the doctor is in ... feb 08

(I am back from a well-deserved doctor’s respite at … well, nowhere. Just been busy with my day job. We have a new case – Red and Swollen Eye in a 61-Year-Old Man. Not sure what to make of it. Let’s start with the pic.)


(Oh, my! Somebody done poked that dude in the eye with a stick or something! Must’ve hurt. What’dya think it could be? Something about this guy looks dirty to me. Let’s get some data …)

BACKGROUND
A 61-year-old man presents to the emergency department (ED) with a 5-day history of pain with associated redness and swelling in his right eye. (“Five days,” you say. Uhunh … scribble scribble … ok.)

The patient had been diagnosed with herpes zoster (is that like Herpes Complex Z? Z?!? Z is like towards the end of the alphabet. That can’t be good) a few days before this presentation; he was discharged to home with a prescription for acyclovir and hydrocodone. (AAH—AAK—PSYCH—AAHPSYCH—LOVER. Acyclovir … got it here somewhere. OK, “first-time or repeat outbreaks of genital herpes.” This boy got sexed in his eyeball. That’s disgusting.)

Since he started taking acyclovir, the pain and swelling in his eye has increased. (Good. Done go have sex involving your eyeball it oughta hurt. At least now we know it weren’t no stick that got stuck there. Damn boy, whatchu thinking? You on the other side of some sleazebag glory hole?) He also reports binocular diplopia and decreased visual acuity. (BI-nocular? He got one eye shut from a getting a dick jammed in it. The only “bi” thing around here is his sexual orientation.)

On the day of presentation, he is nauseous and vomiting (yeah, after you woke up, saw the glory hole, the line of satisfied customers … I am quite sure you were puking), and he cannot open the affected eye (stick, stick, stick, poke, poke, poke. Of course he can’t open it! Hell, he probably passed out from getting clubbed by somebody’s ankle spanker), which demonstrates ptosis (p-p-pu-TOE-s-s-s-sis) of the upper eyelid, generalized proptosis, and mild periorbital erythema with associated edema.

The right pupil is 8 mm in diameter and nonreactive to direct and indirect light. (Still trying to get the license plate off that man club that hit him.) Intraocular pressure in both eyes is normal at 12 mm Hg.

What is the diagnosis? (He got a little excited about his first gay experience, went to a bar, and became a bit too intrigued about what was on the other side of those holes in the wall. Poor guy. Still puking his guts out. He got love clubbed …)

DIAGNOSIS: (See above.) Cerebro-rhino-orbital phycomycosis (CROP)/mucormycosis. (Yeah, the only “crop” he saw was the riding kind when he had the bit in mouth up on stage. Poor dude – the first time can be so humiliating.)

(Alright, alright, we’ll let the fake docs have their say … fine. Be that way. I know how it is with people like you. You know, just a side note – I kinda HAVE to leave this other stuff in. You should see my page rankings for just god-awful diseases. I do have some fraction of a conscious, somewhere, I am sure I do. Well, maybe not, but I read a lot and I know what one looks like. So read on – just remember – they are WRONG. The guy just had a very rough first outing at the club. That’s all.) CROP is an aggressive, invasive infection that is caused by broad, nonseptate fungi with irregularly shaped hyphae from the class Phycomycetes. The genera that typically cause infection are Rhizopus, Rhizomucor, Absidia, and Basidiobolus. The spores of these fungi are ubiquitous and gain entrance to the human body through the mouth and the nose. Individuals who are immunocompetent will phagocytize these spores; therefore, they do not develop the disease.

Infection is most common in immunosuppressed persons, specifically in patients with poorly controlled diabetes mellitus (often in the setting of metabolic acidosis), and in patients receiving the iron-chelating drug deferoxamine. Unlike immunocompetent individuals, whose bodies phagocytize the spores, immunocompromised patients have massive spore proliferation. Mucormycosis is described almost exclusively in patients with compromised immune systems or metabolic abnormalities. The spores attach to the nasal or oral mucosa, where massive germination and hyphae formation occur, allowing the fungus to directly invade the blood vessels. Areas of ischemic infarction and necrosis are seen in the infected tissue. The fungi invade the blood vessel lumina and cause thrombosis through inflammatory occlusion. Infection usually begins in the nasal cavity and the maxillary sinuses, followed by direct invasion of contiguous structures, such as the palate, the orbits, the ethmoid sinuses, and the brain. Orbital involvement occurs when the ethmoid sinuses are affected. Intracranial spread can occur through the ophthalmic artery, superior fissure, or cribriform plate.

Rhinocerebral infections are usually fulminant and have high morbidity and mortality rates, despite improved diagnostic and therapeutic interventions. Mortality rates of 30-70% are quoted in the literature, with higher mortality rates seen in older series. The mortality rate in diabetic patients appears to be lower than it is in nondiabetic patients and in patients with intracerebral involvement. Death may occur within 2 weeks if CROP is left untreated or is unsuccessfully treated. Additionally, until the 1950s, this disease was almost always fatal. Even with recovery, permanent residual effects, such as blindness and cranial nerve defects, occur in up to 70% of cases.

The clinical manifestations of CROP may include orbital and facial pain, fever, periorbital and orbital cellulitis, proptosis, purulent nasal discharge, and mucosal necrosis that appears as black eschars in the nasopharynx, the oropharynx, and the tissues surrounding the orbits and sinuses. These clinical features are not universally seen; therefore, a high index of suspicion is required. Ocular involvement leads to afferent papillary defects and loss of visual acuity. Progressive extension of necrosis into the brain can lead to cavernous sinus thrombosis and abscess formation. The patient may demonstrate an altered mental status, convulsions, aphasia, or hemiplegia.

Patients with diabetic ketoacidosis are most often affected, but opportunistic infections may also develop in association with renal deferoxamine therapy (eg, in patients with chronic renal disease) or with immunosuppression (particularly in patients with neutropenia or those receiving high-dose corticosteroid therapy).

The diagnostic study of choice is computed tomography (CT) scanning of the orbits and sinuses. In affected patients, CT scans demonstrate soft-tissue swelling, sinus mucosal thickening, and bone erosion. Intracranial and cavernous sinus involvement may also be present. Magnetic resonance imaging (MRI), if available, can show extension of the infection into the surrounding blood vessels, orbital fat, and intracranial areas. Urgent biopsy is usually indicated. Necrotic and edematous tissue with neutrophilic infiltrate is frequently seen with fungal elements (which are broad, nonseptate hyphae with branching at 90°).

The cornerstone of medical treatment for CROP is the administration of systemic amphotericin B at the highest patient-tolerable dose. Local packing of the involved mucosal membranes with an amphotericin B solution is effective for minimizing local disfigurement. When on the medication, the patient should be assessed for nephrotoxicity, as well as other systemic symptoms of toxicity, including fever, nausea and vomiting, phlebitis, anemia, and electrolyte abnormalities. Liposomal amphotericin B may be more efficacious; it is less toxic, thus allowing higher doses of the medication to be given. Additionally, local irrigation and packing of the areas to aid delivery of amphotericin to necrotic and poorly perfused tissues is recommended, because poor vascular supply may prevent systemic therapy from reaching the fungus and because local irrigation of infected tissue has been reported to be an important adjunct to treatment that may even help prevent disfiguring surgery. Treatment of the underlying disease (eg, hypoxia, acidosis, hyperglycemia, electrolyte abnormalities) and discontinuation of any immunosuppressants are also important. The physician should evaluate any steroid medication, antimetabolites, or immunosuppressants that the patient is taking, and such agents should be discontinued if appropriate. It is encouraged that the advice of an infectious disease specialist be obtained.

Aggressive, emergency surgical debridement of all necrotic tissue is necessary; sometimes, multiple procedures are needed to clear all necrotic tissue. The vaso-occlusive effect of mucormycosis leads to infrequent bleeding of the involved tissue; therefore, debridement of affected tissue until normal, well-perfused, bleeding tissue is encountered is ideal. Intraorbital irrigation of amphotericin B may be considered as an adjunct treatment. Surgery may often be disfiguring. Orbital exenteration, as well as removal of the sinuses, may be necessary. Some authors have suggested hyperbaric oxygen as an adjunctive treatment. Reconstructive surgery after complete resolution of infection should be considered.

Indeed, a multidisciplinary approach is best for the treatment of this condition. An ophthalmologist is required to evaluate for ophthalmoplegia and optic neuropathy. An oculoplastic surgeon can provide an orbital evaluation, as well as perform debridement and reconstruction. An otolaryngologist is required for biopsy or debridement of the nasal and sinus cavities. An infectious disease specialist can provide guidance for appropriate medical treatment with antifungal agents. Internal medicine specialists and endocrinologists are useful for the medical management of underlying systemic etiologies. Neurosurgery may be necessary if intracranial involvement is present. Finally, a pharmacotherapy specialist can assist with dosing of amphotericin B.

The complications of CROP include intracranial invasion, cavernous sinus thrombosis, blindness, occlusion of the central retinal artery, and airway obstruction caused by infections of the head and neck (with spread to the carotid sheath or the mediastinum through the fascial planes). The prognosis of CROP is guarded, with reported mortality rates of 30-70% (as stated earlier).

In this patient, treatment with amphotericin B was promptly initiated. CT scans of the orbits and sinuses demonstrated an air-fluid level in the right maxillary sinus, mucosal thickening of the right anterior ethmoid sinus, and preseptal cellulitis. An MRI of the head showed enhancement of the intraconal fat and rectus muscles of the right eye. The patient received emergency sinus debridement, and a biopsy was performed. Pathology demonstrated fungal angiitis and orbital inflammation that was consistent with mucormycosis. The patient underwent 3 additional operations, including exenteration of the right eye, and received hyperbaric oxygen treatments. After hospitalization for 3 weeks, he was discharged to home in good condition.

peeing on the trailer skirting is normal, ain't it?

I always watch for suggestions of links when people die. The inventor of Gatorade died from liver failure. Don’t know if it means anything. I only play a doctor on the internet. But I will make an entry in my Book of the Dead for future reference. I have noted a strong correlation between Rap singers and gun shot wounds. As a result, I make a habit out of humming the tunes and dancing only with the lights out and shades drawn. Seems safer to me that way. Gun shot wounds are not like in the old movies where the guy falls slowly backward and gasps a few final words. They hurt. A lot.

I found my new favorite site on the internet. I was surfing for internet radio stations. Found all sorts of listings. Got frustrated pretty quickly because they all make money through advertising of one form or another. Then I found Pandora Radio. An incredibly well-designed and well-run site. It claims to have taken the genome approach to music. You select an artist and create a radio station around that type of music. Each song that comes up, you put your cursor over the image and give it a thumbs up or down. The station is refined according to your choices. You can create a lot of different stations. The only limit I have run into has been the amount of songs you can skip within one hour – seems to be about 5, then it tells you that their licensing agreements only allow so many skips per hour (but doesn’t give you the number). There is no advertising, no feed issues – amazing site. I have two stations – one built around Frank Black, the other B.B. King. My daughter has about 15, but she’s a rock star and is allowed.

I rarely watch movies. Way to ADHD-Hyperactive for that. Funny, I can sit for hours and watch sports or work on my computer, but even a 30-minute sitcom drives me to pacing. I think it has to do with being able to fully engage. If I cannot, I am psychological toast. My body begins to thump inside. If I ignore it, it feeds back into my thought processes and I have to change locales. Physical movement helps a lot, even just standing. However, when I did watch movies, I enjoyed tracking data on Box Office Mojo. Lots and lots of detail. Sometimes you will get a screen that tells you that you have to register – just hit “back” on your browser and make your selection again. It will bypass the registration screen.

Daytime is 30s and 40s, nighttime 20s and 30s. Winter temperatures have arrived. I am drinking coffee in the afternoon and tea at night. My sweater is on most of the time.

I told this mutt to pee on the rug, but it won’t. Sure, it’ll die, but it won’t pee. Not very realistic in that way. Oh well.

Do you live in the Philadelphia area and suffer from heavy, long-lasting, or frequent menstrual cycles that seriously impact your regular lifestyle? If so, this guy named Larry wants to talk to you. I think he has some experimental drugs with your name on them.

Learn something new every day. I thought a “nocturia” study in Lancaster, PA, would be related to Amish cows keeping you up at night. Guess not. I will say this, however, the description is written very poorly.

I remember years ago my boss reviewed a memorandum of mine and said to me, “you say ‘stocks’ up here and ‘certificates’ down there. Those two different things?” Uh, no. “Then why do you use two different names?” It was a great lesson in consistency. Jonathan Wolter, Failure Analysis. Best boss I ever had.

Want to know what “nocturia” is? Choose from the following: 1. Wake up more than twice a night to use the bathroom; 2. Wake up with an urge to go to the toilet during the night; or 3. Waking too often with an urge to pass urine at night.

Using the bathroom more than twice could be from Explosive Bowel Syndrome, wherein the patient presents micro-blasts into the porcelain god on a frequent basis. No bladder involvement. Having an urge to go to the toilet could be a fetish the specifics of which I am uncomfortable describing, or could be a problem masturbator. Having an urge to pass urine is an old drinking game. Someone would pee in a cup, and the cup got passed until the music stopped, then, well, you complete the sentence. More often than not, however, the last one to hold the cup still tried to pass, and (laughing) the n-n-ext guy (oh, god, such fun times!) would t-t-try to refuse it, and (snort!) the cup w-w-would (Stop IT! You're KILLING me!!) tip and piss would fly all over the place and (oh, boy! Such great times those were!) ... of course, with all the drinking going on, there would be sometimes be 3 or 4 cups in circulation! OK, enough. Fifth grade was so much fun - ah, the good old days! God bless Artie's dad for being such a drunk that we could plow through his keg on tap and he would just buy a new one! Alright, back on track ... defining "nocturia." Let’s not forget that where I come from, if you had to pee during the night, you could bet the dog did, too – so we all went outside and pissed on the trailer skirting (women included). No bathroom involved.

How about this: “Nocturia is a condition wherein the patient has an urge to urinate frequently during nighttime hours, where such urges cause the patient to actually leave the bed more than once each night to urinate.” I mean, you clowns are doctors with grant money, right? And you wonder why us internet docs have no respect for you anal-obsessed “real” docs. Man. Get an editor.

How do you approach a website that lists an item as, ”U.S. G.I. Innertube FUN, FUN, FUN !!!”. The site has an incredible array of stuff, and I have been to their location. Good stock, good prices. But, “FUN, FUN, FUN”? The superlatives may be more apt when describing a Finnish Gas Mask (“Yaw, I smell dat, too”), an M-856 Projectile (“INCOMING!!”), a Dutch Military Geiger Counter (“Read the meter, Private, what’s it say?” “It says, ‘We’re fucked,’ Sir”), or even a Dummy Pineapple Grenade (“Pull the ring and threaten gramma! Loads of fun at every party!!”), but an innertube? Naw.

All done.

greed can form loving relationships

There’s something about good ole fashioned greed that brings a smile to my lips, a sparkle to my eye, and that warm hug inside.

Our story begins in the hometown of ALF, that loveable alienable life force from 20 years ago (that’s 8 to 16 lifetimes in sitcom years depending on the week night upon which the show airs), nestled above Los Angeles and along the sea, Oxnard, California.

In this sleepy salt-laden town operates Haas Automation and, operating no more (albeit I get ahead of myself), its owner, 54-year old Gene Haas.

Haas Automotive is a half-billion dollar operation and employs about 1,000 people, as the “nation's largest computerized machine tool maker.”

How much profit can $500 million generate every year? Well, Gene-boy, or as his cellie may soon be calling him, My Wife, is also the owner of a NASCAR team, fielding a car in each of the Nextel and Busch series, operating as “Haas CNC Racing.” So apparently enough to play in an expensive sport. Is that enough for Genette to be happy?

Alas, no.

“Let’s squeeze another $20 million out of this puppy. Ideas?” And so began a course of events that resulted in several indictments, including the king of all horrors to defense counsel: an unindicted co-conspirator (read, rat).

Here’s a great quote: “The owner of Supermill Inc., a nonexistent Nevada company that allegedly issued fake bills to Haas Automation.” Let’s parse that: Owner of a nonexistent company. He owns something that does not exist. Did they really write that? It’s in the linked article above. I own a unicorn – did I ever tell you that? I own this really super-cool plane-car-boat-barberchair-bar-be-que thingey. Takes you anywhere, gives you a shave and a haircut, and feeds you the best grilled tuna. I didn’t get the optional geisha-girl attachment.

The “nonexistent company” issues “fake bills.” No shit. It doesn’t exist – do you expect it to issue real bills?

Where was I? Oh yeah, so this nonexistent company has a name, Supermill (my unicorn’s name is Fred). Seems the non-entity issued non-real invoices for non-real expenses. (I am sensing a pattern here, although clustering can also be attributed to random chance) There was a total $20 million in fake invoices. All the invoices were issued to Hass Automation, who promptly paid them with non-real money but took very real tax deductions. Ut oh! Add a rat to the recipe and you are, well, fucked. And so will be Genette soon enough. Repeatedly, all the while yelling, “Yes, I’m your bitch! Yes, I’m your bitch!”

Initially, Mrs. Gene pled not guilty (everyone does – you can’t plead otherwise at an arraignment. They have separate proceedings for guilty pleas.), and pointed the finger at his financial guy, claiming with all the gusto of a wronged-man, that the “tax issues ‘revolve around’ the company's former financial officer, John Phillips.”

“Revolve around”? What the hell is that? A denial? No. My shower water “revolves around” the drain. My tires “revolve around” the axel. Ms. Gene’s life is about to “revolve around” the shithole. Here’s a denial: “That cocksucker Phillips did all of this. I knew nothing. I sure hope he doesn’t make bail and is found guilty, then does a long, long time in prison. Cuz if I get my hands around his neck, he’ll be begging for prison time. That miserable, lying prick. I never liked him. FUCK HIM AND EVERYONE THAT LOOKS, SMELLS, OR TALKS LIKE HIM! I HOPE THEY ALL GET BUTTHOLE CANCER” A denial?

Alas, no.

As June 2006 left with its indictments (and rat) a dusty trail in the horizon, now arrives November 2007. Has Miss Genette established her innocence in the face of these vicious allegations by an overzealous prosecutor and that cocksucker Phillips?

Alas, no.

“LOS ANGELES -- A NASCAR team owner was sentenced Monday to two years in federal prison after he pleaded guilty to defrauding the government of more than $34 million in taxes.

“Gene Haas … was ordered to begin serving his term on Jan. 14, the U.S. Attorney's office said.
…

“As part of his plea agreement, Haas paid a $5 million fine, plus more than $70 million in back taxes and interests.”

Poor baby?

Alas, no.

good eats

I was ten years old when this commercial came out. I thought at the time, and still do now, that it was a catchy tune.



I was contemplating a certain class (perhaps the wrong word) of recipes with my twin. We concluded that “Sciurus carolinensis on Toast Points with a White Sauce” would be such a recipe. Let me try to make up the recipe.

2 Sciurus carolinensis (aka Eastern Grey Squirrel), dead, skinned, and deboned
8 slices Wonderbread
1 cup Mayonnaise
4 ounces recent vintage fortified wine

Cook the deboned squirrel in a cast iron pan with a bit of lard, turning frequently until it begins to look stringy. Remove the meat and place on a newspaper to degrease.

Toast the wonderbread to a light brown, and cut the toasted bread diagonally twice, forming four triangles from each piece.

With a coffee spoon, mix the wine into the mayonnaise to thin it out.

Pull apart the squirrel meat with your fingers, and cut the stringy strips into lengths not exceeding 2 inches.

Arrange three toast points on a plate, place enough meat on them for about half a sandwich, and drip some of the white sauce to cover.

Salt and pepper to taste.

Serves 2 to 8 depending upon girth (of eater, not eatee).

Next week: Perogie Pudding with a Faux Brandy Flambé.

My little girl’s all grown up. I helped empty the clothes dryer, and found a small key. I said, “hey, I thought you outgrew having a diary with a keylock on it.” She said, “yeah, I did, daddy, that key is for a pair of handcuffs.” Oh.