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IVC
Right gonadal vessels
Right renal vein
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Narrowing of the renal vein between the aorta and superior mesenteric artery( nutcracker syndrome) |
Left renal vein
Left gonadal vessels
Varicocele
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ALL IMAGES DRAWN BY AUTHOR.
MORE ON THIS DIAGNOSIS ONLINE ausdoc. com. au / spot-diagnosis
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SPOT DIAGNOSIS
What’ s behind this itchy rash? SIMONE is a 29-year-old primigravida who presents with two weeks of an itchy rash. She is currently 36 weeks’ gestation in an otherwise uncomplicated twin pregnancy. The rash began as a few red patches within striae on her lower abdomen but has extended to involve most of the abdomen( sparing the periumbilical region), thighs and upper arms. With this progression, the rash has become increasingly itchy. Simone is usually very well, with no previous skin concerns, no known allergies or atopy. Blood tests, including FBC, EUC, LFTs, bile acids and coagulation profile, are normal. She takes no regular medications and has not been applying anything to the area. Examination is unremarkable apart from the rash( pictured).
DERMATOLOGY ATLAS
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What is the most likely diagnosis? a Cholestasis of pregnancy b Pemphigoid gestationis c Polymorphic eruption of pregnancy d Atopic eruption of pregnancy |
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Sperm is not available for analysis, given younger boys may not yet have ejaculated or developed the practice of masturbation.
Some patients may experience improvements in sperm parameters with treatment of the varicocele; however, at this stage it is not clear which group to treat to best achieve this.
A long-term screening study that looked at paternity rates after varicocele treatment found a non-significant difference in paternity rates, which were 85 % in the control group and 78 % in the treatment group. 8 This is contrasted by other studies that show a significant positive difference in paternity rates with early treatment. 9
The current guidelines from the European Association of Urology recommend considering treatment of adolescent varicocele based on the features shown in box 1. 10
Sclero-embolisation of the gonadal vein, from above or below, is a minimally invasive treatment option. This is performed by an interventional radiologist, with access gained through the internal jugular or femoral vein. Coils are then deployed into the gonadal vein. This may result in congestive pain temporarily; however, there is no associated risk of hydrocele. The wounds are much smaller so recovery is easier( see figure 2).
A microsurgical inguinal approach is a longer, more complex technique, often used for recurrent varicoceles. This uses a groin approach, and the veins are accessed locally to ligate or
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Table 1. Clinical grading of varicocele
Grade
Small / Grade 1
Moderate / Grade 2
Large / Grade 3
Examination
Palpable when standing with Valsalva
Palpable when standing
Visible when standing
Box 1. Features warranting treatment of adolescent varicocele( European Association of Urology guidelines) 10
• Testicular hypotrophy(> 20 % difference)
• An additional testicular condition affecting fertility
• Symptomatic
• Bilateral palpable varicocele
• Pathological sperm quality( in older adolescents)
• Cosmetic concerns
embolise them( see figure 3).
In this patient’ s case, the varicocele is symptomatic, and therefore treatment is likely to be beneficial. If Ethan had been otherwise asymptomatic with his varicocele at presentation, future review would be required to decide on his best treatment option.
References on request from kate. kelso @ adg. com. au
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ANSWER The answer is c. Polymorphic eruption of pregnancy( PEP), also known as pruritic urticarial papules and plaques of pregnancy, is a benign self-limiting inflammatory disorder typically occurring in nulliparous individuals in the third trimester or immediately postpartum. 1, 2
It is characterised by extremely pruritic, erythematous papules occurring within striae, usually abdominal initially, but which may progress to striae on the chest, back and legs. Periumbilical sparing is a characteristic feature. As the condition progresses, polymorphic lesions may develop, including target-like lesions, erythematous patches and vesicles. 1, 2
The condition is common, affecting up to one in 150 pregnancies. 1 Around three-quarters of affected women are nulliparous. 1 Women with multiple gestations are also more likely to be affected. 1, 2
The aetiology is unclear. Hypothesised causes include abdominal skin distension resulting in connective tissue damage with exposure of dermal antigens triggering an inflammatory response. It has also been theorised that the condition represents an immunological response to circulating fetal antigens. 1
Diagnosis is usually clinical. However, early pemphigoid gestationis may closely mimic PEP, so skin biopsy is warranted if there is any diagnostic uncertainty. 1
Treatment is symptomatic, with resolution typically occurring spontaneously within several weeks of delivery. Mid- to high-potency topical steroids are first line, along with an appropriate oral antihistamine. 1-3 Cyproheptadine and dexchlorpheniramine are sedating antihistamine options, but loratadine or cetirizine may be used if sedation is a concern. 3 Oral corticosteroids may be warranted for severe cases.
Like PEP, pemphigoid gestationis also typically presents in the third trimester and in its early stages can be clinically indistinguishable from PEP. It does not spare the periumbilical region and progresses to form large blisters or bullae. Intrahepatic cholestasis of pregnancy due to defective excretion of bile salts causes an intense generalised, rather than localised pruritus. The resulting skin changes are secondary to scratching, most commonly on the distal limbs and abdomen. Bile acids are increased, and with progression, LFTs will become abnormal. Atopic eruption of pregnancy( AEP) typically occurs earlier than PEP, usually in the first or second trimester. The itchy rash, or AEP, may affect widespread areas, including the face, neck, knee and elbow creases, abdomen and limbs. 4
Dr Kate Kelso is a GP and medical editor at Australian Doctor. References on request from kate. kelso @ adg. com.
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