Nivolumab induced encephalopathy in a man with metastatic renal cell cancer: a case report

Great progress has recently been made in the treatment of metastatic renal cell carcinoma, including the introduction of nivolumab, an immune checkpoint inhibitor. Despite promising results, this treatment bri...

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Pineoblastoma in a child with 22q11.2 deletion syndrome

Description 

A 4-year-old girl with a history of chromosome 22q11.2 deletion syndrome presented to the emergency department with 2–3 weeks of worsening emesis. CT of the head revealed a large pineal region calcified tumour with associated hydrocephalus. Contrast-enhanced MRI of the brain and spine status postexternal ventricular drain placement confirmed a pineal tumour with diffuse metastatic leptomeningeal spinal spread (figure 1A,B). The child had a normal MRI of the brain 2 years prior (figure 1C) as work-up for her developmental delay. The diagnosis of 22q11.2 deletion syndrome was made by chromosomal microarray testing, which revealed a 2.5 MB deletion of 22q11.2 that included the TBX1 gene. Neuropathology on a subtotal resection showed clusters and sheets of tightly packed, small, blue cells with oval or slightly angulated nuclei and scant cytoplasm, consistent with a primitive neuroectodermal tumour. The tumour showed no loss of expression of INI...

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Coronary artery ectasia: a rare cause of acute coronary syndrome

Coronary artery ectasia (CAE) is defined as a localised or diffuse dilatation of coronary artery lumen more than 1.5 times that of an adjacent normal segment. CAE may present with or without functionally significant stenosis. Such patients may manifest with stable angina or with acute coronary syndrome. Ectasia may serve as a nidus for thrombus formation with likelihood of distal embolisation or it may lead to dissection or spasm. This condition presents a challenge for an interventionist. Should we intervene or manage it medically. We describe a case of CAE where all the vessels were diffusely ectatic with variable degree of stenosis. In brief we discuss the causes and management issues in ectasia.

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Uncommon cause of chest pain in a postoperative spinal patient

An 84-year-old woman with previous spinal operations including vertebroplasty and lumbar decompressions was admitted electively under the spinal team for right-sided L4/5 decompression for worsening back pain which she undergoes using a posterior approach. Postoperatively, she develops stabbing upper central chest pain and given unremarkable chest X-ray, ECG and cardiac troponin, she undergoes a CT pulmonary angiogram which shows a fracture of the upper part of sternum but no pulmonary embolism. There is no history of recent trauma and this is deemed to be secondary to prolonged spinal surgery in the prone position in a patient with osteopenic bones. To date, we have not come across a case of spontaneous sternal fracture as a complication of spinal surgery at our regional spinal unit. Most cases of sternal fractures are secondary to blunt anterior chest wall trauma with spontaneous fractures and stress fractures being rare.

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Spin-top-like encrustation of suprapubic cystostomy catheter: when proper counselling is all that it takes!

Description 

A 25-year-old man from a rural background and suffering from psychiatric illness had complaints of acute urinary retention 1 year ago for which trocar-guided suprapubic cystostomy (SPC) Foley catheter placement was done elsewhere after failed attempt of per-urethral catheterisation.

There was no history of haematuria, lithuria, catheterisation and endourological intervention in the past. On further eliciting the history, there was a retrograde urethrogram film taken 1 year back which revealed a short segment (1.0 cm) bulbar urethral stricture. He had undergone optical internal urethrotomy with Foley catheter placement (14F) under regional anaesthesia for his urethral stricture. Per-urethral catheter was removed after 7 days and he voided well with good urinary stream. He was sent back home and instructed to follow-up after 3 days for removal of SPC catheter and need of de-clamping SPC catheter in case of urinary retention again.

However, a thorough counselling about catheter's care and related complications was not...

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A rare case of cellular angiofibroma affecting the periurethral region in a 38-year-old woman

Cellular angiofibroma (CAF) is a rare, site-specific, benign mesenchymal tumour affecting both women and men in the genitourinary region. The tumour usually presents as a small, asymptomatic lesion involving the vulvovaginal regions in women and inguinoscrotal regions in men. We report the case of a 38-year-old woman presenting with a painless mass in the vulval region, especially on the right side of urethral meatus for 8 years with progressively increasing lower abdominal discomfort. A simple excision was performed. The diagnosis of CAF was confirmed histopathologically.

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Cervical tuberculous lymphadenitis in an elderly adult

Description 

A 94-year-old man presented with complaints of increasing fatigue and generalised weakness for 1 month's duration. On admission, the patient had tachycardia of 112 bpm and fever of 101.1 °F. His initial physical examination was otherwise normal. Lactic acid was elevated (4.13 pg/mL), but other laboratory markers were within normal limits. No apparent source of infection was identified by initial urinalysis, chest radiography or CT of the abdomen without contrast. The lactic acidosis resolved after administration of normal saline, but he continued to have fever, which prompted more thorough physical examination that revealed a painless right-sided neck mass. CT of the neck without contrast confirmed a low-density neck mass in the right posterior cervical region measuring 7 cm in the maximum diameter (figures 1 and 2), suspicious for necrotic tumour or an abscess. Ultrasound-guided drainage of the mass recovered 50 mL of purulent material that was submitted for...

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Cytomegalovirus-associated haemophagocytic lymphohistiocytosis: a rare cause of febrile neutropenia during cancer chemotherapy

Febrile neutropenia (FN) is a common complication in patients with cancer during treatment with antineoplastic drugs. The initial cause is usually bacterial, and treatment of FN follows well-defined algorithms. We report a case of a 62-year-old patient with chronic lymphocytic leukaemia (CLL), who developed FN, which was unresponsive to both empirical antibacterial and empirical antifungal therapy. Surprisingly, a diagnosis of the life-threatening condition haemophagocytic lymphohistiocytosis (HLH) associated with cytomegalovirus (CMV) infection was made and treated successfully. CMV-associated HLH has not previously been described in patients with CLL treated with rituximab and bendamustine. It is concluded that HLH should be considered in patients with cancer with FN not responding to conventional antibiotic therapy.

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Patella incarceration with associated patella fracture: a rare case of a paediatric patient with no associated femoral fracture

We describe the case of a 15-year-old girl who presented to the Accident and Emergency Department with right knee pain and a tense effusion following a twist and fall directly onto her right knee. An MRI scan demonstrated that she had an incarcerated dislocated patella with an associated patella avulsion fracture. This required open reduction. Open reduction and fixation was performed using suture anchors. We feel that this case is particularly pertinent since nearly all previous case reports describe an incarcerated patella with an associated femur fracture. Furthermore, no previous case reports have been published in a child.

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Tibial osteomyelitis with cold abscess within calf muscles in a toddler referred with suspected oligoarthritis to rheumatology clinic

Description 

A 2-year-old male child was referred to the paediatric rheumatology clinic with history of limping, swelling of right knee and low-grade fevers for 6 weeks. About 2 months prior to this presentation, he had an episode of upper respiratory infection which was followed by swelling of the right knee. He was initially treated with oral analgesics by his primary physician. After 6 weeks when there was no improvement, he was referred for evaluation of possible juvenile idiopathic arthritis.

On examination, there was visible swelling of his right knee compared with his left and he was refusing to bear weight on his right lower limb (figure 1). On closer observation, a diffuse swelling was noted over the right calf region with fullness of the popliteal fossa (figure 1). The swelling was not warm or tender. There was no contact history with tuberculosis. The patient...

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Management of oesophageal intramucosal carcinoma

We present an interesting case of an intramucosal carcinoma (IMC) in the setting of Barrett's oesophagus in a 66-year-old woman. Her clinical course highlights the shifting paradigm in the approach to management of Barrett's oesophagus and IMC. With innovation in imaging and endoscopic treatment modalities, patients are detected earlier and managed prior to development of malignancy. The patient was treated with endoscopic modalities, and after 3 years' follow-up, she remains recurrence free.

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Chronic hyperglycemia with elevated glycated hemoglobin level and its association with postoperative acute kidney injury after a major laparoscopic abdominal surgery in diabetes patients

Abstract

Background

The relationship between preoperative hyperglycemia and postoperative acute kidney injury (AKI) occurrence in non-cardiac surgery including laparoscopic surgery remains unclear. This study aimed to assess the relationship between preoperative chronic hyperglycemia and postoperative AKI occurrence after a major laparoscopic abdominal surgery.

Methods

We retrospectively reviewed medical records of diabetic patients (≥ 20 years old) who underwent elective major laparoscopic abdominal surgery procedures between 2010 and 2016. Patients were divided into two groups based on a cut-off value of hemoglobin A1c (HbA1c) at 6%. Serum creatinine value was used for the diagnosis of AKI, and all assessments and diagnoses of postoperative AKI were performed on 0–3 postoperative days (POD) using the criteria of Kidney Disease: Improving Global Outcomes.

Results

In all, 1885 patients were included in the final analysis, and patients were divided into the following groups: < 6.0% group with 1257 patients (66.7%), and ≥ 6.0% group with 628 patients (33.3%). Sixty-nine patients (3.7%) were diagnosed with postoperative AKI within 3 POD. Multivariable logistic regression analysis showed no significant difference in the incidence rate of postoperative AKI between the HbA1c ≥ 6.0% group and the < 6.0% group (odds ratio 1.10, 95% confidence interval 0.57–2.15; P = 0.770). In addition, there was no significant interaction between preoperative HbA1c group and exposure to acute hyperglycemia (serum glucose > 200 mg/dL) for incidence of AKI on POD 0–3 (P = 0.181).

Conclusions

In diabetic patients, preoperative chronic hyperglycemia is not associated with postoperative AKI occurrence within 3 POD after a major laparoscopic abdominal surgery.

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