Hepatocellular carcinoma presenting as spinal cord compression in Native Americans with controlled hepatitis C: two case reports

Hepatocellular carcinoma is a common malignancy in Asia. It is associated with chronic hepatitis B virus or hepatitis C virus infection and alcoholic hepatitis. Commonly, the tumor metastasizes to the lungs, r...

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Diagnosing microscopic pancreatic neuroendocrine tumor using 68-Ga-DOTATATE PET/CT: case series

Abstract

Neuroendocrine tumors (NETs) are an uncommon diagnosis which often present asymptomatically or with vague symptoms. They can originate from many different organs such as the GI tract, lungs, pancreas and others. ⁶⁸Gallium DOTATATE positron emission topography/computed topography has been shown to be an effective imaging modality for diagnosing NET and evaluating management options for patients. Here, we present two cases of positive findings in the distal pancreas on the DOTATATE PET/CT scans without any morphological lesion found to be NET in a healthy 48-year-old male and 68-year-old male.

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Adult ileocecal intussusception induced by adenomatous ileal polyp: case report and literature review

Abstract

Intussusception is a rare cause of bowel obstruction in adults, and has generally an organic etiology. However, adenomatous polyp of the small bowel is an uncommon etiology. Moreover, there's a great difference with childhood intussusception in its presentation, etiology and management. We describe herein a case of adult ileocecal intussusception due to an adenomatous ileal polyp with a preoperative diagnosis made on computed tomography. We performed a right hemicolectomy, without attempting to reduce the intussusception, and an end-to-end ileotransverse anastomosis. The pathological examination of the surgical specimen revealed an adenomatous polyp with a high grade dysplasia on the terminal ileum, being the cause of the ileocecal intussusception.

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Biliary obstruction secondary to migrated intra-duodenal gastric band: a case report

Abstract

Adjustable gastric banding (AGB) was a previously popular bariatric procedure, but adverse events such as erosion have surfaced as common complications. We present an interesting case of an AGB causing biliary obstruction after eroding into the stomach.

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Spontaneous rupture of the urinary bladder due to bacterial cystitis

Abstract

We report a case of spontaneous rupture of the urinary bladder (SRUB) due to bacterial cystitis in a 76-year-old woman with chief complaint of abdominal pain a day before presentation. She had fever (38.0°C), and her systolic blood pressure dropped to 70 mmHg; she was referred to our hospital, where she was admitted with a diagnosis of ileus. However, her abdominal pain worsened the following day, and abdominal CT showed free air. Emergency laparotomy was performed for suspicion of digestive tract perforation, which revealed a small hole at the dome of the urinary bladder and another at the peritoneum. Suture repair was performed. We reviewed the abdominal CT on admission and noted that the perforation of the urinary bladder was present during admission, whereas that of the peritoneum occurred the following day. SRUB is rare, and bacterial cystitis rarely causes it; thus, accurate diagnosis and proper treatment are essential.

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Adenoma mimicking hyponatremia of SIAD

Hyponatremia is a common electrolyte disorder, with prevalence as high as 20% in inpatient settings. It is classified based on volume status, urine sodium and osmolality results. While this approach might help narrow down the differential diagnoses, it can leave other diagnoses unentertained. In this case, we report recurrent and refractory hyponatremia secondary to hypocortisolism due to non-functioning pituitary macroadenoma. Interestingly, urine studies mimicked syndrome of inappropriate antidiuresis, but exclusively responded to hydrocortisone replacement. Hospital course was also complicated by hyponatremia-induced rhabdomyolysis, which is a rare complication of severe hyponatremia. We also discuss the role of anchoring heuristics and how they influence the physician's decision leading to possible diagnostic errors. One way to minimise the effect of anchoring bias on physicians is their cognitive awareness of such bias. In addition, discussing complicated cases with all members of medical team can highlight the clinician's thought processes, share uncertainty and help broaden differential diagnoses.

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Pneumatosis cystoides intestinalis (PCI) in a patient with undiagnosed systemic sclerosis

Pneumatosis cystoides intestinalis (PCI) refers to the presence of gas within the wall of the small or large intestine. The pathophysiology is incompletely understood and is probably multifactorial in nature. PCI is a known but rare complication of systemic scleroderma, and the aetiology of PCI in patients with scleroderma is not fully understood. We present the case of a patient who was referred to gastroenterology clinic by her general practitioner for investigation of 8 months of weight loss, urgency, diarrhoea, bloating and crampy abdominal pain. Extensive investigations were performed to exclude infective, inflammatory or malignant aetiologies for these symptoms. She was diagnosed with PCI on her colonoscopy and was subsequently screened for secondary causes. Our patient was diagnosed with the limited cutaneous (CREST) variant of systemic scleroderma. This case report illustrates that PCI could be an uncommon presentation of systemic sclerosis, therefore clinicians should be aware of the association between these conditions.

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Correction: Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis

Webb E, Parkes RJ, Gough AT, et al. Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis. BMJ Case Rep 2018. doi:10.1136/bcr-2017-223560.

This article was published with an error in the funding statement. The correct funding statement should read: 'the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors'.

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Perianeurysmal vasogenic oedema (PAVO) following aneurysm embolisation: a unique case of asymptomatic long-term progression and review of the literature

Perianeurysmal vasogenic oedema is a recognised although rare phenomenon following endovascular treatment of certain intracranial aneurysms. We present a unique case of asymptomatic perianeurysmal vasogenic oedema following bare platinum coil embolisation of an incidentally discovered right middle cerebral artery aneurysm that slowly increased over a period of 6 years before stabilising and regressing. During this time, the coiled aneurysm per se remained completely stable on serial magnetic resonance angiography.

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Pneumopericardium due to bronchopericardial fistula in a patient with lung cancer

Description 

Documented cases of pneumopericardium in patients with lung cancer are extremely rare.

We report the case of a 66-year-old man with a 45 pack-year smoking history and an Eastern Cooperative Oncology Group performance status 4. He presented with dyspnoea and chest pain in the last 2 hours. There were no signs of cardiac tamponade present.

CT angiography of the chest revealed a 78 mm right pulmonary mass containing small areas with gas density and a pneumopericardium of 28 mm in maximum thickness (figure 1). Transthoracic echocardiography showed the air gap sign, identified as the loss of signal during the systolic phase presented in patients with pneumopericardium. Bronchofibroscopy showed extensive infiltration and destruction of the carina bronchial wall and of the main bronchi by malignancy and endobronchial disease (figure 2). Endobronchial biopsies revealed an invasive squamous cell carcinoma.

Figure 1

CT angiography of the chest...

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Unusual case of primary pulmonary Hodgkins lymphoma presenting with a continuous murmur

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin's lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin's lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.

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Gardener-associated fibroma: an unusual cause of upper airway obstruction

We present the first case of upper airway obstruction secondary to a retropharyngeal Gardner-associated fibroma (GAF). A 16-month-old infant presented with a 3-month history of worsening dyspnoea and apnoeic episodes. Examination revealed stridor and left-sided retropharyngeal asymmetry. MRI demonstrated a mass in the retropharynx. Tracheostomy and pharyngeal biopsy under anaesthesia were performed, and histology confirmed a diagnosis of GAF. The mass was excised using a transcervical approach, and postoperative recovery was unremarkable. GAF is associated with Gardner's syndrome (GS) and familial adenomatous polyposis (FAP), both of which are associated with multiple colonic polyps and increased risk of colorectal malignancy. Subsequent testing for an APC mutation seen in GS and FAP was negative in our patient. The details of this unusual presentation of a rare disease are given in addition to a review of the literature.

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Liver transplantation for inferior vena cava leiomyosarcoma: from a Maslows hammer to the Occams razor

Leiomyosarcoma (LMS) of primary vascular origin is a rare entity with only potentially curative option being complete surgical resection; despite which the prognosis remains dismal. Tumour recurrence is very common, and the benefits of adjuvant therapy are undefined. A 39-year-old woman presented with 6 months' history of abdominal pain, abdominal distension and pedal oedema. On evaluation, she was diagnosed to have chronic Budd-Chiari syndrome (BCS) secondary to a tumour arising from the inferior vena cava (IVC) on evaluation. Her liver decompensation included jaundice, gastrointestinal bleed and ascites. Following a detailed multidisciplinary team discussion, she underwent complete excision of the tumour along with a segment of the IVC with living donor liver transplantation. She remains disease-free 24 months following surgery. This is the first reported case of liver transplantation for IVC LMS causing chronic BCS.

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Kiloh-Nevin syndrome associated with humeral shaft fracture

Fracture humerus may be associated with nerve injuries. However, among them median nerve is uncommonly involved and clinical affection of the anterior branch of median nerve is rare which can be easily missed and could be under-reported. A 42-year-old man presented with closed fracture of shaft of humerus right sided following fall. He had isolated weakness of flexor pollicis longus and flexor digitorum profundus of index finger without any other sensorimotor dysfunction. The findings were consistent with isolated palsy of anterior interosseous nerve (AIN). The patient was operated with fixation of humerus without exploring the AIN. At 6-month follow-up, the patient had complete recovery of both the muscles. This case highlights the classical clinical presentation of a rare injury associated with humerus fracture. Awareness and knowledge of this entity is of paramount importance for the practitioners.

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Neuromyelitis optica with unilateral diaphragmatic paralysis

In this case report, we describe the course of a female patient who is known to have neuromyelitis optica (NMO) and developed left hemiparesis and unilateral diaphragmatic paralysis. She was initially treated with intravenous methylprednisolone 1 g daily for 5 days without improvement. Subsequently, she received five sessions of a plasmapheresis. Her hemiparesis had improved after few days. however, the phrenic nerve palsy remained.

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Leptomeningeal dissemination of spinal pilocytic astrocytoma: a rare entity

Description 

A currently 12-year-old boy presented at the age of 8 months with sleepiness, irritability and a tense fontanelle with upgaze palsy on a background of a 2-month history of vomiting, difficulty feeding and weight loss. Acute communicating hydrocephalus was diagnosed using ultrasonography and CT and treated with Ventriculo-Peritoneal shunt insertion. Further investigation with MRI (2006) found a thoracic intramedullary mass with further intracranial and spinal leptomeningeal dissemination (LD) (figures 1 and 2). A biopsy of the thoracic intramedullary mass showed pilocytic astrocytoma (PA) (figure 3).

Figure 1

Initial MRI whole spine (2006). (A) T2 sagittal, (B) T1 sagittal and (C) postcontrast T1 sagittal. Black arrows in (A) and (B) show upper thoracic intramedullary mass. The white arrow in (C) shows no significant enhancement. Thick white arrows in (C) show leptomeningeal enhancement.

Figure 2

Initial MRI brain...

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Severe calcium pyrophosphate dihydrate deposition disease of the metacarpophalangeal joints

We report a case of calcium pyrophosphate deposition disease (CPPD) with an unusual presentation of severe chondrocalcinosis with atypical large burden deposited in the metacarpophalangeal joints as well as more typical deposition in wrists and knees as demonstrated on plain radiographs. A 77-year-old African-American woman 1-year status post parathyroidectomy for hyperparathyroidism initially presented to the rheumatology clinic to treat suspected rheumatoid arthritis given her pattern of joint involvement but was found to have CPPD. The patient's history is notable for end-stage renal disease which complicates medical management. This case illustrates radiographic findings of CPPD and explores the challenges of treating CPPD in the setting of comorbid conditions.

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Effect of high-flow high-volume-intermittent hemodiafiltration on metformin-associated lactic acidosis with circulatory failure: a case report

Metformin-associated lactic acidosis is a well-known life-threatening complication of metformin. We here report the case of a patient who developed metformin-associated lactic acidosis without organ manifestat...

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