Pulmonary embolism diagnosed on computed tomography contrast angiography despite negative venous Doppler ultrasound after spinal surgery
STUDY DESIGN/METHODS:The focus of this study was on the frequency of negative initial/subsequent ultrasound (US) of the lower extremities but positive spinal computed tomography contrast angiography (CTA) diagnostic of pulmonary embolism (PE) among 75 patients undergoing cervical laminectomy/fusion and 165 patients having lumbar laminectomy/noninstrumented fusion. OBJECTIVE:To determine the percentage/incidence of patients undergoing spinal surgery with negative US but with positive CTA. SUMMARY OF BACKGROUND DATA/BACKGROUND:The frequency of patients with negative US but with positive CTA after spinal surgery is not well documented. METHODS:For 240 spinal surgery patients, postoperative prophylaxis against deep venous thrombosis consisted of alternating pneumatic compression stockings alone. The patients were routinely screened on postoperative days 1 to 2 for deep venous thrombosis using US. The incidence of initial/subsequent negative US and positive CTA diagnostic for PE in patients with mild/major symptoms was evaluated, in conjunction with the frequency of hypercoagulation syndromes. RESULTS:Five (6.7%) patients undergoing cervical surgery and 6 patients (3.6%) undergoing lumbar surgery exhibited negative US but positive CTA on postoperative days 1 to 21. All the patients immediately received inferior vena cava filters (2 permanent and 9 retrievable). Five patients (45%) tested positive for hypercoagulation syndromes. Two patients were fully anticoagulated on postoperative days 3 and 21 with major symptoms attributed to saddle emboli; 1 had hypercoagulation syndrome. Anticoagulation was delayed for 6 to 12 weeks in 7 patients with milder symptoms, as magnetic resonance imaging scans showed residual seromas; 4 had hypercoagulation syndromes. Two elderly patients, at high risk for falls, without hypercoagulation syndromes were not anticoagulated. CONCLUSIONS:The frequency of negative US of the lower extremities but with positive CTA for PE after 240 cervical/lumbar spinal procedures in patients with mild/major symptoms ranged from 3.6% to 6.7%; 5 of the 11 patients exhibited hypercoagulation syndromes. To avoid failure to diagnose PE after spinal surgery, one should have a "low threshold" (eg, based even on minor symptoms) for requesting the CTA.
Successful treatment of secondary hemophagocytic lymphohistiocytosis in a patient with disseminated histoplasmosis [Case Report]
Hemophagocytic lymphohistiocytosis (HLH) is an overwhelming inflammatory response, associated with an outpouring of cytokines and inappropriate activation of the macrophage system, causing severe morbidity and possible death. HLH has inherited and acquired forms. Secondary HLH can be related to any number of underlying conditions including infections, malignancy and autoimmune diseases. There are similarities between "cytokine storm" seen in HLH and the clinical findings of avian influenza. We report a patient with a history of sarcoidosis on chronic steroid treatment, who developed HLH secondary to an infection with Histoplasma capsulatum.