Cutaneous metastatic breast cancer is the most common cutaneous metastatic malignancy in women. The assessment of cutaneous metastatic disease can be perplexing because the clinical presentation appears simila...
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Παρασκευή 21 Σεπτεμβρίου 2018
Dermoscopy of skin metastases from breast cancer: two case reports
Rare case of Propionibacterium acnes-related splenic abscess
A 64-year-old woman with a medical history of morbid obesity, chronic hepatitis C, essential hypertension, multiple episodes of abdominal cellulitis, diabetes mellitus type 2 on insulin, intravenous and subcutaneous drug abuse presented to the emergency department complaining of left lower chest pain for 6 weeks along with multiple episodes of vomiting. Initial laboratory data revealed leucocytosis of 17 200x103/μL with left shift. She reported multiple episodes of fever spikes. Abdominal and pelvic CT showed a splenic hypodense lesion. Specimens from interventional radiology aspiration and splenectomy grew Propionibacterium acnes. Following splenectomy, patient's symptoms resolved. To the best of our knowledge, this would represent the fifth reported case of P. acnes splenic abscess.
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Alpha-2 antiplasmin-associated aortic valve thrombus presenting as a STEMI in a patient with Graves disease
Description
A 36-year-old Caucasian woman with a medical history of Graves disease presented to the emergency department with typical chest pain, and she was found to have a ST-elevation myocardial infarction (STEMI) via ECG and elevated troponins. Emergent cardiac catheterisation revealed distal blockages in the left anterior descending artery and second obtuse marginal artery (figure 1A,B). After distal balloon angioplasty, the decision was made to further treat the patient medically and discharge home after clinical stability was achieved. She was readmitted 2 days later for new onset of palpitations with up-trending troponins. Laboratory tests were significant for a low thyroid-stimulating hormone of <0.01 µLU/mL (reference range: 0.27–4.2 µLU/mL), and elevated free T4 of 4.02 µLU/mL (reference range: 0.9–1.7 ng/dL), free T3 of 4.8 pg/mL (reference range: 2.5–4.3 pg/mL) and a thyroid stimulating immunoglobulin of 386 (reference range: <140% baseline). She was immediately started on both methimazole 20 mg and potassium iodine oral solution (SSKI). Further workup...
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Haemorrhagic cholecystitis: a rare entity not to be forgotten
Haemorrhagic cholecystitis is a rare entity of acute cholecystitis that carries a high morbidity and mortality rate if management is delayed. Its clinical course can mirror that of acute cholecystitis. Characteristic findings on ultrasound or CT scan are useful clues to early diagnosis. Urgent cholecystectomy is required prior to progressing to perforation of gallbladder. Most of the literature are case reports with causes associated with anticoagulation. Herein, we described a morbidly obese patient with poorly controlled diabetes presenting with non-specific right upper quadrant pain and was subsequently diagnosed with haemorrhagic cholecystitis. A review of the literature was also performed to summarise the potential clinical presentations, distinctive imaging findings and management options available for this rare condition.
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Pneumomediastinum: a complication of reinserting a dislodged tracheostomy
Description
A 54-year-old woman with a background of obesity and hypertension presented following a pulseless electrical activity (PEA) cardiac arrest. Cardiopulmonary resuscitation (CPR) was commenced on arrival of the paramedics and she was intubated and ventilated (figure 1). Return of spontaneous circulation was achieved in the emergency department following a total of 45 min of CPR. No clear cause of her arrest was identified. She was transferred to the intensive care unit (ICU) for post-arrest management.
Figure 1
Initial chest radiograph following return of spontaneous circulation, with endotracheal tube present (included as a baseline for comparison).
Seizure activity off of sedation necessitated further investigation. Her CT head was unremarkable, but her lumbar puncture showed features in keeping with meningitis. She was therefore treated with antibiotics and antiepileptics. Her cerebrospinal fluid viral PCR and blood HIV tests were negative.
Although appropriate seizure control was achieved,...
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Naclerios V sign and continuous diaphragm sign after endoscopy
Description
An otherwise healthy 72-year-old woman presented with dyspnoea and systemic subcutaneous emphysema. She had undergone upper endoscopy, in which duodenal ulcer was found. The community hospital where the endoscopy was conducted transferred her to our tertiary hospital for further diagnosis and management. On arrival, she complained of severe difficulty in breathing; massive subcutaneous emphysema on her chest to the feet was observed on palpation. Chest X-ray image showed Naclerio's V sign (figure 1A, black arrow) and continuous diaphragm sign (figure 1A, white arrows). CT scan confirmed massive subcutaneous and mediastinal emphysema with pneumothorax, pneumopericardium and free air in retroperitoneal space (figure 1B,C). Emergent laparotomy revealed duodenal perforation, 9 mm in diameter at the descending part of duodenum (figure 1D, white arrow), and was surgically repaired. After the surgery, the emphysema gradually disappeared in weeks and had not recurred at 6-month follow-up.
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Hypertrophic pyloric stenosis following repair of oesophageal atresia and tracheo-oesophageal fistula in a neonate
Development of hypertrophic pyloric stenosis (HPS) after a few weeks of repair of an oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) is a rare condition in early infancy. Although vomiting or feeding intolerance in operated cases of OA+TOF are attributed to oesophageal stricture, gastro-oesophageal reflux and oesophageal dysmotility, it may also be caused by HPS. Herein, we report a newborn infant who had OA and TOF operation on day 2 of life and diagnosed to have HPS at 15th day of age. Even though it is a rare anomaly, HPS should be kept on mind in the presence of persistent vomiting following repair of OA.
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Primary renal angiosarcoma: a diagnostic and therapeutic challenge
Primary renal angiosarcoma is an exceedingly rare and aggressive neoplasm. Although it may occur in youth, this tumour is frequently reported in the sixth and seventh decades of life. The clinical presentation is frequently varied. Pathogenesis remains largely unknown and it has overlapping features with other tumours of the kidney. Current treatment options include variable combinations of surgery, chemotherapy and radiotherapy. Reports regarding the disease prognosis and natural history are limited. In this article, we chronicle the case of a patient with primary renal angiosarcoma presenting at an advanced stage as a widely metastasised tumour. Additionally, we undertake here a brief literature review highlighting the rarity and aggressiveness of this condition, its poor prognosis, and the lack of specific management guidelines.
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Intestinal obstruction with a twist: a rare case of congenital portal vein aneurysm causing intestinal obstruction
Bilious vomiting is often a presenting feature of upper intestinal obstruction in newborn. We present a case of intestinal obstruction in a newborn baby caused by abnormal vascular band arising from portal vein aneurysm in association with a midgut volvulus. Congenital anomalies of portovenous system are very rare, and it usually presents with portal hypertension in late infancy or childhood. In this particular child, the portal vein aneurysm contributed to intestinal obstruction due to both a failure of intestinal rotation and a mechanical band over the transverse colon.
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Significant cephalad lead migration with use of externally powered spinal cord stimulator
Spinal cord stimulation has been an effective therapy for treatment of chronic low back pain over the last four decades. Over the years, there have been significant technological advances in the neuromodulation devices. Externally powered neuromodulation devices, that do not require an internal pulse generator (IPG) implantation, have recently been approved for treatment of chronic pain and the data on potential pitfalls and unforeseen complications with these devices is minimal. Here, we report a case of a 60-year-old woman with chronic back pain who underwent the implantation of one of such devices and developed complication that required neurosurgical intervention. The epidural stimulator leads in the patient migrated cranially to the T2 level that required extensive neurosurgical exploration. We believe this is the first reported case of such significant cranial epidural lead migration with the use of neurostimulation devices and demands more research into the safety of externally powered neurostimulation devices.
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Intrahepatic sarcomatoid cholangiocarcinoma
Sarcomatoid carcinoma is a rare tumour composed of intermingled malignant epithelial and mesenchymal cells, and it has been reported in various organs including the liver. Sarcomatoid cholangiocarcinoma (CCC) is an extremely rare liver primary tumour. Here, we report a case of an elderly man who was admitted to our hospital after head trauma. He performed a head CT that diagnosed cerebral metastasis. On abdominal CT, he presented a 10x8x9 cm-sized hypodense liver mass in the VII and VIII segments, with peripheral enhancement. Histological and immunohistochemical examination of the tumour showed a malignant neoplasm with both carcinomatous and sarcomatous components and positive expression of cytokeratin and vimentin antibodies. The patient was diagnosed with intrahepatic sarcomatoid CCC at an advanced stage and died 45 days after the diagnosis. We emphasise the importance of immunohistochemistry which may provide a clue to proper diagnosis.
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Case of colonic mucosal Schwann cell hamartoma and review of literature on unusual colonic polyps
Mucosal Schwann cell hamartomas (MSCH) are benign mesenchymal tumours rarely seen in the gastrointestinal tract. They occasionally present as incidental sessile polyps during colonoscopy. A 55-year-old asymptomatic female patient with a medical history of multiple sclerosis presented for a screening colonoscopy. A 5 mm low-risk tubular adenoma was noted in the caecum, and a second 5 mm polyp was found in the ascending colon. Histopathology of the ascending colon polyp showed proliferation of spindle cells without ganglion cells in the lamina propria. Immunohistochemical findings are compatible with an MSCH. Surveillance colonoscopy was scheduled in 5 years based on the presence of a single low-risk tubular adenoma.
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A new rocuronium formulation not causing vascular pain in a flexor reflex model of anesthetized rats
Abstract
Purpose
Intravenous administration of the brand formulation of rocuronium bromide, currently used as a muscle relaxant, has been associated with vascular pain accompanied by withdrawal movements of the arm and wrist. The purpose of this study was to identify the cause of vascular pain induced by the brand formulation and to develop a new rocuronium formulation, not causing vascular pain, using a vascular pain-evoked flexor reflex response model of anesthetized rats.
Methods
A rat flexor reflex model, monitored by electromyography, was used to evaluate a flexor reflex response as the index of vascular pain. A catheter for drug administration was inserted into the superficial caudal epigastric artery. A needle electrode was inserted into a muscle in the femoral area to obtain an electromyogram (EMG) value. The integrated EMG values obtained after the administration of each test drug were compared to the baseline value and quantified.
Results
The acetate buffer contained in the solvent could cause flexor reflex response. Furthermore, the flexor reflex response increased in an acid concentration-dependent manner. Based on these results, we prepared a new rocuronium formulation using a low-acid-concentration buffer solution and found that it decreased the integrated EMG value in the rat model. The integrated EMG value acquired using the brand formulation was reduced by pretreatment with the TRPA1 channel inhibitor.
Conclusion
Our findings suggest that the high acid concentration in the brand formulation buffer solution is the cause of vascular pain. The rocuronium formulation developed using a low-acid-concentration buffer solution might help eliminate vascular pain in the clinic.
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Traumatic arteriovenous fistula formation secondary to crush injury
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Acute anterograde intussusception as a late complication of distal gastric bypass
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Large rib osteochondroma in a child in Aleppo, Syria
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Wilkie’s syndrome, a missed opportunity
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