We describe a rare case of small bowel infarction due to fibro muscular dysplasia in superior mesenteric artery in a young patient.
A 28 year old Asian female presented with acute onset left sided abdominal pain and watery diarrhea. She had a laparotomy due to further deterioration. It showed infracted small intestine, gall bladder and parts of liver. Abdomen had to be closed without any therapeutic procedure. She died in early post operative period. Autopsy showed fibro muscular dysplasia of superior mesenteric artery.
Fibro muscular dysplasia of SMA is rare, is treatable but has a high mortality.
Hypoparathyroidism is a chronic condition which requires a lifelong substitution with vitamin D analogues and careful monitoring. This is especially true for older patients and older compounds as dihydrotachysterol with longer half-life that might lead to long-lasting hypercalcemic episodes.
A 74-year old male patient with postsurgical hypoparathyroidism who has been successfully supplemented with dihydrotachysterol (1.7 ml/day) for over 50 years presented with neuropsychiatric disturbances, constipation, renal insufficiency and polyuria. Laboratory investigation demonstrated serum calcium 3.7 mmol/L, serum creatinine 180 micromol/L, urine calcium excretion 1.1 mmol/mmol of the creatinine, normal 25 OH vitamin D3 and low parathormone and 1,25 di OH vitamin D3. Careful history revealed that he has been erroneously taking 2.5 ml of dihydrotachysterol per day for at least 6 to 8 weeks that caused vitamin D intoxication and symptomatic hypercalcemia. He was treated with intravenous saline infusion, prednisolone and 60 mg of intravenous sodium pamidronate. On the fourth day after admission serum calcium dropped rapidly within the reference range. The treatment for hypoparathyroidism had to be reinstituted 10 days after dihydrotachysterol had been discontinued when the patient was switched to shorter acting calcitriol.
Here we reported that the immediate use of pamidronate in addition to classic treatment of dihydrotachysterol intoxication with intravenous saline, diuretics and glucocorticoids is an effective treatment choice that leads to rapid resolution of hypercalcemia.
Cirrhosis of the liver commonly leads to a state of chronic hypervolemic hyponatremia. Profound exacerbation of the hyponatremic state may occur in patients with decompensated cirrhosis in conjunction with acute stressors such as infection or binge alcohol ingestion.
A 47 year old man with a history of alcoholic cirrhosis presented to the hospital with symptomatic profound hyponatremia (serum sodium concentration of 105 meq/L) due to a recent infection and binge drinking. The patient was treated with antibiotics, diuretics and hypertonic saline and was placed on a fluid restricted diet. The serum sodium level corrected slowly over four days with symptomatic improvement occurring after two days. A brief discussion of the symptoms and treatment of acute and chronic hyponatremia in the setting of cirrhosis is included.
In patients with cirrhosis, it is important to recognize the symptoms of hyponatremia, identify and treat any exacerbating conditions early in their course, and correct the serum sodium concentration slowly with frequent monitoring.
We present the contrast-enhanced spiral CT findings in a case of acute celiac artery occlusion with gastric perforation and total splenic infarction. Spiral CT depicted thrombus in the celiac axis and its branches, stenosis of the superior mesenteric artery, splenic infarction and lack of enhancement of the gastric wall with a large necrotic gap. Spiral CT enabled prompt diagnosis and therapy in this rare condition in a patient with suspicion of acute mesenteric ischemia.
Proliferating trichilemmal tumour defined with more than one terms by many author, after well documentated series reported as "proliferating epidermoid cysts" by Wilson-Jones, firstly in 1966. They are rare, slowly growing, lobular masses inherited autosomal dominantly and localized on scalps of older women and believed to arising as a complication of a trauma and inflammation and effect 5-10% of people.
We intented to present the case of a 62 years old Turkish woman with a history of slowly growing scalp mass after the trauma, especially during last 15 years. After surgical evaluation, histopathological slides exhibited the characteristic structures of proliferating trichilemmal tumour. The patient was lost to follow-up and no recurrens or distance metastasis detected during 40 months follow-up.
In our opinion, widely surgical excision with long-term surveillance is the best choice for both diagnosis and treatment still today.
Although the advanced stages of neoplasms have a risk of superior mesenteric venous thrombosis (MVT), an initial clinical diagnosis of MVT is sometimes difficult and it can be treated as a cancer-related pain using NSAIDs and/or opioids.
We herein present a case of palliative stage of cancer with acute MVT, which was successfully treated with immediate anticoagulant therapy. We believe this case provides an important clinical lesson, which is that we should remember that MVT is one of the potential causes of abdominal pain with cancer patients and the thrombosis can be easily identified by US and CT.
Hematogones are the normal bone marrow constituents of bone marrow in children and their number decreases with age. As hematogones can resemble malignant lymphoblasts by their morphologic features and by expression of an immature B-cell phenotype, an accurate distinction of hematogone-rich lymphoid regeneration from leukemic lymphoblasts is critical for patient care. The increased number of hematogones had been reported in the bone marrow of children recovering from chemotherapy, aplastic conditions, other forms of bone marrow injury, infections like Cytomegalovirus, HIV and immune thrombocytopenia disorders. We describe here a case of one and half month old male infant with bicytopenia and leucocytosis associated with increased hematogones in the bone marrow due to an unknown probable viral infection.
Castleman's disease or angiofollicular lymphoid hyperplasia is a rare benign lymph node hyperplasia usually presenting as an asymptomatic mediastinal mass in children. The disease can present at any extra thoracic site with lymphoid tissue such as retroperitoneal, mesentery, axilla, and pelvis. Hepatic localization castleman disease is very rare in children. Herein, we reported a case of Castleman's disease arising from the lymph node in hilum of liver.
A 5 -year-old girl with chief complaint of abdominal pain for two months which exaggerated in last three days was referred to the hospital. On routine physical examination, only a generalized abdominal pain was noticed. Routine laboratory investigations and Chest X-Ray were normal. Abdominal Sonography revealed a 3.7 × 3.1 cm solid mass in the hilum of the liver. On the MRI images, a lobulated mass in the portal hepatic associated with mass effect on the portal vein was visible. Histological examination revealed expansion of mantle zone in lymphatic nodules accompanied by burnt out germinal centers. This pattern was matched with the diagnosis of the hyaline-vascular type of Castleman disease. The patient underwent a laparotomy. The patient had an uneventful postoperative course.
This pattern was matched with the diagnosis of the hyaline-vascular type of Castleman disease.
Pseudohyperkalemia can appear in a variety of settings and should be recognized early. Treatment of pseudohyperkalemia can lead to an inappropriate decrease of actual serum potassium levels which may lead to life threatening conditions. In the case presented, an 81-year-old male presented with massive leucocytosis and an extremely elevated potassium level. This case report emphasizes the importance of recognizing pseudohyperkalemia in a patient with a severely increased potassium and WBC level; such patients may be clinically asymptomatic or may have a normal ECG.
We report a rare case of late knee locking after an open knee injury in a polytrauma patient with a pelvic fracture and a contralateral femoral artery injury. Once the life and limb threatening injuries were addressed, debridement and washout of the knee wound was performed. X-rays and subsequent CT revealed only an undisplaced patella fracture. The patient presented 6 months later to a knee surgeon with recurrent locking. An arthroscopy was performed and a 10 mm plastic soft drink bottle cap was retrieved leading to the immediate resolution of symptoms without complications.
Open knee injuries require thorough debridement washout and joint assessment. Late locking should raise the suspicion of an intra-articular loose or foreign body. Arthroscopy is an excellent first line tool in the diagnosis and late management of this unusual problem.
This case report documents the effectiveness of inositol treatment on a chronic patient with bipolar disorder I and severe psoriasis. Her lithium treatment was discontinued due to psoriasis exacerbation and inositol was administered. The remarked positive effect of inositol was noted on her stable mood during the last 4 years, the absence of psoriatic lesions, which lead to an improved quality of life of the patient.
A 62-year-old female Caucasian patient suffering from bipolar disorder, since the age of 32, presenting manic episodes when without lithium treatment. Lithium treatment caused severe exacerbation of psoriasis and was discontinued while anti-psoriatic treatment had no effect. The last 4 years the patient receives 3 gr per day of inositol alone and her mood has been stabilized while there is also a remarkable improvement on her psoriatic lesions.
Taking into consideration the course of her bipolar disorder when lithium was discontinued previously we consider that the 4 years of follow up assessments of this patient as a satisfactory time period for concluding that inositol has been a very effective treatment, replacing lithium, for mood stabilization and psoriasis.
A 68-year-old white female presented with two years of progressively worsening dyspnea. Echocardiography revealed a large right atrial mass and partial obstruction of the inferior vena cava. Further imaging revealed a cystic dense mass in the inferior vena cava and right atrium. Immunohistochemical stains were consistent with leiomyosarcoma. Intraoperatively, the tumor was noted to originate from the posterior aspect of the inferior vena cava. The patient underwent successful resection of the mass. Adjuvant radiation therapy was completed. The patient's dyspnea gradually improved and she continues to remain disease free five years post-resection.
Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or a major vessel (vena cava, pulmonary vein, pulmonary artery). They are usually diagnosed by coronary arteriography. Clinical presentations are variable depending on the type of fistula, shunt volume, site of the shunt, and presence of other cardiac conditions.
This report describes a 46-year-old Greek female patient who was admitted to the hospital because of an acute coronary syndrome. She underwent coronary angiogram which showed a coronary artery fistula from the left anterior descending artery to the main pulmonary artery and severe coronary disease. The patient was referred for coronary artery bypass surgery and fistula closure operation.
Coronary artery fistulas between left anterior descending artery and main pulmonary artery are very rare anomalies. This case report describes a patient with this anomaly combined with severe coronary disease, reviews the current literature and discusses the available options for treating this rare condition.
Lately, there has been an increased incidence of late stent thrombosis; especially following Drug eluting stent (DES) implantation. Several factors are associated with an increased risk of stent thrombosis, including the procedure itself, patient and lesion characteristics, stent design, and premature cessation of anti-platelet drugs. We present a case of late stent thrombosis (LST) following DES implantation after a period of 68 months, making it the longest reported case of LST reported in the literature, despite the use of dual anti-platelet therapy.
The effect of hypothyroidism on the cardiovascular system has been well documented. Cardiac dysfunction due to hypothyroidism manifests as both systolic and diastolic dysfunction of the heart leading to cardiac arrhythmia and congestive heart failure. Its presentation in the form of refractory hypotension is rare. We describe a 52 year old man on whom Hypothyroid Cardiomyopathy manifested as cardiogenic shock responsive only to thyroxin replacement.
The incidence of tuberculosis is increasing in the United States. Extra-pulmonary involvement is more common in patients with HIV/AIDS. The diagnosis of Tuberculosis osteomyelitis requires a high degree of suspicion for accurate and timely diagnosis.
We present a case of a 49 year old Caucasian male with HIV/AIDS who presented with a four-month history of soft tissue swelling in the left proximal thigh unresponsive to various broad spectrum antibiotics who was eventually diagnosed with Mycobacterium tuberculosis osteomyelitis of the left proximal femur.
Suicidal cut throat injuries are either unreported or fortunately rare in our country. The management of these injuries requires a multi-disciplinary approach.
This paper presents our experiences with managing three unemployed adult Nigerian males - two of Hausa ethnicity and one from the Tiv ethnic group presenting with cut throat injuries following suicidal attempts.
The purpose of these reports is to emphasize that suicidal cut throat injuries do occur in our environment and there is a need for the collaboration of the otorhinolaryngologist, anesthesiologist and psychiatrist in the effective management of these patients. We recommend the socioeconomic improvement of individuals as a way of reducing the incidence of these injuries as unemployment was cited as a motivating factor for suicide in our patients. Ways must also be found to identify the many people in society without mental disorders who are at risk of suicidal behaviors.
Cardiac abnormalities can be seen with subarachnoid hemorrhage. To date, there have been isolated case reports of transient left ventricular apical ballooning cardiomyopathy, also known as Takotsubo cardiomyopathy in patients suffering from subarachnoid hemorrhage.
An adult female was brought to the emergency department with somnolence. A 3 × 3 mm ruptured basilar aneurysm was found and successfully embolized. Two days after the patient developed acute heart failure. Troponin-I was elevated to 4.2 (normal <0.4). On ECG, new symmetric T wave inversion in V3, V4, V5 with prolonged QT were evident. Transthoracic echocardiogram showed severe systolic dysfunction with an ejection fraction of 20% and akinetic apex along with the distal left ventricular segments, consistent with Takotsubo cardiomyopathy. Myocardial contrast echocardiography showed a decrease in capillary blood flow and volume in the akinetic areas with delayed contrast replenishment, sparing the basal segments. A repeat study 2 weeks later showed near normalization of the perfusion parameters. The patient improved with medical management. A repeat echocardiogram, a month later revealed an ejection fraction of 45% with no identifiable wall motion abnormality.
Our case, as well as others reported previously, supports the diagnosis of Takotsubo cardiomyopathy in patients with Subarachnoid Hemorrhage who fulfill the clinical and imaging description of this syndrome.
Schwannoma of frontoethmoid region is a rare presentation. We report a case of 11-year-old girl with a swelling at the root of nose and nasal dorsum. Based on clinical picture and radiological findings it was not possible to establish a definitive diagnosis. But the histopathological picture was suggestive of schwannoma. A novel surgical approach was adopted to facilitate complete removal of the tumor and provide best possible cosmetic results.
Damage to ethmoid structures following removal of nasal polyps can cause severe complications. A patient aged 48 years with damage to right orbital structures sustained in the course of transnasal endoscopic surgery for ethmoid polyps was operated. After operation were complications.
This case report describes a 13-year-old boy with alveolar bony defect resulted from surgical removal of impacted upper canine transposed in the anterior region. The boy had a normal occlusion with malposition of upper central and lateral incisors. The treatment objectives were to align teeth, close spaces by mesial movement of the buccal segments in the upper jaw to repair bone loss. Fixed appliance with palatal root torque was used for the mesial movements, levelling, and alignment of teeth.
Orthodontic tooth movement consisted of a sequence of root movement in a direction to increase the thickness of the labial cortical plate of bone, could ensure healthier periodontium. A healthier periodontium prior to space closure ensured repair of alveolar bony defect after surgical intervention. Orthodontic tooth movement should be added to our armamentarium for the repair of alveolar bony defect.
Community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is considered an underreported entity in India. In this case report, the authors describe a thirty-five year old immunocompetent male presenting with severe respiratory distress requiring intubation. On further work up, a CT thorax showed features consistent with necrotizing pneumonia. The morphology and sensitivity pattern of the organism found in the bronchoalveolar lavage fluid and blood culture were consistent with MRSA. The patient's stay in the hospital was complicated by acute renal failure due to rhabdomyolysis with CPK levels of 9995 U/L. The patient was started on dialysis and improved there after. This case brings to light that CA-MRSA is becoming a problem in developing nations where antibiotics are frequently used empirically with little laboratory guidance. It also is a rare reporting of rhabdomyolysis due to CA-MRSA.
Stiff limb syndrome is a clinical feature of the stiff person syndrome, which is a rare and disabling neurologic disorder characterized by muscle rigidity and episodic spasms that involve axial and limb musculature. It is an autoimmune disorder resulting in a malfunction of aminobutyric acid mediated inhibitory networks in the central nervous system. We describe a patient diagnosed by neurological symptoms of stiff limb syndrome with a good outcome after treatment, and a review of the related literature.
A 49-year-old male patient presented with a progressive stiffness and painful spasms of his both legs resulting in a difficulty of standing up and walking. The diagnosis of stiff limb syndrome was supported by the dramatically positive response to treatment using diazepam 25 mg/day and baclofen 30 mg/day.
This clinical case highlights the importance of a therapeutic test to confirm the diagnosis of stiff limb syndrome especially when there is a high clinical suspicion with unremarkable electromyography
Patients who present with a co-existing connective tissue disorder add a degree of complexity to operative intervention. We present an unusual case of a 53-year-old Caucasian female patient with Ehlers Danlos syndrome who presented with an occult perforation of the distal ileum. The patient had known small bowel diverticulae yet the perforation occurred within the normal bowel wall. The pre-operative CT only showed malrotation of the large bowel and did not correlate with the intra-operative findings. Our case has highlighted that although small bowel perforation is a rare occurrence, it may be more common in Ehlers Danlos and may present with atypical features. Perforation may also occur alongside normal bowel as well as diverticulae within the bowel. Where diverticulae exists within a patient with Ehlers Danlos syndrome and there is some diagnostic uncertainty, there should be a lower threshold for operative intervention. We present in the discussion a number of salient features and learning points.
Few cases of pulmonary toxicity related to epidermal growth factor receptor-targeted agents have been described.
We report a case of a 63-year-old white male with stage IV non-small cell lung cancer treated with erlotinib who developed a interstitial lung disease.
Respiratory symptoms during treatment with erlotinib should alert clinicians to rule out pulmonary toxicity. Early erlotinib withdrawal and corticoid administration were successful.