•This case has illustrated the difficulty of promptly diagnosing an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease, in the absence of pulmonary involvement in an immunocompetent patient.•A high index of clinical suspicion with a multidisciplinary team approach is required.•The first line of treatment for gastrointestinal tuberculosis is medical treatment, indicating that 6 months of an anti-tuberculosis regime is satisfactory. Surgical treatment should be sought for patients who develop complications such as obstruction, perforation, and stricture formation.•In the absence of positive pathological (polymerase chain reaction or acid-fast bacilli staining) and radiologic tests, the diagnosis is often established by obtaining a surgical histopathology specimen.
We present a case of primary gastrointestinal tuberculosis that has culminated in ulcer formation, in the absence of pulmonary involvement in an immunocompetent patient.
PRESENTATION OF CASE
A 28-year-old Asian male presented to casualty with a 1-week history of epigastric cramping abdominal pain and several episodes of non-bilious vomiting. The patient deteriorated clinically, becoming more cachectic and given his unexplained weight loss, an oesophageal-gastro-duodenal endoscopic imaging confirmed a duodenal ulcer. The biopsy of the non-healing ulcer was the hallmark of the disease, revealing evidence of granulomatous inflammation consistent with tuberculosis bacilli.
Gastrointestinal tuberculosis with ulceration is rare with respect to the oesophagus, stomach and duodenum. This case proves to be unique, as our patient had experienced primary isolated gastric tuberculosis in the absence of pulmonary tuberculosis in a healthy individual. Immunohistochemical staining, histopathology and radiological investigations have demonstrated their importance in confirming abdominal tuberculosis and the extent of bowel involvement.
This case has illustrated the difficulties associated with a prompt diagnosis of an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease in an immunocompetent patient.
Tuberculosis; Duodenum; Abdominal; Ulcer; Pathogenesis; Investigation
Pneumoperitoneum in the presence of acute abdominal pain is well recognised as an indication for laparotomy. We present a case of acute abdominal pain in the presence of an incidental pneumoperitoneum secondary to the rupture of pneumatosis intestinalis. We will discuss the importance of clinical context in the diagnosis and management of pneumoperitoneum and pneumatosis intestinalis.
Pneumoperitoneum; Pneumatosis intestinalis; Laparotomy; Conservative management
Facile reduction of alkylamino-, anilino-, and pyridyl-N-oxides can be achieved via the use of diboron reagents, predominantly bis(pinacolato)- and in some cases bis(catecholato)diboron [(pinB)2 and (catB)2, respectively]. Reductions occur upon simply mixing the amine N-oxide and the diboron reagent in a suitable solvent, at a suitable temperature. Extremely fast reductions of alkylamino- and anilino-N-oxides occur, whereas pyridyl-N-oxides undergo slower reduction. The reaction is tolerant of a variety of functionalities such as hydroxyl, thiol, and cyano groups, as well as halogens. Notably, a sensitive nucleoside N-oxide has also been reduced efficiently. The different rates with which alkylamino- and pyridyl-N-oxides are reduced has been used to perform stepwise reduction of the N,N’-dioxide of (S)-(–)-nicotine. Because it was observed that (pinB)2 was unaffected by the water of hydration in amine oxides, the feasibility of using water as solvent was evaluated. These reactions also proceeded exceptionally well, giving high product yields. In constrast to the reactions with (pinB)2, triethylborane reduced alkylamino-N-oxides, but pyridine N-oxide did not undergo efficient reduction even at elevated temperature. Finally, the mechanism of the reductive process by (pinB)2 has been probed by 1H and 11B NMR.
Skin sparing mastectomies (SSMs) represent a surgical approach that preserves the natural skin envelope of the breast and, when combined with immediate reconstruction, offers a good cosmetic outcome. The aim of this retrospective study was to compare the risk of local recurrence (LR) in this series with the known rate of recurrence following a conventional mastectomy.
A total of 108 patients with breast cancer who underwent an SSM and immediate breast reconstruction over a 6-year period were reviewed.
A follow-up of more than eight years showed that three patients (2.78%) had developed LR.
The rate of LR is low with SSMs and is comparable to that seen with conventional mastectomies.
Breast; Reconstruction; Mastectomy
Cerebral hemorrhage occurs rarely in infective endocarditis. Here, we present an interesting case of infective endocarditis complicated by sever cerebral hemorrhage. Later, his blood culture grew S bovis. To the best of our knowledge, this is the first ever reported case of S Bovis infective endocarditis complicated by extensive intracranial hemorrhage.
Cerebral Hemorrhage; Infective endocarditis; S. bovis.
Acute aortic dissection is a rare clinical entity that mainly affects patients older than 50 years. It is unusual in younger patients and its presence has been traditionally associated with trauma, Marfan syndrome, bicuspid aortic valve and pregnancy. We present here, a case of a 30 year old pregnant female with acute aortic dissection type A (De Bakey II), without family history of connective tissue diseases and signs of Marfan syndrome.
Acute aortic dissection; Peripartum
This study was undertaken to examine the outcomes of surgery for active infective endocarditis.
Fifty consecutive patients underwent surgery for active infective endocarditis in a tertiary care center between January 2000 and June 2003. Modified Duke Criteria was used to include the patients in the study.
Mean age of the patients was 55.72 years (range 18-89 years). Underlying heart disease was the most common cause of acute infection, accounting for 30 % of all the cases. 16 % patients had a recent dental procedure and 10 % had a recent surgical procedure. The most common infective organism was staphylococcus aureus (24%), followed by streptococcus viridians (20%). The most common indications for surgery were congestive heart failure (CHF) (52%), embolic phenomenon (18%) and septic shock (10%). Most common postoperative complication was respiratory failure (30%) followed by renal failure (24%) pacemaker implantation 22%; stroke 18%, bleeding 16% and GI bleeding 2 %. Seven out of 50 patients died during hospital course that accounts for 14% of the motility rate.
Surgery for endocarditis continues to be challenging and associated with high operative mortality and morbidity. Age, shock, prosthetic valve endocarditis, impaired ventricular function, and recurrent infections adversely affect long-term survival.
active infective endocarditis; surgery
The congenital long QT syndrome (LQTS) is characterized by abnormally prolonged ventricular repolarization due to inherited defects in cardiac sodium and potassium channels, which predispose the patients to syncope, seizure like activity, ventricular arrhythmias, and sudden cardiac death. Early diagnosis and preventive treatment are instrumental in preventing sudden cardiac deaths in patients with the congenital LQTS. The diagnostic criteria for congenital LQTS are based on certain electrocardiographic findings, clinical findings and findings of epinephrine stress test. Recently genotype specific electrocardiographic pattern in the congenital LQTS has also been described. Recent studies suggest feasibility of genotype specific treatment of LQTS and, in near future, mutation specific treatment will probably become a novel approach to this potentially fatal syndrome. We describe one case that fulfilled the electrocardiographic, historical diagnostic criteria and epinephrine stress test suggestive of LQT syndrome.
congenital long QT syndrome; cardiac sodium; potassium channels
The incidence of transuterine perforation and migration of intrauterine contraceptive devices (IUCDs) into the abdominal cavity has been estimated at less than 0.1%. It has been suggested that intraperitoneal IUCD have low morbidity and may be left in situ. We report the first case of closed loop small bowel obstruction due to migration of a “Saf-T-Coil” IUCD into the abdominal cavity, where it became embedded in the omentum and ultimately, 31 years after deployment, coiled both arms around a loop of ileum. This late complication underlines the dangers of intra-abdominal foreign bodies, even when chemically and biologically inert.
The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.
Aims and Objectives
To study the effect of Heart Rate Variability (HRV) and QT dispersion (QTd) in patients presenting with Acute ST elevation myocardial infarction (STEMI).
This is a retrospective study conducted on patients admitted with the diagnosis of acute ST elevation myocardial infarction. In all 100 patients with acute myocardial infarction in one year were subjected to a complete evaluation in terms of history and examination. Besides routine investigations standard 12 lead ECG was evaluated in all cases on admission, after 4 hrs, 24 hrs, 48 hrs and on discharge.
The most common presenting symptoms were chest pain (88%) and dyspnea (50%). Tachycardia was seen in 56% while congestive heart failure was present in 29% patients. Patients who died had a higher QTd in comparison to patients who survived.
Markers of autonomic regulation of heart like QTd provides valuable information about the future course of events in a patient following acute STEMI which can be utilized to plan the future course of management in patients especially predisposed to adverse and catastrophic outcomes.
acute ST elevation myocardial infarction; QT dispersion
Acute embolic occlusion of the bilateral lower limbs from the left ventricular thrombus is an extremely rare medical condition that is not only limb threatening but also potentially life threatening. Several strategies are available but not even a single treatment modality is clearly the best. Here, we present an interesting case that presented with bilateral lower limb ischemia and was later found to have a big thrombus in the left ventricle as the source of the emboli.
Myocardial Infarction; LV thrombus; Emboli
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.
Gastro-intestinal stromal tumours are the most common mesenchymal tumours of the gastro-intestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to rebleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management.
A 61-year-old male presented to the accident and emergency department with a one-day history of haemetemesis with coffee ground vomiting. After initial resuscitation, he underwent upper gastrointestinal endoscopy under sedation which demonstrated a large, bleeding, gastric mass with a central crater along the greater curvature of the stomach. A partial gastrectomy was performed taking a wedge of the stomach with clearance from the tumour, with no signs of extraperitoneal disease.
Early surgical intervention, either open or laparoscopic resection, is the treatment of choice to prevent rebleeds. In general, complete surgical resection is accomplished in 40-60% of all gastro-intestinal stromal tumours patients, and in >70% of those with primary non- metastatic gastro-intestinal stromal tumour. In our case we had completely excised the tumour. Following surgery, all patients must be referred to centres which have more experience in treating gastro-intestinal stromal tumours. Imatinib is proven to be the first effective systemic therapy in cases of unresectable or metastatic disease. All gastro-intestinal stromal tumours have the potential for aggressive behaviour with the risk being estimated from tumour size and mitotic count.
Small cell carcinoma of the anus is a very rare but aggressive tumour. We present a case of a 60-year old lady with small cell carcinoma of the anus. She had no metastatic disease on presentation. She had chemotherapy and radiotherapy but developed distant metastasis after completion of treatment. Immunohistochemistry is required to make a diagnosis. Chemotherapy remains the mainstay of treatment for small cell carcinoma of the anus with or without metastatic disease. Radiotherapy is for local control and relief of symptoms.
Adrenal myelolipoma is a rare benign neoplasm composed of mature adipose and hematopoietic tissue. Most lesions are small, unilateral and asymptomatic, discovered incidentally at autopsy or on imaging studies performed for other reasons. We would like to present a case report of this rare tumour. Cross-sectional imaging is helpful in making a pre-operative diagnosis. The size of the lesion should be a criterion for surgical intervention.
Acute compartment syndrome is a surgical emergency requiring immediate fasciotomy. Spontaneous onset of acute compartment syndrome of the lower limbs is rare. We present a very rare case of pneumococcal sepsis leading to spontaneous acute compartment syndrome.
A 40-year-old Caucasian man presented as an emergency with spontaneous onset of pain in both legs and signs of compartment syndrome. This was confirmed on fasciotomy. Blood culture grew Streptococcus pneumoniae.
Sepsis should be strongly suspected in bilateral acute compartment syndrome of spontaneous onset.