Postoperative hemiparesis following tonsillectomy

Abstract

We report a rare complication following a routine elective tonsillectomy. A 32-year-old woman woke up from general anaesthesia with left sided hemiparesis. She underwent extensive investigations, which were normal. At follow-up neurology clinic she was given a new diagnosis of hemiplegic migraine and commenced on treatment. This case draws attention to a rare cause of postoperative hemiparesis. Hemiplegic migraine is a differential diagnosis for postoperative motor deficit after exclusion of an acute neurological or metabolic event.

http://bit.ly/2I1DC8D

Laryngeal ulceration in Behçet’s disease: the role of centres of excellence in the UK

Abstract

Introduction

Behçet's disease (BD) is a rare complex multisystem inflammatory condition characterized by the triad of symptoms: aphthous ulcers of the mouth and genitalia and uveitis.

Case report

We present the case of a 31-year-old Caucasian male who had a prolonged journey from first presentation until diagnosis of BD. For 11 years, he presented symptoms affecting the oral cavity and oropharynx, with worsening odynophagia and dysphagia and ultimately, development of stridor. Flexible laryngoscopy showed significant laryngopharyngeal ulceration and scarring. Treatment was with colchicine, corticosteroids and azathioprine and supervised by one of three newly established BD Centres of Excellence in the UK.

Discussion

Although uncommon, ENT manifestations in patients with BD should be taken into consideration to allow for early recognition and treatment of what can become a life-threatening condition. In such situations, early referral to a BD Centre of Excellence is essential to provide confirmation of diagnosis and supervision of treatment.

http://bit.ly/2GhLgKG

A rare case of small bowel obstruction secondary to activated charcoal administration

Abstract

Intestinal obstruction is a rare complication of the administration of activated charcoal. We describe a 22-year-old patient who had received multiple-dose activated charcoal for carbamazepine intoxication. The patient presented with sudden-onset abdominal pain after discharge from the emergency room, and abdominal imaging examinations revealed findings consistent with small bowel obstruction. Laparoscopic-assisted exploration of the abdomen was offered, and a hard obstructing charcoal mass was found in the small bowel. Clinicians should be aware of the rare occurrence of gastrointestinal complication or obstruction following the administration of multiple-dose activated charcoal, especially in patients who ingested a drug that is potentially antiperistaltic.

http://bit.ly/2I1DzJZ

When breast cancer gets complicated. A case report of synchronous bilateral breast cancers with discordant tumor markers from the primary to nodes with findings of a sentinel internal mammary subpectoral lymph node

Abstract

This case reviews synchronous bilateral breast cancer with left infiltrating ductal carcinoma ER+/PR−, Her2− and right invasive lobular carcinoma ER+/PR−, Her2−. Independent primary bilateral breast tumors are present in 0.2–3.2% of breast cancer. Biopsy also showed differing ER status on the left breast versus the node which was triple negative. The final sentinel node was a left internal mammary node. Recent studies have found that the ER, PR and HER2 status of the primary tumor do not always correlate to the ER, PR and HER2 status of the metastatic sites. This can have deleterious effects on survival. There are no clear guidelines on course of treatment for these complex cases. A review of the current literature is supportive of treating the highest-risk breast malignancy. Despite the unusual pathology and severity of disease, our patient is doing well with treatment.

http://bit.ly/2Ghfxt2

Primary midgut volvulus in a patient with Marfan syndrome

Abstract

Marfan syndrome is a mutation in the fibrillin-1 gene resulting in a connective tissue disorder primarily affecting musculoskeletal, cardiovascular and ocular systems. However, patients with Marfan's rarely manifest gastrointestinal symptoms. Midgut volvulus is abnormal twisting of small bowel around its mesentery that can result in compromising blood flow to the bowel causing intestinal ischemia and obstruction. Primary midgut volvulus is a term used when there is no underlying cause for the volvulus. This case describes an 80-year-old female with Marfan syndrome presenting with primary midgut volvulus, which preoperatively was suspected based on imaging, and later confirmed upon operative exploration. The small bowel mesentery was long with a narrow base twisted around its mesentery 360°. The long narrow base and floppy mesentery likely contributed to hypermobility leading to volvulus and small bowel obstruction. To our knowledge, this is the first reported case of primary midgut volvulus associated with Marfan's syndrome.

http://bit.ly/2I9p47g

Extra-gastrointestinal stromal tumor with a large cyst

Abstract

Gastrointestinal stromal tumors (GISTs) arising at sites other than the alimentary tract are rare, and they are called extra-GISTs (EGISTs). We report a case of a large EGIST forming a cyst, probably arising in the mesentery of the transverse colon. A 64-year-old Japanese man presented to a hospital with an abdominal tumor forming a large cyst. Intraoperatively, the tumor was neither present in nor in contact with the alimentary tract. It was present in the mesentery of the transverse colon and was attached to the greater omentum and peritoneum, immediately anterior to the body of the pancreas. The tumor was resected with the spleen and a part of the pancreas. Histological examination of the tumor revealed that it belonged to the high-risk category of cystic EGISTs.

http://bit.ly/2Gi8z6N

Paraneoplastic opsoclonus–myoclonus syndrome as a rare presentation of breast cancer

Abstract

Opsoclonus–myoclonus paraneoplastic syndrome is a medical condition that includes opsoclonus along with diffuse or focal body myoclonus and truncal titubation with or without ataxia and other cerebellar signs. This rare neurological syndrome is poorly understood and can result in long-term cognitive, behavioral and motor sequelae. We report a case of a 49-year-old woman with anti-Ri antibody opsoclonus–myoclonus syndrome and an invasive ductal carcinoma with axillary nodes involvement. Following the diagnosis of opsoclonus–myoclonus syndrome, a multimodal immunotherapy treatment, with partial remission of the neurological symptoms. The patient underwent lumpectomy and axillary node dissection and the surgical pathology confirmed the diagnosis of breast cancer stage IIA. This was followed by chemotherapy, radiotherapy and hormone therapy with tamoxifen. At the 6 months follow-up there was a partial improvement, anti-Ri antibody was subsequently reported as negative and there was no evidence of disease recurrence.

http://bit.ly/2I9p0o2

Knee locked in flexion: incarcerated semitendinosus tendon around a proximal tibial osteochondroma

Abstract

This case reports on a knee locked in flexion due to incarceration of the semitendinosus tendon around an osteochondroma in a patient with a history of multiple hereditary exostoses (MHE). An 18-year-old female with history of MHE presented with acute right medial knee pain and inability to extend her knee. Radiographs confirmed multiple lower extremity osteochondromas, notably a large, 3-cm pedunculated osteochondroma about her right medial proximal tibia. This was assessed as a locked knee secondary to incarcerated hamstring tendons around an osteochondroma. Excision of the osteochondroma restored normal flexion and extension of her knee. At the 3-month follow-up visit, she had returned to all activities with no recurrent medial knee pain or locking. The differential diagnosis for a locked knee joint can be broad, but tendon incarceration should be considered in appropriate patients with significant symptoms. In patients with a history of MHE, osteochondromas may be the cause of tendon entrapment.

http://bit.ly/2GfwGTH

Glioblastoma and prolactinoma: a rare simultaneous occurrence

Abstract

The simultaneous development of two or more primary central nervous system (CNS) tumors of different cell types represents 0.9% of all diagnosed CNS tumors. To the best of our knowledge, the simultaneous occurrence of glioblastoma and pituitary adenomas has been reported four times in the English literature, with only two cases harboring prolactinoma and glioblastoma. We report a case of a 42-year-old male who was diagnosed with a sporadic co-occurrence of glioblastoma and a prolactin-secreting pituitary adenoma (prolactinoma). This case report discusses the clinical presentation, radiological/histopathological features, and outcome as well as reviewing the pertinent medical literature. Glioblastoma and a prolactin-secreting adenoma may be detected within the same patient. Further studies are required to delineate the tumorigenesis of the development and co-occurrence of multiple intracranial tumors.

http://bit.ly/2I9oXsm

Open brachiocephalic artery stent for static obstruction caused by acute type A aortic dissection

Abstract

Brachiocephalic artery dissection complicated by acute type A aortic dissection occasionally causes cerebral malperfusion. Although immediate central aortic repair has been the standard treatment for aortic dissection, dissection in supra-aortic vessels frequently remains after the surgery. The residual brachiocephalic artery dissection is reported to be associated with late neurological events. Therefore, additional intervention for brachiocephalic artery dissection during central aortic repair should be considered in selected cases. In this report, we describe two cases requiring open brachiocephalic artery stenting simultaneous with central aortic repair. There were no neurological or stent induced complications at latest follow-up.

http://bit.ly/2GhT92D

Intraductal papilloma of the male breast: a case report and review of the literature

Abstract

Intraductal papilloma is a benign neoplasm rarely found in the male breast. In this report, we present the case of a 55-year-old Caucasian man who presented with spontaneous bloody nipple discharge of the right breast. Ultrasonic and mammographic investigations revealed a sub-centimetre solid mass within a dilated duct. He underwent a total duct excision. Histopathologic examination confirmed a benign intraductal papilloma with no evidence of atypia or malignancy. A systematic review of the literature revealed six published cases of intraductal papillomas in men. Clinical presentation is the same as in women with single duct blood stained discharge being the most common presenting symptom. Surgical excision offers both histologic confirmation and definitive treatment. There is one case where the lump was not removed and progressed to malignancy years later. Male intraductal papillomas may be associated to medical treatments with hormonal activity given for other reasons or endocrine abnormalities.

http://bit.ly/2I9oV3I

Collapsed wall: destructive and reconstructive surgery of anterior abdominal wall tumour in a young girl

ABSTRACT

Natural history of abdominal wall soft tissue sarcoma is still poorly understood due to its rarity. In unpublished data of our institution, only seven cases of abdominal wall soft sarcoma with ICD-10 coding of 49.4 were found for past 10 years. We illustrate a case of juvenile fibrosarcoma of anterior abdominal wall. This is a case of young girl with anterior abdominal wall tumour, underwent wide local excision with immediate reconstruction. There are few options of surgical treatment for this case, but which is the best. It is always a challenge in managing young patient with giant abdominal wall defect in view of long term effect namely weakened abdominal wall, pregnancy related issue and risk of herniation and surgical site recurrence as well.

http://bit.ly/2GhLcKW

Laparoscopic deroofing of a ruptured hepatic cyst presenting as an acute abdomen

Abstract

The rupture of a nonparasitic hepatic cyst is a rare complication for which there is no optimal treatment strategy yet. Laparoscopic deroofing is the standard approach for the elective treatment of symptomatic NHCs but it has seldom been described as an option for a ruptured hepatic cyst. The authors report a case of a male patient presenting to the emergency room with an acute abdomen caused by the rupture of a hepatic cyst. The patient was successfully treated by urgent laparoscopic deroofing of the cyst. Laparoscopic surgery can be a valid option for treating urgent cases presenting the same efficacy and less morbidity than open surgery.

http://bit.ly/2I9oRRw

Bariatric surgery and the evaluation of subclinical systemic lymphedema

Abstract

The aim of the study was to report an improvement in clinical lymphedema in a patient who went from morbid obesity to overweight following bariatric surgery. A 52-year-old female patient reported having undergone bariatric surgery with a body mass index (BMI) of 51.2 kg/m², losing 40 kg and arriving at her current BMI of 37.1 kg/m². She would previously awake with bilateral edema that involved her feet and worsened throughout the day, corresponding to clinical stage II lymphedema, and currently no longer had this problem. Eight years after the surgery and weight loss, the patient was submitted to electrical bioimpedance analysis, which revealed an increase in total intracellular and extracellular fluids in the limbs and trunk. Active exercise and further weight loss were recommended. This study paves a path for a new line of investigation in the treatment of obesity and changes in the lymphatic system caused by obesity.

http://bit.ly/2GfSjn5

The tales of two neighbours: when cholecystitis does not preclude pancreatitis

Abstract

An 83-year-old lady with no previous history of gallstones, presented with a sudden-onset severe epigastric pain radiating through to the back associated with nausea and vomiting. On examination, the patient's vital signs were normal. There was severe epigastric tenderness on palpation, as well as moderate right upper quadrant tenderness. Serological investigations showed raised inflammatory markers and serum lipase of 13 000, confirming the diagnosis of acute pancreatitis. Liver function tests were mildly deranged with a normal bilirubin of 12 μmol/L. An abdominal ultrasound demonstrated a distended gallbladder with multiple subcentimeter gallstones and diffuse wall thickening up to 7 mm, consistent with cholecystitis. A follow-up CT abdomen demonstrated evidence of pancreatitis with moderate peripancreatic fat stranding. The diagnosis of concomitant acute cholecystitis and gallstone pancreatitis was made based on the radiological and biochemical findings. The patient underwent an uncomplicated laparoscopic cholecystectomy. The histopathology confirmed cholelithiasis with acute on chronic cholecystitis.

http://bit.ly/2I9oQgq

Upper extremity distal dual bypass enables arteriovenous fistula construction in a critical limb ischemia

Abstract

Background

Arteriovenous fistula (AVF) trouble in a dialysis patient sometimes results in severe forearm ischemia.

Case presentation

We present the case of 27-year-old man with severe steal syndrome complained of AVF malfunction. There was a condition where an upstream artery of AVF is occluded and AVF is maintained by regurgitation from the palmar arch with ischemic digits. The patient underwent distal dual bypass: proximal to peripheral artery arterioarterial and arteriovenous bypasses and brachial arterioplasty. His skin perfusion pressure improved from 17 to 90 mmHg with enough quantity of blood: 250 ml/min for hemodialysis.

Conclusions

In severe steal syndrome cases, it is often observed that proximal artery is occluded and AVF inflow was supplied from palmar circulation and collateral vessels. Distal dual bypass is effective to re-establish digital circulation and repair AVF malfunction simultaneously in PAD patients.

http://bit.ly/2GhPtO7

Colon adenocarcinoma with metastases to the scaphoid: a case report and review of the literature

Abstract

Metastases to the hand and wrist are extremely rare, with <250 cases described in the literature. We present a case of acrometastasis of colon adenocarcinoma to the scaphoid in an 81-year-old male. Adenocarcinoma of the colon metastasizes to bone in an estimated 10% of cases; however, we are unaware of reports of this tumor metastasizing to the scaphoid or to any of the other carpal bones. We were able to identify only two cases of scaphoid metastases in the literature. This case highlights the potential for metastatic disease and other lesions to develop in the scaphoid and carpus.

http://bit.ly/2I1Dnuf

Transverse colon perforation secondary to fish bone ingestion

Abstract

Accidental ingestion of foreign bodies can be a common occurrence in clinical practice and subsequent perforation is quite rare. The rate of fish bone ingestion is predicted to be higher in some cultures given culinary differences. We report a case of 62-year-old gentleman in rural Australia who had severe left sided abdominal pain and fevers, with a presumptive diagnosis of diverticulitis. Computated tomography revealed intraabdominal abscess. Surgical intervention via laparotomy and right hemicolectomy was performed for an extensive abdominal abscess with a transverse colon perforation and fish bone foreign body in situ (Grunter fish).

http://bit.ly/2GhL91I

Portal venous gas and pneumatosis intestinalis: ominous findings with an idiopathic aetiology

Abstract

Pneumatosis Intestinalis and hepato-portal venous gas are rare but ominous radiological findings that are synonymous with mesenteric ischaemia and bowel infarction in the majority of cases. Very uncommonly benign pathology have been implicated, including respiratory and inflammatory bowel disease. We provide a case of a 69-year-old gentleman with extensive peripheral vascular disease, who presented with generalized abdominal pain and findings of both pneumatosis intestinalis and hepato-portal venous gas. Laboratory investigations were unequivocal, with only mild lactatemia. Emergency laparotomy was performed, which revealed no obvious cause and only some turbid pelvic free fluid. The patient had an uncomplicated recovery. This case illustrates the importance of guiding decisions based on the patient's clinical state, and of keeping an open mind to benign pathology. It also highlights the importance of early surgical intervention in cases of high clinical suspicion.

http://bit.ly/2I1DlT9

Guidelines for the use of cerebral oximetry by near-infrared spectroscopy in cardiovascular anesthesia: a report by the cerebrospinal Division of the Academic Committee of the Japanese Society of Cardiovascular Anesthesiologists (JSCVA)

Abstract

Cerebral Oximetry by Near-infrared Spectroscopy (NIRS) has been used in cardiovascular anesthesia, but there was no guideline of regional cerebral oxygen saturation measured by cerebral oximetry by NIRS. This guideline provides recommendations applicable to patients at a risk of developing cerebral ischemia in cardiovascular surgery. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances, and should not replace clinical judgment. The Japanese Society of Cardiovascular Anesthesiologists (JSCVA) Task Force on Guidelines make an effort to ensure that the guideline writing committee contains broad views in using cerebral oximetry. Adherence to recommendations could be enhanced by shared decision making between healthcare providers and patients. This guideline was focused on cerebral oximetry of pediatric and adult cardiovascular disease. We hope this guideline would play an important role in using cerebral oximetry by measured NIRS.

http://bit.ly/2BqJkLv

Vogt-Koyanagi-Harada Disease-Like Uveitis during Nivolumab (Anti-PD-1 Antibody) Treatment for Metastatic Cutaneous Malignant Melanoma

Nivolumab is an anti-programmed cell death protein 1 monoclonal antibody that is used to treat metastatic cutaneous malignant melanoma. Although bilateral uveitis has been reported as a side effect of nivolumab administration, there are few reports of Vogt-Koyanagi-Harada disease (VKH)-like uveitis. We report such a case. A 63-year-old woman with metastatic cutaneous malignant melanoma experienced visual loss in both eyes 10 days after her second nivolumab injection. Her decimal best-corrected visual acuity (BCVA) was 0.7 in the right eye and 0.4 in the left eye. Examination revealed bilateral granulomatous keratic precipitates and posterior synechiae in the left eye. Optical coherence tomography showed multiple sites of serous retinal detachment (SRD) in the left eye and wavy retinal pigment epithelium in both eyes. Fluorescein angiography revealed multiple pinpoint-sized areas of leakage in both eyes and active leakage from the disc in her right eye. Indocyanine green angiography (IA) showed choroidal hyperfluorescence due to choroidal vascular leakage, with hypofluorescent dark spots during the late phase. These findings supported a diagnosis of VKH-like uveitis following nivolumab injections. Nivolumab was discontinued because of headache. Anterior chamber inflammation disappeared 3 weeks after starting topical corticosteroid treatment, and the SRD disappeared within 3 months. Her decimal BCVA recovered to 1.0 in the right eye and to 0.9 in the left eye. Also, the fluorescein angiography and IA findings had improved by 4 months. We concluded that careful follow-up is required after nivolumab treatment because VKH-like panuveitis might develop.
Case Rep Ophthalmol 2019;10:67–74

http://bit.ly/2DYpvgz

Abdominal girth has a strong correlation with ultrasound-estimated epidural depth in parturients: a prospective observational study

Abstract

Background

Preprocedural ultrasound examination of vertebral column guides to locate desired intervertebral space and provides a prevision of needle trajectory and estimated needle depth in parturients. The objective of this study was to assess the correlation between ultrasound-estimated epidural depth (ED) with abdominal girth (AG), body mass index (BMI), weight, height, and age.

Methods

In this prospective, observational study, ultrasound imaging was done at L3–4 interspace in transverse median plane (TP) and paramedian sagittal oblique plane (PSO) to obtain ultrasound estimates of skin to epidural space depth. Combined spinal epidural anesthesia was performed at L3–4 interspace. AG, BMI, age, height, and weight were recorded for every parturient.

Results

Data from 130 parturients were analyzed. Estimated ED was 56.5 ± 9.5 mm in TP, 57.5 ± 9.3 mm in PSO, and actual epidural depth was 57.9 ± 9.4 mm. Correlation coefficients between ED and AG were 0.797 in TP (95% CI 0.727–0.854, p < 0.001) and 0.803 in PSO (95% CI 0.733–0.857, p < 0.001). Correlation coefficients between ED and BMI were 0.543 in TP (95% CI 0.405–0.661, p < 0.001) and 0.566 in PSO (95% CI 0.428–0.680, p < 0.001). Correlation coefficients between ED and weight were 0.593 in TP (CI = 0.466–0.695, p < 0.001) and 0.615 in PSO (CI = 0.500–0.716, p < 0.001). Height and age had no significant correlation with ED.

Conclusions

Abdominal girth has a strong correlation with ultrasound-estimated epidural depth in parturients.

http://bit.ly/2SD7Vqu