Ultrasonographic assessment of the lens

Description 

B scan ultrasonography is the most commonly used modality for the assessment of posterior segment pathologies.1–3 On placing the probe along the lateral longitudinal axis, the nasal aspect of the retina, ciliary body, the lens in its entirety, iris, angle and peripheral cornea can be appreciated easily. Using this technique, the anatomy of the lens can be studied in terms of its width along the horizontal and anteroposterior extent; similarly, by placing the probe along the inferior longitudinal axis, the vertical width of the lens can be defined, along with the anteroposterior thickness. This technique helps in the assessment of lens in its entirety, from the anterior capsule to the posterior capsule. Herein few pathologies of the lens and its capsule are illustrated using B scan ultrasound (Sonomed, New York, USA).

After making the patient lie down in a comfortable supine...

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First report of concomitant pheochromocytoma and duodenal neuroendocrine tumour in a sporadic multiple endocrine neoplasia type 1

A 77-year-old woman was diagnosed with pheochromocytoma followed by adrenalectomy at age 57. Hyperparathyroidism without osteoprosis was diagnosed at age 58. At age 75, Dual Energy X-ray Absoptiometry (DEXA) revealed osteoporosis and sestamibi scan showed a left parathyroid adenoma. Criteria for parathyroidectomy were met, and she underwent parathyroidectomy. Furthermore, she presented with haematochezia at age 75. An abdominal CT demonstrated a mass in the second portion of the duodenum. Additionally, octreoscan revealed somatostatin receptor positive tissue in the duodenum and Gallium 68 dotatate scan also showed a well-differentiated duodenal neuroendocrine tumour (NET). Genetic testing for MEN1, MEN2 and MEN4 was negative. Diagnosis of sporadic MEN1 syndrome was made. The patient underwent resection of the duodenal NET at age 76. She is in good health 21 years after her first presentation of MEN1. In summary, we present the first sporadic case of MEN1 with concomitant pheochromocytoma and duodenal NET which occurred 20 years apart.

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Mumps presenting with unilateral, synchronous parotid and submandibular gland swelling

A previously healthy 22-year-old woman presented with acute, unilateral facial and neck swelling, associated with fever and malaise. She was initially treated with intravenous antibiotics; however, CT imaging showed unilateral, synchronous swelling and inflammation of the parotid and submandibular glands, and a PCR swab from the parotid duct was positive for mumps. She was fully immunised and had no contact in the preceding period with anyone diagnosed with mumps. She responded to supportive management and her symptoms resolved over the course of her admission. Unilateral, synchronous swelling and severe inflammation of both the parotid and submandibular glands in mumps is a very unusual presentation, and not one previously reported in the literature.

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Management of a giant uterine leiomyoma

Uterine leiomyomas are the most common tumours arising from the female reproductive tract. However, giant myomas, which are greater than 11.4 kg in weight, are exceedingly rare. They may cause a pressure effect on surrounding organs, heart and lungs, which can be potentially life threatening. We present a case of a 53-year-old woman with a massive uterine mass complicated by restrictive lung disease. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy with frozen section and reconstruction of the abdominal wall by the gynaecologists and plastic surgeons. The excised specimen weighed 27.8 kg, which included a benign subserosal leiomyoma measuring 64 by 50.5 by 15 cm. Intraoperative blood loss was 7 L and her postoperative recovery was complicated by coagulopathy and haemorrhagic shock. This case illustrates the pivotal role of multidisciplinary care in the management of complicated surgical patients and the need for careful perioperative care.

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Vacuum-assisted right atrial infected clot extraction due to persistent bacteraemia: a percutaneous approach for the management of right-sided endocarditis

A 56-year-old woman with non-ischaemic cardiomyopathy with implantable cardioverter defibrillator (ICD) presented to the hospital with progressive dyspnoea of 4 weeks' duration. She soon spiralled down to develop septic shock with methicillin-sensitive Staphylococcus aureus bacteraemia. A transoesophageal echocardiogram revealed a 2.4x2.1 cm large mobile echodensity in the right atrium likely attached to the ICD lead and to the interatrial septum. Although the ICD along with its leads was extracted, bacteraemia persisted despite appropriate antibiotic therapy. Because of her worsening condition, she underwent a right atrial infected clot extraction by the AngioVac system. Her clinical condition noticeably improved soon after evacuation of the infected clot.

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Laryngopyocoele with contralateral laryngocoele: a rare cause of respiratory distress

We present the case of a 76-year-old patient who attended our emergency department with signs of sepsis and severe respiratory distress. She had stridor, type 1 respiratory failure and a left-sided neck swelling. On CT, it was initially misdiagnosed as parapharyngeal abscess. When the imaging was reviewed, it was found to be a left-sided mixed laryngopyocoele obstructing the larynx with an asymptomatic contralateral laryngocoele. The internal component of the left laryngopyocoele was excised through a microlaryngoscopy approach while the external component was approached through a transcervical incision. The patient recovered well despite a postoperative myocardial infarction. Both laryngocoeles and laryngopyocoeles are rare, with the latter being the rarer of the two, however, extensive literature review could not identify any previous cases where both have coexisted in the same patient.

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Hereditary sensory and autonomic neuropathy in a male child: 'The other side of not feeling pain

Description 

A 1-year-old boy was brought to our outpatient department with complaints of whitish opacity in both eyes noticed 3 months ago. The mother also gave a history of self-mutilating behaviour in the child. There was a history of absence of crying during vaccination. There was no history of consanguinity and a similar disease in the family. The child was following light binocularly. On anterior segment examination, bilateral corneal scarring secondary to keratitis was seen (figure 1A). Corneal sensations were absent. An ocular ultrasonography was done for posterior segment evaluation, which revealed no abnormalities. There were signs of self-mutilation in the perioral area in form of damage to both upper and lower lips that caused as a result of repeated insults in form of tooth bite (figure 1B). Apart from this, similar injuries were present in fingers of hands (figure 1C) as...

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Atypical presentation of acute aortic dissection in a young competitive rower

A 27-year-old man (who is also the lead author) presented with dull pain deep to the suprasternal notch, following a period of intense exercise (rowing). He was initially sent home with no diagnosis, but 24 hours later returned to a different Accident & Emergency (A&E), due to continued discomfort and an increasingly altered mental state, and was diagnosed with an extensive type A aortic dissection extending from the aortic root to the iliac bifurcation of the aorta, with an ~8 cm aneurysm on the ascending aorta and a diseased aortic valve. Following emergency surgery to replace the aortic valve and the aorta from the aortic root to the middle of the aortic arch (hemiarch), the patient recovered well.

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Missed ureteral injury in a young man with stab injury

Description 

An 18-year-old man was referred to us from the department of emergency surgery for management of his ureteric injury. The patient underwent exploratory laparotomy for bowel injury that he had sustained due to a stab wound to his left flank 1 month ago. At that time his ureteric injury was missed. Two weeks after being discharged he developed fever and his ultrasonogram was suggestive of a large left retroperitoneal collection with mild left hydronephrosis. A contrast-enhanced CT (CECT) scan was done that demonstrated leak of contrast from left ureter into the collection (figure 1A). The patient then underwent insertion of a percutaneous nephrostomy tube into the left kidney along with placement of a drain into the retroperitoneal collection. The drain placed into the collection had purulent output suggesting an infected urinoma. Two weeks later another CECT scan was done, which showed persistent retroperitoneal urinoma, and ureter...

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Typhoid fever with isolated left lateral rectus palsy

A 17-year-old young woman presented to Patan Hospital, Kathmandu, Nepal, with high-grade fever and headache for 4 days and non-projectile vomiting for 1 day. She also had blurred vision with dizziness on and off. There was no abnormal physical finding. Enteric fever was suspected, and she was empirically started on azithromycin (20 mg/kg) for 7 days. She became afebrile after 2 days and was followed up in 7 days with diplopia since 5 days. At this time, the blood culture was positive for Salmonella serovar typhi. On examination, there was isolated left lateral rectus palsy which accounted for her diplopia. Methylprednisolone (1 mg/kg) was prescribed which was tapered over 1 month and gradually her diplopia subsided. We hypothesise that vasculitic change in the blood vessel supplying the left abducens nerve could be causing the diplopia.

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Clear cell chondrosarcoma of the larynx

Chondrosarcomas represent a group of malignant tumours composed of cells producing cartilage, and clear cell chondrosarcomas (CCC) represent a variant of these. A rare case of a laryngeal CCC is presented. The patient was a 70-year-old man who presented with a 6-week history of throat pain, worsening dysphonia and a lump in the neck. Examination revealed a level 3 neck mass and positron emission tomography imaging revealed a metabolically active right laryngeal mass. Biopsies revealed a cartilaginous neoplasm. The patient underwent total laryngectomy, and the pathology confirmed CCC of the larynx. Chondrosarcomas are the most common type of sarcoma in the larynx but the CCC variant is rare. CCC are usually low-grade tumours affecting long bones, with a male predominance. Less than six cases have been described in the literature affecting the larynx. Management of these malignancies is complete surgical excision given the high risk of local recurrence.

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Double pylorus

Description 

A 69-year-old man with a past medical history of asthma, chronic back pain and hypertension presented with symptoms of light headedness, epigastric pain and blood-mixed bowel movement of 2 days duration. Since the past 9 months the patient had been taking two to three pills of ibuprofen almost on a daily basis for his back pain. He had also received short courses of prednisone tablets frequently in the last 6 months for his poorly controlled asthma. On arrival in the emergency room, his blood pressure was 84/48 mm Hg, heart rate 121/min, respiratory rate 18/min, temperature 36°C and oxygen saturation was 94% on room air. His haemoglobin (Hb) was 7.2 mg/dL. The patient was given proton pump inhibitor (PPI) therapy, volume resuscitated and was admitted to the intensive care unit. After 2 units of packed red blood cell transfusion his Hb was 9.1 mg/dL. He underwent upper gastrointestinal (GI) endoscopy which showed two openings into...

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Incidentally detected adrenocortical carcinoma in familial adenomatous polyposis: an unusual presentation of a hereditary cancer syndrome

Description 

A 30-year-old woman presented to us with complaints of intermittent bleeding per rectum, vague abdominal pain and altered bowel habits for last 3 months. There was no history of headache, palpitations, diarrhoea, weight loss, skin lesions, haematuria and hypertension. Her grandmother had history of colostomy for acute intestinal obstruction and died of unexplained cause at age of 55 years. Her laboratory investigations were normal. On digital rectal examination, multiple polypoidal firm masses were felt approximately 1–5 cm from anal verge. On colonoscopy, number of polyps were seen in the colon around 40–50 in number, ranging from few millimetres to largest measuring around 3 cm. These polyps spread over ascending to sigmoid colon and rectum in increasing number. The biopsy from these polyps was suggestive of tubular adenomas. A definitive diagnosis of familial adenomatous polyposis (FAP) was made. FAP is associated with a myriad of presentations, and hence, a thorough work...

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Atypical giant prolactinoma with frontal lobe manifestations

Description 

Prolactinomas having the diameter above 4 cm are termed 'giant prolactinomas'.1 2 Their incidence is approximately 2%–3% of all prolactinomas1. These are associated with very high prolactin concentration and numerous neurological sequelae, arising from their extension into surrounding structures. However, frontal lobe symptoms have not been reported frequently in the literature.3 These are more common in males with the male-to-female ratio of 9:1.1 We report an atypical case of a giant prolactinoma that presented with frontal lobe symptoms but responded remarkably well to dopamine agonist treatment.

We present a case of a 65-year-old woman who presented with progressively worsening short-term memory loss, confusion, mild intermittent headaches, increased somnolence, difficulty in walking due to unsteadiness and urine incontinence of 2 months' duration. There was a major change in behaviour and personality. On examination, she was confused with Montreal Cognitive Assessment...

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Bronchobiliary fistula: a rare complication after pancreaticoduodenectomy

Biliary anatomic pathologies are rare disease occurrences that can result from a number of causes, most commonly iatrogenic, infectious and malignant aetiologies. Communications between the biliary and bronchial systems are even rarer and few cases have been documented in the literature. The present study describes a case of a 70-year-old man who underwent a pancreaticoduodenectomy (Whipple Procedure) as a curative procedure for an early stage neuroendocrine tumour. He presented nearly a decade after surgery with a communication between the biliary and bronchial tree initially manifesting as bilioptysis. His underlying medical conditions and poor clinical picture made treatment options limited. Therefore, he was treated conservatively with percutaneous biliary balloon dilation of the anastomotic stricture followed by temporary percutaneous internal/external drain and made a full recovery.

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Mitral Valve Endocarditis due to Lactobacillus

Lactobacillus species are Gram-positive, facultative anaerobic, rod-shaped bacteria. They belong to the lactic acid bacteria group and are also known as a usual part of the normal flora of the gastrointestinal tract as well as of the urinary and genital tracts. They are an infrequent human pathogen but can induce several infections such as bacteremia and infectious endocarditis. We report the case of an 81-year-old woman with Lactobacillus bacteremia and mitral valve endocarditis as well as splenic abscesses.

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