Outcome of a giant coronary artery mycotic pseudoaneurysm secondary to non-typhoid Salmonella managed without surgical intervention

A 48-year-old woman with a history of AIDS, a recent coronary artery bypass graft operation and prior bacteraemia with non-typhoid Salmonella presented with non-exertional chest pain and elevated troponins. The cardiac catheterisation and coronary CT angiography revealed a 9 cm pseudoaneurysm arising from the proximal left anterior descending artery. The blood cultures confirmed non-typhoid Salmonella. Emergent surgery was initially deferred due to her complex anatomy. Moreover, the hospital course was complicated by Epstein-Barr virus meningitis and an associated decline in the patient's mentation. Consequently, the mycotic pseudoaneurysm was medically managed with antibiotics and strict blood pressure goals. The natural history of giant mycotic coronary artery pseudoaneurysm formation and progression is appreciated through this first reported medically managed case. The follow-up coronary CT angiography at 3 months showed evidence of pseudoaneurysm leakage into surrounding tissue. The patient expired at 5 months from an unknown cause.

http://bit.ly/2N1iNJk

Atypical presentation of IgG4 sclerosing cholangitis

IgG₄ sclerosing cholangitis (ISC) is a rare disease which usually presents in patients in their 60's or above. Patients often present with obstructive jaundice as the first symptom, especially when associated with autoimmune pancreatitis. We report the case of a 20-year-old man who presented with acute abdominal pain, which was subsequently diagnosed as ISC in addition to autoimmune pancreatitis following magnetic resonance cholangiopancreatography (MRCP). The patient was thus treated with steroids.

http://bit.ly/2SNUJ26

Child with unusual combination of sickle cell disease and autosomal recessive agammaglobulinemia associated with a novel CD79a gene mutation

This article describes a novel mutation in CD79a gene identified in a child with sickle cell disease (SCD), who was diagnosed with autosomal recessive agammaglobulinaemia in the context of prolonged febrile syndrome. The association of a primary immunodeficiency with SCD in the same child was unexpected.

http://bit.ly/2N42BHh

Bilateral maxillary palatal talon cusps in deciduous central incisors

'Talon cusp' is a developmental dental disturbance characterised by a cuspal projection in the cingulum area or cementoenamel junction, with normal enamel and dentin containing varying degrees of pulp tissue. The prevalence of talon cusp varies with race, age and the criteria used for diagnosis. It has been reported in the maxillary and mandibular arches of both the deciduous and permanent dentitions. The prevalence of the talon cusp in the deciduous dentition is reported to be 2.1% in Saudi Arabian subjects. The purpose of this paper is to report the rare bilateral presence of talon cusps on the deciduous maxillary central incisors of a 4-year-old female patient with a family history of consanguineous marriage.

http://bit.ly/2SNjoUi

Intermediate uveitis in a child with phosphatase and tensin homolog gene mutation and Bannayan-Riley-Ruvalcaba syndrome

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is a congenital disorder characterised by macrocephaly, multiple hamartomas, lipomas, and pigmented macules of the glans penis. Intermediate uveitis is characterised by chronic inflammatory cells aggregates on the pars plana (snowbanks) and within the vitreous cavity (snowballs). We describe what we believe to be the first case of intermediate uveitis associated with BRRS. Early examination under anaesthesia should be considered in the management of young children diagnosed with this syndrome in order to provide appropriate ocular evaluation, treatment and follow-up. Further research is needed to establish a better understanding of the ophthalmic manifestations of this syndrome.

http://bit.ly/2N20Eew

Cutaneous angiosarcoma with lymphoedema: the Stewart-Treves syndrome

http://bit.ly/2SNUAM6

Isolated superior petrosal sinus dural arteriovenous fistula treated with selective sinus packing using a quadriaxial catheter system

A 67-year-old patient presented with a headache, vertigo and nausea, followed by a disturbance of consciousness. CT and MRI showed venous ectasia at the left cerebellopontine angle and extensive oedema in the left cerebellum. Angiography demonstrated a dural arteriovenous fistula that appeared at the left superior petrosal sinus–cavernous sinus) junction. After the evaluation of the shunt point, occluded areas were recanalised via the femoral vein with a quadriaxial catheter system using a 6-Fr guiding sheath, 6-Fr guiding catheter, 4.2-Fr catheter and microcatheter. Selective coil embolisation was performed, resulting in shunt removal.

http://bit.ly/2SL56Ub

The Devil Is in the Details

Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information by sharing relevant background and reasoning with the reader (regular type). The authors' commentary follows. Stage. A 75-year-old woman…

http://bit.ly/2Gml3dV

Gastrointestinal stromal tumor of the lesser omentum: a case report and review of the literature

Abstract

A 72-year-old woman visited our hospital for a routine health examination and underwent abdominal ultrasonography, which revealed an intra-abdominal tumor. Abdominal computed tomography and magnetic resonance imaging showed a well-defined solid mass of ~3 cm in diameter lying adjacent to the stomach. The mass was preoperatively diagnosed as gastrointestinal stromal tumor of the stomach. At laparotomy, a well-encapsulated tumor was found in the lesser omentum. It was slightly adherent to the stomach wall but was removed without difficulty. Therefore, only enucleation of the tumor was performed. The excised tumor, which was 35 × 30 × 25 mm³ in size, had a white cut surface without necrosis or hemorrhage. According to the pathological findings, the tumor was classified as a very low-risk gastrointestinal stromal tumor originating in the lesser omentum. Gastrointestinal stromal tumor of the lesser omentum is very rare, and surgical resection is the only effective treatment modality.

http://bit.ly/2GoeDdY

Perforation of Heterotopic Gastric Mucosa in ileal duplication in an adult: A case report

Abstract

Bowel duplication with heterotopic gastric mucosa (HGM) is a known but uncommon pathology. It usually presents with intussusception or melena in the early years of life. We present a case of ileal duplication with HGM with a rare presentation of bowel perforation and peritonitis in an adult male.

http://bit.ly/2IhvPE6

Massive adult cystic lymphangioma of the breast

Abstract

Adult cystic lymphangiomas are exceedingly rare tumors resulting from malformation of the lymphatic vessels. Like their pediatric counterparts, these lesions almost exclusively involve the head and neck. However, adult cystic lymphangiomas have been reported in several organs. Those involving the breast are exceptionally rare, with only a few reported instances. Here, we present the case of a 27-year-old woman who attended a surgical breast clinic with a 2-year history of a large, disfiguring left breast mass. Pathology was consistent with adult cystic lymphangioma of the breast. Measuring 21.0 × 20.0 × 6.0 cm³, this represents the second largest of its kind and the largest reported case in an African American patient.

http://bit.ly/2GmoZeG

Approach to a large rare diaphragmatic hernia in a patient undergoing cardiac surgery

Abstract

Hernia of Morgagni is an unusual congenital defect of the sternal portion of the diaphragm. Its concurrence with cardiac surgical pathology is rarely described in the literature. Notwithstanding, huge hernia of Morgagni have been noted to cause serious peri-operative impediment and complications. We report the case of a 50-year-old gentleman with a massive Morgagni hernia that threatened strangulation during cardiopulmonary bypass. We describe the combined surgical approach undertaken to repair this hernia, with an accompanying review of the literature relating to misadventure and management of similar large hernia coinciding with cardiac surgery.

http://bit.ly/2I9NSvM

Recurrent acute pancreatitis in a patient with both gallbladder and cystic duct agenesis and polycystic liver disease

Abstract

Agenesis of the gallbladder and cystic duct is a rare congenital anomaly occurring in <0.1% of the population. However, combined gallbladder and cystic duct agenesis (CDA) with polycystic liver disease associated with recurrent acute pancreatitis (RAP) has not been reported earlier. Herein we report a case of a 36-year-old female patient who was admitted to the hospital and successfully treated for acute pancreatitis most probably caused in the background of gallbladder and CDA with polycystic liver disease. In case of non-visualization of gallbladder with the presence of biliary symptoms after repeated ultrasonographic examinations, advanced techniques like MRCP, computed tomography, EUS and even endoscopic retrograde cholangiopancreatography (ERCP) to visualize biliary anatomy must be conducted before any surgical intervention. We present a case of gallbladder and CDA causing RAP by the formation of microlithiasis treated successfully with ERCP and without any unnecessary surgery, its management and review of the literature is assessed.

http://bit.ly/2GkWNsx

Spontaneous regression of a sporadic intra-abdominal located desmoid-type fibromatosis

Abstract

Background

Desmoid-type fibromatosis (DTF) is a rare benign proliferation of myofibroblasts with an unpredictable disease course. Treatment of intra-abdominal located DTF is difficult because of the close relationship with vital organs.

Case presentation

A healthy young male presents with an asymptomatic palpable mass in the lower right abdominal quadrant. A computed tomography shows a 10 × 7 cm² pear-shaped mass, and pathological examination revealed DTF. A watchful waiting approach was initiated, as the patient was asymptomatic and surgery would imply a significant amount of intestinal resection. After a follow-up of 2 years, the tumor has regressed spontaneously and the patient is still without symptoms.

Conclusions

DTF is a difficult to treat condition where individualized management is appropriate. An asymptomatic patient could be treated with a watchful waiting approach, even with intra-abdominal location. Thereby sparing unnecessary morbidity as the tumor can be stable for many years or even regress spontaneously.

http://bit.ly/2I8Ge4M

Madurella mycetomatis infection of the buttock in an Eritrean refugee in Switzerland: a case report

Mycetoma is a neglected infectious disease caused by a fungus (eumycetoma) or bacteria (actinomycetoma); it is characterized by chronic local inflammation with sinus formation and purulent discharge. Its cours...

http://bit.ly/2GEeO4v

Low-dose spinal anesthesia for cesarean section to prevent spinal-induced hypotension

Purpose of review Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic conditions. Recent findings Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can reduce significantly hypotension. Summary Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires attention and training. Correspondence to Marc Van de Velde, MD, PhD, EDRA, Professor, Department of Cardiovascular Sciences, Chair, Department of Anaesthesiology, Herestraat 49, B - 3000 Leuven, Belgium. E-mail: marc.vandevelde@uzleuven.be Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

http://bit.ly/2N2BoVt

Time-efficient, goal-directed, and evidence-based teaching in the ICU

Purpose of review Teaching in the stressful, high-acuity environment of the ICU is challenging. The intensivist-educator must use teaching strategies that are both effective and time-efficient, as well as evidence-based approaches to the ICU curriculum. This review provides an overview of pertinent educational theories and their implications on educational practices, a selection of effective teaching techniques, and a review on feedback. Recent findings Evidence supports the role of conceptual frameworks in providing the educator with a key perspective to obtain a deeper understanding of the factors contributing to an effective and goal-directed education in the ICU. The role of simulation training for technical and nontechnical skills acquisition is growing. Feedback is difficult to provide, but critical to facilitate learner success; frameworks, and approaches are becoming more standardized. Summary Direct teaching should be goal-oriented, sequential, and adjusted to the level of the learner. The ICU curriculum should optimize cognitive load, reduce stress that is unrelated to the activity, include resilience training, and help trainees deal with stressful clinical situations better. Simulation is a powerful tool to promote technical and nontechnical skills. Providing feedback is essential and a skill that can be taught and enhanced with structure, prompts, and tools. Correspondence to Marek Brzezinski, MD, PhD, VA Medical Center, Anesthesiology Service (129), 4150 Clement Street, San Francisco, CA 94121, USA. Tel: +1 415 750 2069; e-mail: marek.brzezinski@ucsf.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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