Sweet's Syndrome Diagnosis & Treatment Case Study

Pages: 19 (5846 words)  ·  Bibliography Sources: 17  ·  File: .docx  ·  Level: Doctorate  ·  Topic: Disease  ·  Written: November 5, 2019

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In addition, more recent population surveys have included data concerning gender identity, and the findings that have emerged from this research confirm that growth in the LGBT community which has also contributed to growing public acceptance. This cycle has, in turn, encouraged even greater numbers of individuals to publicly reveal their gender identities and it is reasonable to suggest that additional scholarship in this area will show that clinicians can expect to encounter increasing numbers of the LGBT community in the future.

Based on their analysis of the most recent population survey data, Meerwijk and Sevelius estimate that the current population of transsexual individuals in the United States is 390 adults per 100,000 or approximately one million adults nationwide. Although Meerwijk and Sevelius concede that this estimate could be more reflective of rates for younger adults because these population segments accounted for more than half of the respondents in their analyses, they also emphasize that nationwide surveys in the future will likely identify even greater percentages of members of the LGBT community. Some indications of recent growth trends in this community can be easily discerned from the data depicted in Figure 1 below.

Figure 1. Meta-Regression Showing the Proportion of Transgender Adults against Survey Year

Source: Meerwijk & Sevelius, 2017

Note:

BRFSS = Behavioral Risk Factor Surveillance System

NCHA = National College Health Assessment

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NIS = National Inmate Survey

There has also been a 19% increase in the number of female-to-male transsexual procedures that have been performed in the United States from 2015 to 2016 (U.S. gender confirmation surgery, 2019). A survey by the American Society of Plastic Surgeons found that while female-to-male transsexual procedures are still relatively rare, they account for nearly half (46%) of transsexual surgeries in the United States today (U.S. gender confirmation surgery, 2019).

Case Study on Sweet's Syndrome Diagnosis & Treatment Assignment

Taken together, it is clear that the numbers of transsexuals is projected to increase dramatically in the United States over the next several years, and it is equally apparent that members of the LGBT community are faced with some profound health care issues that are attributable, at least in part, to their lifestyles, including the individual of interest to this case study report who is described further below.

Case Report

The individual of interest to this case study report is a 24-year-old female-to-male transsexual male presenting with recurrent myonecrosis of his upper chest and neck that was subsequently diagnosed as necrotizing Sweet’s syndrome. The patient reported a previous medical history of Hashimoto's thyroiditis as well as testosterone-induced cystic acne who originally sought help from a community hospital presenting with a 2-day history of increased sub-mental pain and swelling (Otero et al., 2017).

Following his first hospital admission, the patient was placed on broad-spectrum antibiotic therapy comprised of clindamycin, vancomycin and piperacillin/tazobactam. Based on the admitting clinicians’ suspicion that the patient’s condition was a necrotizing soft-tissue infection, a consultation was obtained from the otolaryngology-head and neck surgery service and the patient subsequently received therapeutic incision and drainage procedures for the involved areas (Otero et al., 2017).

Initially, the patient exhibited consistent symptomatic improvements during his 9-day stay in the hospital after initiation of the above-described therapeutic interventions and he was subsequently discharged to his home and directed to complete an intravenous course of antibiotics consisting of piperacillin/tazobactam for 7 days and then oral amoxicillin/clavulanate for another 14 days; in addition, the patient received oral doxycycline for a period of 21 days (Otero et al., 2017).

Notwithstanding the aggressive antimicrobial course of treatment the patient initially received post-discharge, he was readmitted on the 9th day following his discharge due to suspected recurrent necrotizing soft tissue infection. In addition, the patient also presented with rigors, fever, pronounced neck pain and a monomorphous pustular rash on his upper shoulders and back. A computed tomography image of the patient following his second hospital admission showed he had experienced fat stranding of the pectoralis major muscle as well as soft-tissue inflammation and gas in his sternocleidomastoid muscle, images that were congruent with a diagnosis of necrotizing soft tissue infection as shown in Figure 2 below.

Figure 2. Axial and Coronal CT imaging of the neck with IV contrast: (A) Axial and coronal views revealed small foci of air anterior to the right sternocleidomastoid muscle (A) and extensive

subcutaneous fat stranding from the right mandible interiorly to the mid thorax (B)

Source: Otero et al., 2017, p. 5

Extensive necrosis of the sternocleidomastoid fascia and surrounding tissue was identified upon surgical exploration, but there were no compelling causative organisms found on wound culture, acid-fast smear, Gram's stain, or mycobacterial culture derived from the patient’s blood cultures and tissue samples harvested during the exploratory surgical procedure. It should be noted, however, that highly rare Candida albicans were identified in a sample taken from the patient’s upper right chest. As a result, the patient’s medications were subsequently changed to meropenem, clindamycin, IV daptomycin, and fluconazole for broad-spectrum antimicrobial coverage based on a strong clinical suspicion of necrotizing soft tissue infection indicated by the computed tomography and empirical observations during the surgical procedure (Otero et al., 2017)

A dermatological consultation was obtained in order to rule out pyoderma gangrenosum due to the patient’s consistently negative body fluid and tissue cultures as well as his atypical rash. The pathology samples obtained from the patient’s debridement surgeries exhibited a number of outcomes that were congruent with a diagnosis of Sweet’s syndrome, including fat necrosis, with extensive neutrophilic inflammation and abscess formation as well as subcutaneous, skeletal muscle as shown in Figure 3 below.

Figure 3. Histologic images of the deep neutrophilic inflammation involving subcutaneous tissue (A) and extension into skeletal muscle (B).

Source: Otero et al., 2017, p. 8

The results of these clinical tests were provided to the hospital’s dermatopathology consultant service, but discussions with these providers as well as other members of the multidisciplinary treatment team suggested a higher possibility of an infectious etiology such as a nosocomial gram-negative infection for the patient’s symptoms compared to Sweet’s syndrome, particularly since the progression of muscle and skin necrosis had progressed so rapidly. Furthermore, it was not possible at this point to completely rule out an underlying infection as the cause of the patient’s symptoms given the broad-based antimicrobial regimen administered to the patient prior to his second hospitalization. Consequently, the patient was discharged and directed to complete the aforementioned 4-week IV course of meropenem, daptomycin and fluconazole together with supplemental visiting nurse assistants (Otero et al., 2017).

In spite of this new aggressive broad-spectrum IV antimicrobials regimen, the patient presented once again with pain, muscle necrosis of the neck and upper chest as well as recurrent erythema and he was subsequently readmitted. During the patient’s third inpatient stay, surgical debridement of the necrotic tissue was performed and the results were once again analyzed in an effort to identify any causative pathogens. The patient’s tissue cultures and gram’s stain were again negative, however, which resulted in a reevaluation of a non-infectious source for the patient's presenting condition (Otero et al., 2017).

The reevaluation of the test results obtained thus far together with empirical observations of his condition showed extensive myonecrosis and neutrophilic infiltration as well as the patient’s symptoms that were highly resistant to aggressive antimicrobial treatments which resulted in a revised diagnosis of acute febrile neutrophilic dermatosis with necrosis of deep soft-tissues. This revision is not uncommon when confronted with patients that present with these types of symptoms. For instance, according to Geller, Stone, Merola, et al. (2015), “When caring for an immunocompromised patient, the clinician must continually reevaluate the differential diagnosis if the patient has not had the expected response to therapy, bearing in mind that multiple, concurrent disease processes may be present” (p. 77).

Based on this revised diagnosis, the patient’s mediation regimen was subsequently changed to IV corticosteroid (i.e., 2mg/kg methylprednisolone) which resulted in decreased erythema and pain levels in the affected areas shortly after the administration of the first treatment. Based on this notable progress, the patient was once again discharged to home with a 2-week oral prednisone taper as well as a visiting nurse to provide assistance with caring for his wounds (Otero et al., 2017). Despite the revised diagnosis and treatment regimen, the patient experienced another bout with pain in his upper chest, right should and neck as well as severe erythema 14 days post-discharge while receiving 50 mg of prednisone which resulted in yet another inpatient stay (Otero et al., 2017).

Supplemental incision and drainage procedures, as well as IV corticosteroid therapy (2mg/kg methylprednisolone), were started during the fourth admission and because Sweet's syndrome continued to represent the… [END OF PREVIEW] . . . READ MORE

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