Chilaiditi syndrome – a rare case of pneumoperitoneum in the emergency department: a case report

Pneumoperitoneum poses an important diagnostic sign determining the urgency of management of patients in an emergency department. Chilaiditi sign is a rare radiologic finding of large intestines transposition ...

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Chemotherapy in combination with stereotactic body radiation therapy (SBRT) for oligometastatic pancreatic cancer

Metastatic pancreatic cancer is characterised by poor prognosis. High toxicity of chemotherapy limits its use in elderly patients with severe comorbidities. Meanwhile, in metastatic disease, local treatment did not show the positive effect on life expectancy. We present a clinical case of a 72-year-old woman with metastatic pancreatic adenocarcinoma tumour, node, metastases (T3N0M1) (according to the seventh TNM classification of the International Union Against Cancer). Chemotherapy led to partial response, but later was stopped due to severe toxicity. Thereafter, consolidating radiosurgical treatment was performed. Dose to pancreatic and liver lesions was 35 Gy in five fractions. After 9 months, only one liver lesion and primary pancreatic tumour, stable in size were determined by MRI. At present time, the patient is alive and in good condition, the disease is stable 50 months after stereotactic body radiation therapy (SBRT). SBRT provides a high level of local control and in combination with systemic treatment can potentially increase survival.

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Continent cutaneous diversion pouch calculi

Description 

A 62-year-old female patient who presented at our centre with dull aching right flank pain of 6 months duration. She had a history of radical cystectomy and cutaneous continent urinary diversion (Indiana pouch) done 20 years ago for muscle invasive urothelial carcinoma of urinary bladder. The patient followed up regularly since operation. However, for last 3 years, the patient was lost to follow-up. On further eliciting the history, she mentioned her inability to perform pouch irrigation and clean intermittent catheterisation regularly during this period.

On examination, a lump was palpable in the right lumbar region in the region of continent pouch. It was firm in consistency around 5x5 cm in size and did not move with respiration. There was no pain/tenderness on palpation. The stoma was healthy, flush to skin, functioning and easily catheterisable.

Her complete haemogram including renal function test and liver function test were normal. A plain abdominal X-ray revealed multiple...

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Rare case of meningococcal sepsis-induced testicular failure, primary hypothyroidism and hypoadrenalism: Is there a link?

Severe illness can lead to multiple transient endocrinopathies. In adult patients, neuroendocrine alterations include sick euthyroid syndrome, an increase in corticosteroid levels, increase in prolactin levels, decreased insulin growth factor 1 levels and hypogonadism. We report the case of a 24-year-old man with meningococcal sepsis with multiple end-organ complications who developed persistent non-autoimmune hypothyroidism, adrenal insufficiency and primary hypogonadism all requiring hormone replacement. While adrenal insufficiency as part of the Waterhouse-Friderichsen syndrome is well described, reports of primary hypothyroidism and persistent primary hypogonadism in severe illness are exceedingly rare. Multiple combined endocrinopathies as in this case have not been reported previously. This case highlights the necessity of screening for endocrine abnormalities in severe illness and the need for treatment if persistent. It also raises a novel concept of meningococcal sepsis causing multiple endocrinopathies possibly via disseminated intravascular coagulopathy-related ischaemic damage.

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Recurrent pleural effusion in a young woman: calcifying fibrous tumour of the pleura

We present the case of a 23-year-old woman with a long-standing history of recurrent left-sided pleural effusion unrelated to her menstrual cycle. At her last presentation, non-contrast-enhanced chest CT showed a pleural effusion and a lower left hemithorax mass, both large enough to cause complete collapse of the lower lobe and partial collapse of the upper lobe. Thoracoscopic surgery revealed a multilobulated mass originating from the dome of the diaphragm with pleural deposits. Histopathology diagnosed this as a calcifying fibrous tumour of the pleura, a rare benign tumour with excellent prognosis when completely excised.

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Natural killer/T-cell lymphoma and secondary haemophagocytic lymphohistiocytosis in pregnancy

Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disorder. It is challenging to diagnose due to its rarity and variation in clinical presentation, laboratory abnormalities and underlying aetiologies. A reproductive-aged woman, gravida 2 para 1001 at 27 weeks gestation presented with fever, hypotension and subacute upper respiratory infection. She delivered a male infant by caesarean section secondary to fetal distress. Subsequently, she was diagnosed with T-cell lymphoma and secondary HLH. Despite management with supportive care and multiple chemotherapeutic agents, she ultimately died of multiorgan failure. Patients with HLH secondary to malignancy have a particularly poor prognosis. This case highlights the importance of considering secondary HLH in the differential diagnosis of a patient with fever, pancytopenia and systemic symptoms of unclear aetiology in pregnancy.

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Primary intracranial leiomyosarcoma among patients with AIDS in the era of new chemotherapeutic and biological agents

Primary intracranial leiomyosarcoma (PIL) is a rare non-infectious aetiology of focal mass lesions among HIV-infected individuals. With only 16 published cases worldwide, information on its pathophysiology, risk factors, clinical course and management options is limited. We report two cases of PIL in HIV-infected Filipino men who presented with 1–3 months history of persistent headache, progressing in severity. Both had cranial MRI revealing intracranial mass diagnosed as leiomyosarcoma by excision biopsy and immunohistochemical staining. Both patients underwent adjuvant cranial radiotherapy and chemotherapy. Biologics were initiated in one patient. Both patients were alive with evidence of the disease.

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Unilateral cataract associated with eyelid ash-leaf macule in tuberous sclerosis complex

A 9-month-old male child with tuberous sclerosis complex presented with ash-leaf macules on the left periocular region and ipsilateral dense cataract. Fundus showed retinal astrocytic hamartomas. This case is reported for unilaterality of congenital cataract on the same side of eyelid ash-leaf macule in tuberous sclerosis.

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Urachal adenocarcinoma

Description 

A 40-year-old male patient presented at the outpatient department with ulcerative swelling with foul smelling discharge from lower half of abdomen for last 3 months. He had a history of haematuria with increased frequency of micturition for last 6 months accompanied by loss of appetite and subsequent weight loss. There was no history of nocturia, urgency or incontinence.

On physical examination, he was found to have an ulceroproliferative growth around 5x3 cm size in the infraumbilical region with urinary discharge near one end as shown in figure 1.

Figure 1

Ulceroproliferative growth in the infraumbilical region arising from urinary bladder.

It was small to begin with and progressively increased in size to reach the present state.

The growth demonstrated an unhealthy ulcer with everted margins and areas of slough. It was friable and bled actively on manipulation. Rest of the abdominal...

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Common iliac artery thrombosis as a possible complication of the pluck technique in nephroureterectomy

Common iliac artery (CIA) thrombosis is a rare surgical complication which may cause serious leg damage and may occasionally be fatal. We experienced two cases of CIA thrombosis in nephroureterectomy with the pluck technique for upper tract urothelial carcinoma. Patients were treated using emergent femoro–femoral bypass, and one patient was treated with fasciotomy of the lower extremity for compartment syndrome. CIA thrombosis is considered a possible complication of nephroureterectomy, particularly with the pluck technique in open surgery. Arterial thrombosis in intrapelvic surgery including nephroureterectomy should be carefully considered for patients at risk.

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Unusual presentation of pancreatitis with extrapancreatic manifestations

Pancreatitis, panniculitis and polyarthritis syndrome (PPP syndrome) is a rare and complex manifestation of pancreatitis that is currently reported in few cases. We present this case regarding a 77-year-old man who presented unusually with a 6-week history of bilateral lesions on his lower limbs. During this time, he experienced increasing fatigue, joint pain, and reported fevers and significant weight loss. An incidental serum amylase was found to be significantly elevated and remained elevated throughout his 2-month hospital stay. He never complained of abdominal pain or other typical symptoms of pancreatitis. Histological examination of the leg lesions reported evidence of fat necrosis and changes consistent with pancreatic panniculitis. An abdominal CT scan revealed a well-defined lesion posterior to the neck of the pancreas. Further examination by endoscopic ultrasound revealed chronic inflammatory changes. The patient experienced a long admission and was managed supportively until he was well enough to be discharged home.

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Periocular contact dermatitis with use of topical voriconazole 1% in mycotic keratitis

We present two cases of culture-proven fungal keratitis on natamycin treatment which developed periocular erythema, oedema, burning sensation and pruritus within 48 hours of the addition of topical voriconazole. On clinical examination, periocular erythema with induration was noted. A diagnosis of orbital cellulitis was suspected, but the absence of pain and tenderness refuted the diagnosis on clinical grounds. A dermatology consultation was sought, and a diagnosis of periocular contact dermatitis with voriconazole was made. A skin patch test was performed with the same medication; however, it was negative. Topical voriconazole therapy was withdrawn, and the patient was prescribed cold compresses and oral antihistamine medication, to which they responded well.

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Delayed pressure urticaria due to non-invasive blood pressure monitoring in a previously non-atopic man

Description 

A 68-year-old man presented to us with voiding lower urinary tract symptoms due to benign prostatic hyperplasia for which he underwent photovapourisation of prostate using potassium titanyl phosphate laser. The procedure was completed in 104 min uneventfully. Eight hours after the procedure, the patient had burning and itching on his left arm circumferentially in the area where the cuff for non-invasive blood pressure (NIBP) monitoring was applied and on his back. We removed the cuff and in that region of his arm there was erythema along with multiple blisters (figure 1). A similar linear lesion was seen on the right side of his back along the 10th rib (figure 2). We recognised it to be some form of urticaria, and immediately gave the patient an antihistamine (pheniramine). The patient had no history of any skin lesion, neither did he give a history of any allergies. Both lesions...

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Concurrent internal hernia and intussusception after Roux-en-Y gastric bypass

Description 

A 32-year-old woman with medical history significant for open Roux-en-Y gastric bypass performed 11 years prior presented to an urgent care with sudden severe epigastric pain associated with nausea and vomiting. She was profoundly hypothermic (91°F) and bradycardic (40 bpm) but maintained normal blood pressure. Laboratory values were grossly within normal limits except for an elevated lactic acid (2.99 mmol/L). Rewarming protocol, broad-spectrum intravenous antibiotics (piperacillin–tazobactam and vancomycin) and intravenous fluid resuscitation were initiated at this time. CT of the abdomen with intravenous and oral contrast demonstrated intussusception at the site of the jejunojejunal anastomosis with severe oedema of the mesentery and focally dilated bowel consistent with a high-grade obstruction due to an internal hernia (figure 1A). The patient was emergently transferred to the hospital and underwent an exploratory laparotomy. Intraoperatively, the intussuscepted segment of small bowel surrounding the jejunojejunal anastomosis was identified with an associated...

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Late twiddler syndrome in a patient with a submuscular implantable cardioverter defibrillator

Description 

A 20-year-old woman with long-QT syndrome received a submuscular Fortify DR-St Jude implantable cardioverter defibrillator (ICD) after an episode of cardiac arrest. She felt an ICD pocket vibration 23 months later due to a high lead impedance and loss of capture. Chest radiography (figure 1A,B) showed both lead displacement and winding of the leads beside the ICD generator. These findings were confirmed during surgery (figure 1C). The patient strongly denied any box manipulation. She was discharged after new leads implantation with no complications.

Figure 1

(A) and (B) Chest radiography showing both lead displacement and winding of the leads close implantable cardioverter defibrillator generator. (C) Intraoperative finding of lead twisting.

There is a report of three patients with ICD with submuscular devices in whom a twiddler's syndrome occurred despite any risk factors were be seen. It is discussed that the cause...

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Delayed lethal pulmonary air embolism after a gunshot head injury

We present a case of a young male patient with a fatal pulmonary air embolism following a penetrating gunshot head injury. He suffered from severe head trauma including a laceration of the superior sagittal sinus. Operative neurosurgical intervention did not establish a watertight closure of the wounds. Eight days after the trauma, the patient suddenly collapsed and died after an attempt to mobilise him to the vertical. Forensic autopsy indicated pulmonary air embolism as the cause of death. Retrospectively, we postulate an entry of air to the venous system via the incompletely occluded wounds and the lacerated superior sagittal sinus while mobilisation to the vertical created a negative pressure in the dural sinus.

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Open transcatheter aortic valve implantation on a degenerated bioprosthetic valve conduit

Abstract

The degeneration of bioprosthetic aortic Conduit with hemodynamic dysfunction mostly requires a re-do surgery, which is associated with an increased perioperative risk. Considering this, an open implantation of a transcatheter aortic bioprothesis (TAVI) after resection of the degenerated valve leaflets could be of great benefit, reducing cross-clamp and cardiopulmonary bypass duration, especially in combined surgery in high-risk patients. This is a case of a high-risk female (78 years, EuroScore 59%) treated with an open TAVI as an alternative to conventional valve or aortic conduit replacement for degenerative aortic valve due to endocarditis lente, 2 years following a bio-Bentall procedure.

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Esmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care

β-Adrenergic blockade is an important mechanism for reducing morbidity and mortality in patients with hypertension and heart failure. Esmolol has been used widely for its chronotropic and antihypertensive effects. However, there has been recent inquiry regarding perioperative esmolol use and nociceptive modulation. Conventional postoperative analgesic treatment has relied primarily on opioids, which present their own adverse effects and pharmacoepidemiologic repercussions. Esmolol, to date, has not shown any direct analgesic or anesthetic properties; however, recent studies suggest that esmolol may have antinociceptive and postoperative opioid-sparing effects. In this Daring Discourse narrative, we describe the role of esmolol in current perioperative β-blockade guidelines (related to noncardiac surgery), briefly describe studies supporting the antinociceptive effects of esmolol, propose mechanisms for esmolol antinociception, and forecast potential routine esmolol use intraoperatively (as part of a multimodal total intravenous anesthetic) and its effects on opioid sparing. The reading audience of regional anesthesiologists and acute pain medicine physicians is uniquely positioned to take a lead role in promulgating this care advance amid (i) the unwanted effects of the opioid epidemic and (ii) the uncertain notion of whether routine general anesthesia care (with fentanyl) may indirectly be contributing to the epidemic. Accepted for publication April 23, 2018. Address correspondence to: Brian A. Williams, MD, MBA, Department of Anesthesiology, University of Pittsburgh, Suite A-1305 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261 (e-mail: williamsba@anes.upmc.edu). The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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