Last week at family medicine grand rounds, a resident presented a fascinating case of a 36-year-old policeman who came to the clinic with a 2-day history of pain behind his left ear. The patient had no discharge or hearing loss, and the physical findings were nonspecific. An x-ray was suggestive of mastoiditis, so the patient was started on amoxicillin. But the pain worsened over the next 2 days, and he broke out in a vesicular rash and developed a facial nerve palsy.
I’m sure many of you astute diagnosticians have already identified this as a case of Ramsay Hunt syndrome. But there’s another twist to this case. The patient was hospitalized the next day, with difficulty swallowing due to involvement of cranial nerves IX and X. He also developed hearing loss. Although he was treated promptly with steroids and acyclovir, he left the hospital with a feeding tube. We’re hoping for a full recovery, although the prognosis remains uncertain.
Involvement of 4 cranial nerves is unusual for Ramsay Hunt syndrome. But I’m certain that you, too, see unusual cases. If we define a rare or unusual case as one with an annual incidence of 1000 or less, it is safe to assume that most family physicians see at least 4 rare cases per year—or 140 such cases over a typical (35-year) career.
Each month, I receive several case report submissions to this journal. I find them fascinating, and think you would, too. That’s why we are launching a new department, Case Review (at right), starting with this first issue of the year. Over the course of several years, we expect to accumulate a wealth of case reports that will be valuable both for teaching and diagnosis.
Do you have a case you’d like to share? If you have a case that you think readers would be interested in, send it to us for consideration. The format is straightforward: Start with a pithy case history with pertinent positive and negative findings and the clinical course of illness; follow with a brief literature review, a discussion of the condition and its treatment, and a conclusion or recommendations. (McCarthy and Reilly’s article on writing case reports is an excellent resource.1)
Questions to consider: What is the takeaway for the reader? Was this a difficult diagnosis that hinged on a key finding in the history or physical exam? Was this a common problem that presented in an uncommon way?
Also this month… In addition to Case Review, JFP is launching another new feature: Watch & Learn, a how-to video series. This month’s 4-minute video demonstrates the proper way to do a punch biopsy.
Now that you know what’s new at JFP, I invite you to write and tell us what’s happening in your world—and to submit your most interesting cases.
Wishing you a happy, healthy year!