Intrathoracic scapular dislocation following lung cancer resection

Abstract

A 64-year-old man underwent right upper lobectomy combined resection with third-fifth rib for lung cancer and reconstruction of chest wall using Dual Mesh. Six days after surgery, he experienced acute severe pain in the right shoulder. The purulent drainage through the drainage tube was also found. Chest CT showed that the inferior angle of the scapula protruded into the right intrathoracic cavity. We performed a removal of Mesh. Although we did not want to use synthetic materials because of infection, we performed titanium plate fifth rib fixation to avoid the recurrent dislocation of the scapula. After the redo surgery, continuous lavages with physiologic saline of the thoracic cavity was also performed. Patient is now doing well without recurrences of cancer, infection and scapular dislocation, 14 months after the redo surgery.

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Concomittant fibrous dysplasia with aneurysmal bone cyst formation within the skull, humerus and rib

Abstract

Polyostotic fibrous dysplasia (FD) is a rare pathology characterized by the abnormal and gradual replacement of normal bone (calcium hydroxylapatite of osteoid matrix) with fibrous connective tissue. Aneurysmal bone cyst (ABC) is a tumor-like benign lesion with blood-filled cavities that can affect virtually any bone in the body. We report on a 20-year-old male presenting with an extremely rare pathology of FD with ABC formation of the skull, fourth rib and humerus. Our case report represents a novel literary addition to rare FD with ABC pathologies. Optimal diagnosis of this rare pathology can be achieved by a full body evaluation for clinical and radiographic FD with or without ABC, and optimal treatment for this rare pathology is the maximum surgical excision of the tumor and/or soft tissue.

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Case report: irreducible medial subtalar dislocation with incarcerated anterior talar head fracture in a young patient

Abstract

Subtalar dislocations are rare injuries that typically occur from high-energy injuries. All subtalar dislocations should be attempted to be closed reduced, however, ~32% are irreducible requiring open reduction. We present an irreducible medial subtalar dislocation following a motor vehicle accident with no associated fractures demonstrated on radiograph. However, open reduction revealed an incarcerated anterior talar head fracture that was reduced and stabilized with retrograde K-wires.

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Food protein-induced eosinophilic enteritis with intestinal stricture in a neonate: a case report and review of the literature

Abstract

The case of a 21-day-old boy with eosinophilic enteritis with intestinal stricture due to a food protein-induced allergy is reported herein. For the first 4 days of life, he was both breast-fed and formula-fed, after which he was exclusively breast-fed. At the age of 24 days, he underwent laparotomy to investigate the possibility of intestinal obstruction for bilious vomiting, and an ileal stricture was detected and resected. Pathologic analysis showed the presence of eosinophil accumulation in the lesions presented more than 20 eosinophils per high-power field and the eosinophils were oriented towards the epithelium and diffusely distributed throughout the tissue, but the margins of resection showed a few infiltration of eosinophiles. Allergen-specific lymphocyte stimulation testing showed a markedly increased lymphocyte response to lactoferrin. He was finally diagnosed as eosinophilic enteritis with intestinal stricture due to a food protein-induced allergy. The patient remained asymptomatic during a follow-up period of 12 months.

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Total arch replacement as treatment for repeated cerebral infarctions due to unstable plaque simultaneously in the innominate artery and left subclavian artery: a case report

Abstract

We report a case of total arch replacement in a patient who suffered repeated cerebral infarctions due to unstable plaque simultaneously in the innominate and left subclavian arteries.

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Case 22-2018: A 64-Year-Old Man with Progressive Leg Weakness, Recurrent Falls, and Anemia

Presentation of Case. Dr. Molly E. Wolf (Medicine): A 64-year-old man was admitted to this hospital because of progressive leg weakness, recurrent falls, and anemia. The patient had been in his usual state of health until 8 months before this admission, when fatigue on exertion and subjective leg…

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Case 21-2018: A 61-Year-Old Man with Grandiosity, Impulsivity, and Decreased Sleep

Presentation of Case. Dr. Samuel J. Boas (Psychiatry): A 61-year-old man was brought to the emergency department of this hospital by his family because of concerns about grandiosity, impulsivity, decreased sleep, and increased alcohol use. The patient had a history of alcohol-use disorder; he had…

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Optic Neuritis Possibly Induced by Anti-PD-L1 Antibody Treatment in a Patient with Non-Small Cell Lung Carcinoma

Background: Recent immune therapy with checkpoint inhibitors (CPIs) has demonstrated remarkable antitumor effects on specific tumors, such as malignant lymphoma and non-small cell lung carcinoma. By contrast, CPIs cause an imbalance in the immune system, triggering a wide range of immunological side effects termed immune-related adverse effects (irAEs). Here, we report a rare case of optic neuritis and hypopituitarism during anti-programmed death-ligand 1 (PD-L1) antibody treatment. Case Presentation: A patient with non-small cell lung carcinoma received anti-PD-L1 antibody treatment every 3 weeks; however, the patient started experiencing headaches, general fatigue, anorexia, and diarrhea approximately 1 year after the initiation of the treatment. Moreover, sudden visual loss of the right eye occurred 1 week after the interruption of the anti-PD-L1 antibody treatment. MRI findings showed gadolinium enhancement in the left optic nerve, but no enlargement of the pituitary gland and stalk. Laboratory data showed decreased serum adrenocorticotropic hormone (ACTH), cortisol, and free T₄ levels, and a hormone tolerance test indicated hypopituitarism, hypothyroidism, and hypoadrenocorticism. The central scotoma caused by optic neuritis completely disappeared immediately after a course of steroid pulse therapy, and no recurrence occurred up to 2 years after initiation of the steroid pulse therapy while replacement therapy for hypothyroidism and hypoadrenocorticism was continued. Conclusions: The patient presented with optic neuritis and hypopituitarism, possibly due to irAEs of the anti-PD-L1 antibody treatment. Steroid pulse therapy was effective for optic neuritis, suggesting underlying immunological mechanisms. Neurological complications including optic neuritis should be considered when examining patients with cancer undergoing CPI treatment.
Case Rep Ophthalmol 2018;9:348–356

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The 10 fundamental principles of lay resuscitation: Recommendations by the German Resuscitation Council

No abstract available

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Small bowel perforation due to an adhesion ruptured by peritoneal insufflation

Abstract

Background:Despite the widespread use of laparoscopic cholecystectomy, technical complications unique to the laparoscopic approach may lead to significant postoperative morbidity and mortality. Case report: We report the first published case of small bowel fistula due to peritoneal insufflation that broke a thin string adhesion between the peritoneal wall and a jejunal segment, which lead to a focal perforation in a 75-year-old woman. Leakage of enteric fluid through the umbilical scar indicated this adverse event during the early postoperative period. The patient was immediately and successfully treated with a suture of the intestinal lesion. Conclusion: Peritoneal insufflation induced for laparoscopic procedures may break abdominal adhesions and lead to organs and vascular injuries, including small bowel perforation.

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Small bowel obstruction SBO after TAPP repair caused by a self-anchoring barbed suture device for peritoneal closure: case report

Abstract

A 50-year-old man underwent laparoscopic hernia repair for a groin hernia, presenting acute abdominal pain and bowel obstruction syndrome 1 day post surgery. Diagnostic laparoscopy was performed at postoperative the day after the hernioplasty and a volvulus was found. The residual end of the barbed V-LOC adopted in the peritoneal closure was incidentally hooked to the mesentery and caused a small bowel obstruction as a volvulus. The redundant V-LOC strand was released and cut superficial to the peritoneum. A detorsion of volvulus was preformed. Neither bowel ischemia nor significant bowel injury was noted. The following day he was discharged without complication. The residual 'free' barbel suture in the peritoneal cavity invited adhesion formations and subsequently the Bowel obstruction.

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Acute oesophageal necrosis: a rare but potentially fatal association of cocaine use

Acute oesophageal necrosis (AON), also known as 'black oesophagus', is a rare condition characterised by the necrosis of the oesophagus usually involving the distal part. It has been associated with various conditions, and the pathogenesis is thought to involve hypovolaemia combined with decreased function of oesophageal protective mucosal barriers and may be compounded by the effect of gastric secretions on oesophageal mucosa. The hallmark of this condition is characteristic circumferential black discolouration of the distal oesophagus that may extend proximally. We present a case of a man who presented with haematemesis associated with cocaine abuse. Oesophagogastroduodenoscopy confirmed black oesophagus. The patient was managed with intravenous fluids, packed red blood cell transfusions, proton pump inhibitors and sucralfate suspension; however, he failed to recover. We have also reviewed the previous reported cases of AON in association with cocaine use.

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Presentation of papillary fibroelastoma of the aortic valve with atypical symptoms

Papillary fibroelastomas are rare benign tumours arising from the cardiac endothelium. The rationale behind the treatment of fibroelastomas is to eliminate the risk of embolic events and the associated morbidity and mortality. These tumours present predominantly in males during the seventh decade of life and most commonly affect the aortic valve. We report a case of aortic valve papillary fibroelastoma with an atypical clinical presentation, treated with valve-sparing surgical excision. Our case highlights the management of this rare but serious condition and emphasises the need to develop clear guidelines regarding the treatment of asymptomatic patients with a papillary fibroelastoma.

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Unusual cause of sinusitis and cough

Description

A 60-year-old woman with chronic lymphocytic leukaemia (CLL) previously treated with ofatumumab was referred for evaluation of worsening productive cough, sinus pain and nasal congestion. She had received multiple courses of antibiotics, antifungals and steroids with partial symptomatic improvement. CT of the chest demonstrated bilateral bronchial wall thickening and bronchial dilatation associated with patchy opacities (figure 1A). An open lung biopsy revealed a dense monotonous lymphocytic infiltrate in a bronchiolocentric distribution sparing the lung parenchyma with associated vague non-caseating granulomatous inflammation and focal areas of organising pneumonia. These findings suggested pulmonary involvement by CLL (figure 1B, C). Nasal and paranasal sinus biopsies were also consistent with CLL. She was started on salvage therapy with ibrutinib. Sinus, nasal and pulmonary symptoms resolved completely after 4 months without the need for additional antibacterial or antifungal medication. Repeat imaging showed resolution of opacities (figure 1D). The...

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Trans-scleral explantation of posteriorly dislocated IOL-CTR complex in a case of anterior megalophthalmos with an unusually thin cornea

Anterior megalophthalmos and keratoglobus are characterised by corneal thinning and deep anterior chamber. They are clinically distinguished on the basis of normal to slightly decreased corneal thickness with a large corneal diameter (>13 mm) in case of anterior megalophthalmos, and marked limbus-to-limbus corneal thinning with globular protrusion in keratoglobus. To achieve and maintain a centred and stable intraocular lens (IOL) position in the bag is often difficult in cases of anterior megalophthalmos due to a too large diameter of the capsular bag and ciliary ring. We report a case of a 40-year-old man with features of anterior megalophthalmos with extremely thin cornea. He had spontaneous posterior dislocation of IOL and capsular tension ring (CTR) within the bag after initial successful cataract surgery. The dislocated complex could neither have been repositioned with scleral fixation due to large diameter of ciliary ring nor could it have been explanted through a clear corneal incision due to associated very thin cornea. We performed pars plana vitrectomy and separated the IOL-CTR complex inside the eye and explanted them separately through the sclerotomy, as is done for removal of intraocular foreign body. This avoided incision on the thin cornea. We conclude that this method can be very useful in a similar clinical situation but is complex enough to justify its use in routine cases.

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Paracaval pseudolipoma mimicking intracaval mass lesion and thrombus

Description 

A 53-year-old man presented with moderate dull non-radiating right upper quadrant pain for the past 1 month. There were no exacerbating or relieving factors or associated symptoms. His medical history was positive for hepatocellular carcinoma for which segmentectomy was performed 6 months ago. On physical examination, he was vitally stable and all systemic examinations were unremarkable. Contrast-enhanced abdominal CT scan showed an enhancing lesion at the surgical bed, representing recurrence of hepatocellular carcinoma (figure 1 and 2). There was also an apparently intracaval fat-density lesion in the suprahepatic part (figure 1 and 2). However, on detailed inspection, particularly on sagittal images (figure 3), its extracaval location became evident, and it was diagnosed as a paracaval pseudolipoma.

Figure 1

Contrast-enhanced CT scan axial section showing fat density compressing the inferior vena cava (IVC) representing paracaval pseudolipoma, mimicking...

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Total electrical alternans in a patient with malignant pericardial tamponade

We present a case of a 59-year-old man with acute abdominal pain and progressive shortness of breath. A focused assessment with sonography for trauma scan showed free fluid in the hepatorenal recess and in the recto-uterine recess. Later, due to clinical deterioration and the differential possibility of a pulmonary embolism or aortic dissection, a CT scan was performed which revealed large pericardial effusion. This, together with a dilated vena cava inferior and portal system, raised the suspicion of cardiac tamponade. The diagnosis was confirmed by transthoracic echocardiography (TTE). In retrospect, the ECG at admission showed a sinus tachycardia, low-voltage QRS complexes and a total electrical alternans corresponding with the swinging heart seen on TTE. An electrical alternans on ECG is an important diagnostic clue but is often missed, causing an unnecessary delay to proper diagnostic and therapeutic measures.

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Pneumatosis intestinalis in an adult patient with antral stenosis and midgut malrotation

Pneumatosisintestinalis (PI) is a radiological finding with about 0.03% incidence and incompletely understood pathogenesis. We report a case of PI with a rare presentation of pneumoperitoneum that underwent diagnostic surgery and finally diagnosed by midgut malrotation and antral stenosis. A 40-year-old man with 1-year history of dyspepsia and vomiting which was aggravated by 20 kg underweight since 3 months ago, despite medications was presented. His imaging examinations showed partial antral obstruction besides pneumoperitoneum and gas collection in the small intestine wall, which were in favour of PI. Samplings of the small intestine during laparotomy reported simple serosal cysts. Persistence of his symptoms forced him to recourse to another hospital and their new imaging revealed Ladds' band in addition to mentioned findings in previous studies; he underwent subtotal gastrectomy plus Ladds' band division by Braun gastrojejunostomy. PI could be a presentation of antral stenosis and midgut malrotation. PI with pneumoperitoneum needs surgical interventions. Considering that most of the midgut malrotation cases are diagnosed in the first year of life and it is very rare in adults, it may bethat these new findings are due to adhesion band formation after the first surgery in this case.

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Traumatic abdominal wall hernia secondary to seatbelt injury: a case successfully managed by delayed surgical mesh repair and complicated by intervening pregnancy

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia occurring secondary to blunt trauma. We report a case of seatbelt-associated TAWH in a 20-year-old woman who was presented to hospital via ambulance following a road traffic collision with a distended abdomen, peritonitis and free gas, with an associated TAWH identified on CT imaging. The patient underwent delayed surgical repair of her hernia using biological mesh, without recurrence, with a clinical course complicated by pregnancy. We use this report to demonstrate late repair as a safe and effective option for management of TAWH in pregnancy, with active surveillance and a multidisciplinary approach by the obstetric, plastic surgery and trauma teams.

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Genetic testing for a patient with suspected familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a genetic condition that results in elevated low-density lipoprotein (LDL) cholesterol (LDL-C) levels with consequent increased risk for premature cardiovascular disease events. Although it is considered an autosomal-dominant genetic condition, the underlying genetic causes of FH can be complex. Currently most guidelines rely on clinical criteria to diagnose FH. But this approach has some pitfalls. We present a patient who was not formally diagnosed with FH using commonly used and well-accepted clinical criteria but via genetic testing was found to have a mutation for this disorder. This case brings to fore the challenges clinicians face in diagnosing and managing such unusual cases optimally. Through this case report, we hope to stimulate a debate among clinicians as well as other stakeholders regarding the need to develop more efficient ways of selecting patients for genetic testing in response to elevated LDL levels.

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Concurrent emphysematous pyelonephritis and emphysematous cholecystitis due to community-acquired ESBL E. coli

Description  

A 62-year-old man with a history of hypertension and poorly controlled type II diabetes mellitus presented to his primary care physician with a 5-day history of chills, decreased urinary output and haematuria. Urinalysis was consistent with urinary tract infection and the patient was prescribed ciprofloxacin. He did not take the antibiotics as instructed and subsequently had to come to Emergency Room due to worsening of his condition as well as new complaints of increased thirst, dark urine and lower back pain. He also admitted that for the previous 3 days he had not been taken insulin due to his illness. On examination, he was an obese man in no distress, fully alert and oriented. The temperature was 97^oF, the blood pressure 125/58 mm Hg, the pulse 112 beats/min, the respiratory rate 16 breaths/min and the oxygen saturation 93% on ambient air. Abnormal findings included scleral icterus, mild jaundice, tachycardia, right...

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Sealing capacity of the ventricular muscle band after iatrogenic left ventricular perforation during transcatheter aortic valve implantation

Left ventricular (LV) perforation accompanied by acute cardiac tamponade is a rare but one of the most feared complication during transcatheter aortic valve implantation. Few cases with the need of emergent surgical repair are described in literature. Handling of this uncommon but possible life-threatening event requires well-considered action by the implanting team and is associated with substantially increased intrahospital mortality. We present a unique case of LV perforation management with percutaneous pericardiocentesis only. As a possible underlying physiological mechanism, we identified the movement of the ventricular muscle band which possibly sealed the perforation side due to transverse and circumferential muscle contractions.

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Lemierres syndrome and 2016 American College of Physician guidelines for pharyngitis: no to empiric coverage for bacterial pharyngitis. While no role for routine Fusobacterium PCR, keep suspicion for this pathogen

An 18-year-old woman presented to clinic with acute pharyngitis with 4/4 Centor criteria. Rapid streptococcal antigen test was negative. The patient, who was allergic to penicillin, was prescribed azithromycin. Ultimately, after 5 days and without any corticosteroids, she presented to the emergency department with 10/10 chest pain and was admitted to the intensive care unit. CT showed nodular lung disease and blood cultures on admission grew Fusobacterium, likely Fusobacterium nucleatum. She sustained two cardiac arrests, three tube thoracostomies, acute kidney injury requiring dialysis and ventilatory failure requiring tracheostomy. After 16 days in hospital and 18 days in long-term acute care, the patient was discharged home. It is unclear how much of this could have been prevented by prescribing an antimicrobial that had activity against Fusobacterium. When severe pharyngitis occurs, Fusobacterium needs to be considered as an underlying cause. In vitro macrolides have marginal activity against most anaerobes, such as this pathogen, and should be avoided.

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Correction: Splenic myoid angioendothelioma mimicking metastatic disease in an 8-year-old with Stage IV Wilms tumour

Shah AA, Luca DC, Kane TD, et al. Splenic myoid angioendothelioma mimicking metastatic disease in an 8-year-old with Stage IV Wilms' tumour. BMJ Case Rep 2018. doi: 10.1136/bcr-2018-224550.

The correct full name of the second author is Dragos C Luca.

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