A large choledochocystolithiasis mimicking Mirizzi syndrome

An 18-year-old man presented with spontaneous severe epigastric pain, progressing and radiating to back since 3 days. It was associated with epigastric tenderness, bilious vomiting and jaundice. He had been intermittently experiencing these symptoms for the last 1 year. No known comorbid. Ultrasound showed a poorly visualised heterogeneous focus at porta hepatis; considering poor visualisation, this might represent an enlarged calcified lymph node or cystic duct calculus causing extrinsic compression or a large sludge ball within the common bile duct (CBD), leading to dilatation of common hepatic duct and intrahepatic biliary system. Subsequent magnetic resonance cholangiopancreatography revealed a focal saccular dilatation of middle part of CBD, a type I-B choledochal cyst, large heterogeneous focus seen within it representing choledochocystolithiasis. Later, CT was performed for further characterisation of surrounding anatomy and pathology, which confused the appearance of choledochocystolithiasis for Mirizzi syndrome. Later, surgery and histopathology confirmed type I-B choledochocystolithiasis and chronic cholecystitis.

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Bilateral recurrent pyosalpinx in a sexually inactive 12-year-old girl secondary to rare variant of Mullerian duct anomaly

Pyosalpinx is a severe sequel of chronic pelvic inflammatory disease, whereby the fallopian tubes become filled with pus.^{1 2} Pyosalpinx often affects sexually active women and rarely is seen in celibate adolescent girls.³ We report a case of a 12-year-old girl with no prior sexual history who presented to our emergency department with complaints of severe right lower quadrant pain of 1-day duration. Ultrasonography and CT scan of the abdomen and pelvis revealed free fluid collections in the pelvis without visualisation of the appendix. A preoperative diagnosis of acute ruptured appendicitis was given and she was taken to the operating room. Peroperative findings included bilaterally distended, pus-filled pyosalpinges. A definitive diagnosis of bilateral pyosalpinx was then made. Two-week antibiotic therapy was successful but the patient returned with recurrent pyosalpinx and a pelvic abscess 9 weeks later.

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Acromegaly discovered during a routine out-patient surgical procedure: a case report

Acromegaly is a rare syndrome in which there is unregulated hypersecretion of growth hormone. The anesthetic management of patients with this disorder is particularly challenging due to pre-existing cardiovasc...

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Disseminated histoplasmosis in a patient with HIV diagnosed by simple bedside investigations

Description

A 41-year-old HIV-infected woman presented with prolonged fever at another hospital. Besides low CD4 count (8 cell/mm³) and pancytopaenia, blood cultures, chest radiograph, chest–whole abdominal CT and bone marrow examination were unremarkable. Empirical treatment for tuberculosis was given. One week later, she developed rash and was transferred to our hospital. Physical examination showed multiple pruritic erythematous purplish maculopapular rashes with central necrotic areas predominantly on face, back-chest wall and both forearms (figure 1). Peripheral blood smear (figure 2) and skin scraping (figure 3) revealed multiple intracellular yeast-like organisms suggestive of Histoplasma capsulatum. Intravenous amphotericin B was given, followed by oral itraconazole. Her condition improved after 2 weeks of treatment. Antiretroviral medications were initiated 1 month later.

Figure 1

Multiple pruritic erythematous purplish maculopapular rashes with some central necrotic areas predominantly on the (A) face, (B) back-chest wall and (C,D) both forearms.

...

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Down syndrome and Moyamoya disease: unusual cause of stroke

Down syndrome is a frequent clinical entity, being considered one of the most frequent chromosomal aberrations. It is characterised by a typical clinical phenotype and is associated with a heterogeneous group of organ and system-specific abnormalities. The cardiovascular system is commonly affected and if so, it may be associated with an increased morbidity and mortality. Cerebrovascular events in patients with Down syndrome are multifactorial, being possibly related to congenital heart disease, vascular malformations and traditional cardiovascular risk factors. Moyamoya disease is a rare chronic occlusive vascular disease causing stenosis of the distal portion of the internal carotid artery, which has been associated with Down syndrome. The authors report the case of a 26-year-old woman with Down syndrome who presented with an acute stroke secondary to Moyamoya disease. The case is noteworthy for the rarity of this clinicopathological entity, and serves as a reminder for the possible association between these two conditions.

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Microcephaly in infantile Sandhoff's disease

Description

We evaluated a boy aged 16 months with developmental arrest at the age of 6 months followed by neuroregression and recurrent generalised seizures. Perinatal and family history was not contributory. He was first born to non-consanguineous parents by term, uncomplicated vaginal delivery and weighed 2.8 kg at birth. On examination, he was unable to hold neck, fixate, coo or smile and showed no interest in the surroundings. His weight was 9.5 kg (between 15th and 50th centile), length 78 cm (between 15th and 50th centile) and head circumference 44.4 cm (below 3rd centile) with normal head circumference of father (54 cm) and mother (51 cm). He also had hyperacusis, bilateral cherry-red spot, generalised hypotonia, brisk muscle stretch reflexes, bilateral Babinski's sign and no organomegaly. In view of infantile-onset neuroregression, microcephaly, seizures, cherry-red spot and spasticity, clinical diagnoses of GM2 (Tay-Sach's and Sandhoff's disease), GM1 gangliosidosis and Krabbe's disease were considered initially. Skull radiograph showed J-shaped...

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Perforated duodenal diverticulum: a rare complication in a common condition

The authors present a rare case of perforated duodenal diverticulum diagnosed in an 80-year-old Caucasian woman with vomiting and abdominal pain localised to the epigastrium. CT scan showed thickening of the second portion of the duodenum with retroperitoneal fat stranding and perihepatic free fluid, with a presumptive diagnosis of a duodenal perforation. A laparotomy was performed which showed a perforated diverticulum in the second portion of the duodenum. A diverticulectomy with single-layer closure was performed, without complications. The postoperative course was uneventful.

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Survey of nulliparous parturients' attitudes regarding timing of epidural analgesia initiation

At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia.

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Clostridium perfringens 's necrotizing acute pancreatitis: a case of success

Abstract

The authors report a case of a 62-year-old man with upper abdominal pain with few hours of onset and vomits. The initial serum amylase was 2306 U/L. The first CT showed signs of a non-complicated acute pancreatitis. He suffered clinical deterioration and for this reason he was admitted on the intensive care unit where he progressed to multiple organ failure in <24 h. A new CT scan was performed that showed pneumoperitoneum and pneumoretroperitoneum. He underwent an exploratory laparotomy and pancreatic necrosectomy and vacuum pack laparostomy were performed. Intraoperative peritoneal fluid culture was positive for Clostridium perfringens confirming the diagnosis. He was discharged from hospital after 61 days. According to our research this is the second case reported in literature of a spontaneous acute necrotizing pancreatitis caused by C. perfringens, with pneumoretroperitoneum and pneumoperitoneum on evaluation by CT scan, that survived after surgical treatment and vigorous resuscitation.

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Familial spontaneous splenic rupture in a patient with idiopathic splenomegaly—report of a case

Abstract

Spontaneous splenic rupture in a healthy individual is a rare phenomenon. This article reports on a patient with an uneventful medical history, presenting with atraumatic splenic rupture. Three family members of the patients experienced the same in the past.

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Robotic right segmental hepatectomy for the treatment of a giant hepatic hemangioma—a case report

Abstract

Hemangioma is the most common benign hepatic tumor. We present the case of a patient with a giant symptomatic hemangioma, treated with segmental liver resection using the Da Vinci Robotic System. A 38-year-old woman presented to our surgical out-patient Department complaining about abdominal discomfort and recurrent episodes of acute abdominal pain. CT-scan and MRI imaging of the abdomen revealed the presence of a giant hepatic hemangioma (>5 cm) involving segments VI and VII. Robotic right segmental hepatectomy was performed. The procedure was successfully completed in 120 min and with intraoperative blood loss of only 450 ml. Postoperative period was uneventful and the patient was discharged on the second postoperative day. In case of giant hemangiomas, a minimally invasive robotic major hepatic resection is a viable option that can be performed with minimal complications. A careful preoperative and intraoperative strategy is required, while significant experience in liver and robotic surgery is mandatory.

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