experienced several symptoms—fever, malaise, a slight nonproductive cough, headache, and a stiff neck. The case also demonstrates the importance of being aware of CDC announcements and the information they provide. Outbreak of histoplasmosis among travelers returning from El Salvador—Pennsylvania and Virginia, 2008.
On account of its varied clinical presentation, and perhaps due to lack of anticipation and awareness, it has been rarely reported. He is a retired professional swimmer and used to swim 80 laps every day until the onset of breathlessness, which started 1 month ago after he had a flu-like illness. A physical examination revealed normal vital signs and no evidence of clubbing, lymphadenopathy, or enlarged tongue. This process produces an emission spectrum of X-ray frequencies, sometimes referred to as the spectral lines. The intensity of the X-rays increases linearly with decreasing frequency, from zero at the energy of the incident electrons, the voltage on the X-ray tube. A second image is then taken of the same region after iodinated contrast material has been injected into the blood vessels within this area. The contrast compounds have high atomic numbered elements in them that (like bone) essentially block the X-rays and hence the once hollow organ or vessel can be more readily seen. In modern hospitals a photostimulable phosphor plate (PSP plate) is used in place of the photographic plate.
Presentation The patient, a 67-year-old white woman, presented with the symptoms on December 24, 2008, several days after her trip. Spectrum of disease and relation to place of exposure among ill returned travelers [published correction appears in N Engl J Med. Our mission is to save precious time by offering the best and latest on rheumatology in an easy-to-read format, always hyperlinked for more in-depth reading later. What's inside? 1 of the heart dissection investigation ~ What is your prediction?Into the lab  for a heartClean up is important today and tomorrow.

The spectral lines generated depend on the target (anode) element used and thus are called characteristic lines. These two images are then digitally subtracted, leaving an image of only the iodinated contrast outlining the blood vessels. Photographic film largely replaced these plates, and it was used in X-ray laboratories to produce medical images. In the pursuit of a non-toxic contrast material, many types of high atomic number elements were evaluated. After the plate is X-rayed, excited electrons in the phosphor material remain "trapped" in "colour centres" in the crystal lattice until stimulated by a laser beam passed over the plate surface. Electrons accelerate toward the anode, in the process causing further ionization along their trajectory. She had a history of a positive antinuclear antibodies (ANA) test result, Raynaud phenomenon, and macular erythematous rash on her trunk and extremities. News summaries based on studies published in leading medical journals and specialty medical journals, conference coverage, case-based quizzes and more. Findings on the cardiovascular examination were unremarkable, with normal heart sounds without evidence of murmur, rubs, or gallops. The radiologist or surgeon then compares the image obtained to normal anatomical images to determine if there is any damage or blockage of the vessel.
In more recent years, computerized and digital radiography has been replacing photographic film in medical and dental applications, though film technology remains in widespread use in industrial radiography processes (e.g.
For example, the first time the forefathers used contrast it was chalk, and was used on a cadaver's vessels. This process, known as a Townsend avalanche, is detected as a sudden current, called a "count" or "event".
On the basis of chest x-ray results, the patient was hospitalized for pneumonia 4 days later. We also publish case studies and practice-related articles by rheumatologists and other specialists. The neurological examination, including cranial nerves and motor and sensory function, and the abdominal examination findings were also unremarkable. When the film is developed, the parts of the image corresponding to higher X-ray exposure are dark, leaving a white shadow of bones on the film. She was treated with levofloxacin intravenously, followed by azithromycin administered orally.
The lesions were of sudden onset and gradually progressive with an umbilication, ulceration and crusting [Figure 1]. Previously, on a visit to his cardiologist, he had undergone a nuclear stress test, the results of which were normal. Lung examination revealed dullness to percussion and decreased breath sounds at the right base posteriorly.The patient’s past medical history was significant for atrial fibrillation, for which he had undergone radiofrequency ablation 3 years ago, without any complications. Photographic plates are mostly things of history, and their replacement, the "intensifying screen", is also fading into history.
Because symptoms persisted throughout the antibiotic courses, the patient then was given a 10-day course of oral levofloxacin. In the postprocedure period, findings on chest radiographs were normal.As workup for his dyspnea, the patient underwent pulmonary function testing, which showed a restrictive type of lung disease.
The metal silver (formerly necessary to the radiographic & photographic industries) is a non-renewable resource. The patient then “felt well” until about 2 weeks later, when her right ankle became red, swollen, and tender.
A chest radiograph revealed an elevated right hemidiaphragm (Figure 1), which was confirmed by a CT scan (Figure 2). Thus it is beneficial that this is now being replaced by digital (DR) and computed (CR) technology.
She was treated with indomethacin, which she reported “helped a bit with the pain,” but it did not reduce the swelling. Where photographic films required wet processing facilities, these new technologies do not. There was no movement of the right hemidiaphragm observed during a sniff test, (Figure 3) which confirmed the diagnosis.(Click each image to enlarge)  Figure 1. Screening ELISA for Human Immunodeficiency virus (HIV) was reactive for HIV type 1 with subsequent western blot confirmation. Smears showed inflammatory cells comprising mainly of histiocytes containing numerous intracellular small, ovoid cysts surrounded by a clear space [Figure 3]a. He was offered MRI of the cervical spine to rule out cervical spondylosis, which he refused. She had mildly dry conjunctivae and a moist mouth, with no salivary or parotid gland enlargement. The organism showed an intense staining on Periodic-Acid Schiff method, and a diagnosis of cutaneous histoplasmosis was offered [Figure 3]b. He was referred to thoracic surgery for evaluation for surgical plication of the diaphragm. Her neck was supple, there was no lymph node enlargement, and her thyroid was not enlarged. Bone marrow aspiration was performed to exclude systemic involvement and it was unremarkable. By the time he presented for evaluation, however, the dyspnea had greatly improved and he was able to complete 40 laps during swimming sessions.
The diaphragm paralysis was ultimately believed to be related to a post-viral syndrome following the flu-like illness he had initially reported.DiscussionAlthough dyspnea is a common presenting complaint, the diaphragm is rarely the culprit for acute dyspnea.

A heart examination revealed a systolic ejection murmur that was maximal at the apex, with an occasionally heard midsystolic click consistent with mitral valve prolapse.
Phrenic nerve paralysis can present with chest wall pain, cough, and exertional dyspnea mimicking cardiac dyspnea,1 as in our patient. Examination of the extremities showed osteoarthritis changes, with no active synovitis in the hands; there was thenar atrophy consistent with carpal tunnel syndrome on the right. Findings on our patient’s follow-up chest radiograph after ablation had been normal, making this an unlikely cause of the phrenic nerve paralysis. The patient's right ankle was swollen and tender; there was erythema on the posterior aspect of her medial and lateral malleoli.
Differential diagnosis Our initial impression was that the differential diagnosis included an infectious disease that the patient acquired while in El Salvador, perhaps a granulomatous disease, such as tuberculosis, histoplasmosis, or coccidioidomycosis.1,2 The second diagnostic possibility was that the patient had an existing autoimmune disease that flared because of the stress of travel. Histoplasmosis by another strain, capsulatum var duboisii in Africa, shows a giant cell granuloma containing yeast cells of 10-15 microns in diameter. Bilateral diaphragm paralysis, on the other hand, is associated with substantial symptoms (eg, anxiety, insomnia, morning headache) and progressive ventilatory failure that requires noninvasive positive pressure ventilation.
The rash was somewhat suggestive of systemic lupus erythematosus, although it also was compatible with dermatomyositis; both diagnoses would be compatible with the patient's Raynaud phenomenon and photosensitivity. The third possibility was reactive arthritis or a spondyloarthropathy, although it would be difficult to attribute all of her findings to any one of these diseases.
In our case, we found aggregates of histiocytes containing intensely PAS positive smaller yeast forms in our cytological preparations, indicating an American and tropical form of the fungus. These patients do not require treatment unless symptoms persist or exercise limitation becomes significant. Fungal culture remains the gold standard diagnostic test for histoplasmosis, but may be negative in less severe cases. Diaphragm plication becomes an option at this point.4Phrenic nerve paralysis is a rare cause of exertional dyspnea that should be included in the differential diagnosis.
CT scans of her abdomen and chest were ordered (Figure 1), along with x-ray films of her right ankle and both hands. Cultures are positive in about 75% of the cases of progressive disseminated histoplasmosis and chronic pulmonary histoplasmosis.
Fluoroscopy is considered the most reliable way to document diaphragmatic paralysis, and the sniff test is necessary to confirm that the abnormal hemidiaphragm excursion is due to paralysis rather than unilateral weakness.References1. An endobronchial ultrasound-guided fine-needle aspiration biopsy of the paratracheal and hilar lymph nodes was performed with a cytopathologist on site (Figure 2). Histoplasma Ab Screen-Mayo and Histoplasma Immunodiffusion-Mayo laboratory tests were requested (see Table). Additional information was provided by the CDC in the Morbidity and Mortality Weekly Report.3 A fungal disease caused by Histoplasma capsulatum, histoplasmosis may be acquired from soil contaminated with bird or bat droppings.
The disease occurs worldwide and is one of the most common pulmonary and systemic mycoses in the United States. Nanda and co-workers reported a case of primary cutaneous histoplasmosis in an immunocompetent patient from a non-endemic area diagnosed by the skin biopsy.
However, histoplasmosis is rare among international travelers returning from areas in which it is endemic. Our patient also had only cutaneous manifestations of the disease without any systemic involvement. Electrophysiological evaluation of phrenic nerve injury during cardiac surgery—a prospective, controlled, clinical study.
In February and March 2008, the Pennsylvania and Virginia departments of health investigated a cluster of respiratory illnesses among 3 mission groups that had traveled to El Salvador separately to renovate a church. Of 33 travelers in the 3 groups for whom information was available, 20 (61%) met the case definition for histoplasmosis. One of the patients had cutaneous histoplasmosis, and another case presented with painful ulcers over the tongue. The findings emphasize the need for travelers and persons who are involved in construction activities to use personal protective equipment and decrease dust generation when working in areas in which histoplasmosis is endemic.
Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. Clinicians should consider histoplasmosis as a possible cause of acute respiratory or influenza-like illness in travelers returning from such areas. Cutaneous lesions occur in only 6% patients with disseminated histoplasmosis, but may rarely be the presenting sign. It is especially important to consider histoplasmosis in patients with HIV infection, those with solid organ transplants, and those who are receiving tumor necrosis factor ?–blocking therapy (adalimumab, infliximab, etanercept). In addition, there may be a number of non-specific cutaneous manifestations associated with histoplasmosis including erythema nodosum and erythema multiforme. Although this patient presented with somewhat typical hilar adenopathy, pulmonary infiltrates, arthritis, and constitutional symptoms, the clinical manifestations of histoplasmosis are protean. They include a whole range of dermatological findings (eg, erythema nodosum, papules, plaques, ulcers, and pustules), GI findings (eg, bleeding from ulcerative lesions or masses), adrenal insufficiency similar to other granulomatous diseases (eg, tuberculosis), and pleomorphic CNS diseases (eg, meningitis, focal granulomatous disease, or encephalitis). In our opinion, cytology is the office procedure of choice in arriving at a specific diagnosis in most of the cases, which may allow for the rapid institution of life saving therapy. That was thought to be the result of reactive arthritis; the patient responded to sulfasalazine and achieved a full recovery.

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  1. zeri

    Some salt in the crust but intensity.


  2. LoVeS_THE_LiFe

    (Equivalent to strawberries), soybeans, and some.