Suppressed descending pain modulatory and enhanced sensorimotor networks in patients with chronic low back pain

Abstract

Purpose

Although cerebral structural and functional changes were uncovered by neuroimaging in patients with chronic low back pain (CLBP), their associations remain to be clarified. We co-analyzed anatomical and functional magnetic resonance imaging data in those patients and tested whether cortical gray matter volume changes are associated with altered pain modulatory networks underlying chronification of pain.

Methods

In 16 patients with CLBP and 16 heathy controls, we performed functional magnetic resonance imaging during mechanical pain stimulation on the lower back followed by anatomical imaging. We performed voxel-based morphometry and functional connectivity analysis from the seeds with altered gray matter volume, and examined correlations between imaging and psychophysical parameters.

Results

Patients showed decreases in gray matter volume at the right dorsolateral prefrontal cortex, middle occipital gyrus, and cerebellum, and showed increases at the bilateral primary sensorimotor cortices, left fusiform gyrus, and right cerebellum compared with controls (P < 0.001). Dorsolateral prefrontal and fusiform volumes showed negative associations with affective comorbidity, whereas motor cortex volume with impaired daily activity (P < 0.05). Connectivity was decreased between the cerebellar and limbic, and increased between the bilateral sensorimotor regions (P_FDR < 0.05). Higher pain intensity and unpleasantness correlated with enhanced bilateral sensorimotor and dorsolateral–medial prefrontal networks, respectively (P < 0.05).

Conclusion

Patients showed a decreased volume of cortical center for descending pain modulation and an increased volume of sensorimotor network, in association with suppressed descending pain modulatory and cerebellum–limbic networks and enhanced sensorimotor network during pain. Such structural and functional alterations might be part of cerebral pathophysiology of CLBP.

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Paediatric ocular super glue injuries: assessment of two cases

In this report, we elaborate the clinical findings and the optimal management of two cases with ocular glue injuries in two paediatric patients. Both the patients were presented to the ocular emergency with completely closed eyelid and periocular erythema. The eyelids were completely closed due to matting of the eyelashes with glue retention up to lash roots. Thus, in both cases, after the application of local anaesthetic agent, immediate lash trimming was performed along with the removal of crystallised glue particles. However, the ocular surface showed only congestion in absence of any added corneal complications. Patients were followed up with standard treatment protocol as per chemical injuries. Until the end of 5 months, the clinical course was uneventful.

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Comorbid presentation of syringomyelia and Guillain-Barre syndrome, attributed to mycoplasma, in a 6-year-old female patient

Syringomyelia is the development of a fluid-filled cavity or syrinx within the spinal cord that can cause loss of sensation and muscle spasticity. Guillain-Barre syndrome (GBS) is a postinfection autoimmune disease, classified as an acute polyneuropathy. This report describes the emergency admission of a 6-year-old girl presenting with sudden pallor and pain in both lower limbs. The patient's reflexes were normal, as were the results of her sonography, radiography and biochemical tests; however, spinal MRI revealed extensive compartmentalised syringomyelia extending from C2 to T3. A sensory and motor nerve conduction study revealed a demyelinating type motor polyneuropathy which, along with positive Mycoplasma pneumoniae test, was suggestive of GBS. Intravenous immunoglobulin infusion showed excellent results. In conclusion, we report a rare paediatric case of syringomyelia coexisting with GBS. It is important to bear in mind the possibility of other coexisting diseases even if MRI reveals definitive characteristics of another condition.

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Diagnosis of a tick-borne coinfection in a patient with persistent symptoms following treatment for Lyme disease

A 67-year-old woman presented with 5 days of myalgias and fevers on completion of a 21-day course of amoxicillin for Lyme disease (Borrelia burgdorferi infection). She was found to have profound thrombocytopenia, as well as new anaemia and leucopenia. Workup revealed Babesia microti as the causative agent of her symptoms. The patient quickly improved after appropriate antimicrobial therapy directed against babesiosis was started. This case illustrates the importance of basic microbiology, including epidemiology and common vectors, when creating a differential diagnosis. Because the Ixodes scapularis tick can harbour and transmit multiple parasites simultaneously, the possibility of coinfection should be considered in any patient not responding to appropriate initial medical therapy.

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Desire for lasting long in bed led to contact allergic dermatitis and subsequent superficial penile gangrene: a dreadful complication of benzocaine-containing extended-pleasure condom

Description 

A 30-year-old non-atopic, non-diabetic man presented with complaints of swelling, pain and patchy blackening of penile skin for the last 3 days. He stated that for improving the duration of sexual intercourse and for better sexual performance, he recently used a new brand of condom, which contained 5% benzocaine. He, however, denied about the use of any lubricants or topical substance at the time of sexual act. There was no history of fever, inguinal or scrotal swelling, genital trauma, insect bite, known drug allergy, substance abuse or similar complaints in the past. In the past, he was using non-medicated natural rubber latex condom for contraception without any adverse effects. Local examination revealed vesicle eruption, sloughing and patchy blackening of penile skin extending from prepuce to base of penis with a clear demarcation line with non-palpable inguinal lymph nodes suggestive of allergic contact dermatitis as shown in figure 1. The underlying...

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Knotted electric wire in urinary bladder: Can such complex foreign body be retrieved endoscopically!

Various types of foreign bodies have been recovered from the urinary bladder and urethra including telephone cables, pocket battery, little fish, pen tips and so on. Management of such cases include either endoscopic removal or open surgery. We report the case of an 18-year-old boy who inserted an electric wire in the urethra for eroticism and was managed by endoscopic removal following fragmentation of wire under local anaesthesia using holmium laser.

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Recurrent aseptic meningitis with PIGT mutations: a novel pathogenesis of recurrent meningitis successfully treated by eculizumab

We report the case of a patient with PIGT mutations who experienced recurrent aseptic meningitis 121 times over 16 years before developing paroxysmal nocturnal haemoglobinuria (PNH). Each episode was preceded by urticaria and arthralgia. After developing PNH, haemolysis occurred prior to meningitis. Flow cytometry revealed deficiency of the glycophosphatidylinositol (GPI)-anchored complement regulatory proteins, CD59 and CD55, and he was diagnosed with PNH. All the symptoms disappeared on administering eculizumab, an anti-C5 antibody. We did not detect mutation in PIGA, which is regarded as the cause of PNH. However, we detected a germ-line mutation and a somatic microdeletion in chromosome 20q including PIGT; PIGT is essential for transferring GPI anchor to the precursors of CD59 and CD55, which play important roles in complement regulation. Loss of these proteins leads to complement overactivation, causing inflammatory symptoms, including recurrent meningitis. PIGT mutations should be considered a novel pathogenesis of recurrent meningitis of unknown aetiology.

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Obstructive urosepsis secondary to ureteric herniation into the sciatic foramen

A 65-year-old female patient presented with a 2-day history of worsening right-sided abdominal pain and clinical signs of sepsis, on the background of a recent admission for pancolitis. Imaging revealed right ureteric herniation through the sciatic foramen with subsequent hydroureteronephrosis and radiological signs of severe pyelonephritis. The patient underwent emergency decompression with a percutaneous nephrostomy, followed by insertion of an antegrade stent to correct the ureteric hernia once the sepsis was appropriately treated. We describe the presentation and management of this unusual case of herniation of the right ureter into the sciatic foramen.

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Acromioclavicular joint cyst formation in a patient with rotator cuff-tear arthropathy: a rare cause of shoulder discomfort

We report a case of a 77-year-old man who presented to our shoulder department with a soft tissue mass on his right acromioclavicular (AC) joint. Previously attempted puncture aspiration had revealed serous fluid retention which recurred after each of several drainage attempts. Conventional radiography and MRI of the affected shoulder joint demonstrated a progressed cuff-tear arthropathy with an irreparable tear of the supraspinatus tendon, static superior migration of the humeral head, opening of the AC joint capsule and a superior joint-fluid 'eruption' and accumulation called 'Geyser sign'. Given that the patient's cuff-tear arthropathy was very well compensated, arthroscopic rotator cuff debridement and open cyst excision were performed. Closure of the superior aspect of the AC joint capsule was performed by the aid of a collagen matrix with additional closure of the deltotrapezial fascia. One year postoperatively, no cyst recurrence was noted.

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Atypical presentation of molar pregnancy

The classic features of molar pregnancy are irregular vaginal bleeding, hyperemesis, enlarged uterus for gestational age and early failed pregnancy. Less common presentations include hyperthyroidism, early onset pre-eclampsia or abdominal distension due to theca lutein cysts. Here, we present a case of molar pregnancy where a woman presented to the emergency department with symptoms of acute abdomen and was treated as ruptured ectopic pregnancy. The woman underwent laparoscopy and evacuation of retained products of conception. Histological examination of uterine curettage confirmed the diagnosis of a complete hydatidiform mole. The woman was discharged home in good general condition with a plan for serial beta-human chorionic gonadotropin (beta-hCG) follow-up. Complete follow-up includes use of contraception and follow-up after beta-hCG is negative for a year.

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Lupus causing small bowel obstruction

A 20-year-old female patient was admitted to hospital in 2015 with 1 year history of recurrent abdominal pain, distension, borborygmi and nausea. The patient had a background of systemic lupus erythematous (SLE) diagnosed 4 years before, with skin, joint and renal involvement. The initial investigations have shown a long segment of ileal inflammation with upstream obstruction. Differential diagnoses were mainly SLE enteritis or concomitant Crohn's. Patient failed the initial conservative management and had a laparotomy with small bowel (SB) resection and ileostomy. The histology was suggestive of autoimmune enteritis. Although bowel involvement is a frequent feature of SLE, surgery for obstruction is extremely rare. Postoperatively, she had an emergency admission and was diagnosed with SB volvulus with perforation. She underwent further resection and stoma refashioning in 2016. As a consequence, she developed short gut syndrome. Eventually, the stoma was reversed and parenteral nutrition was stopped and weight became stable.

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Idiopathic macrocheilia

A 13-year-boy presented with painless swelling of upper and lower lips accompanied with gingival enlargement. The aetiology for these symptoms included vast pathological varieties but none of them could fit in. Clinical features were similar to orofacial graulomatosis but histopathological examination revealed chronic non-specific infection. Therefore, the final diagnosis was made as idiopathic macrocheilia through exclusion criteria. Management with intralesional triamcinolone acetonide 40 mg, twice a week for 3 weeks, resulted in significant remission in lip swelling without recurrence after a 6-month follow-up.

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Massive gastric dilatation leading to acute respiratory distress 1 year after a Nissen fundoplication

Acute massive gastric dilatation (AMGD) is a recognised complication after Nissen fundoplication.¹ A 63-year-old man recently presented to our emergency department in acute respiratory distress, acute abdominal pain and distension, having had an elective umbilical port incisional hernia repair a day prior. In the year preceding his presentation, the patient had undergone a laparoscopic paraoesophageal hiatus hernia repair and excision of sac, posterior cruropexy, dual mesh reinforcement of repair and 360° fundoplication, as a day case. In between these two events, the patient was asymptomatic, and had a free diet with no further medical or surgical intervention. We hereby present successful management and discuss implications of this exceptional yet potentially life-threatening complication.

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Diabetic ketoacidosis and thyroid storm: coexistence of a double trouble

Diabetic ketoacidosis (DKA) and thyrotoxic crisis are both endocrine emergencies. Here, we present a case of a patient who presented with DKA and on further evaluation was found to also have a thyrotoxic crisis. The coexistence of both of these endocrine emergencies simultaneously is extremely rare and heralds grave prognosis unless identified and treated promptly.

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Bilateral submandibular gland nodular oncocytic hyperplasia with papillary cystadenoma-like areas

A 57-year-old man presented in 2016 with a 4-month history of a right submandibular mass, having undergone left submandibular gland (SMG) excision in 2003. Imaging suggested a benign tumour and subsequent core biopsy findings suggested a nodular oncocytic hyperplasia, similar to the tumour removed from the contralateral side. This was confirmed on histological analysis following right submandibular gland excision which showed characteristic features of nodular oncocytic hyperplasia along with an unusual diffuse papillary cystadenoma-like ductal proliferation, similar to that seen in the 2003 specimen. A diagnosis of multinodular adenomatous oncocytic hyperplasia (MAOH) was rendered in order to communicate the unique histological features that have otherwise not been described in the literature. We believe that this is the first reported case of non-synchronous multinodular oncocytic hyperplasia and the first case affecting the submandibular glands.

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Gossypiboma masquerading as nephrocutaneous fistula

Nephrocutaneous fistula is a rare complication of surgical procedures involving the kidney. Fistula formation is also a complication seen in gossypiboma. We present the case of a patient who was initially suspected to have nephrocutaneous fistula after open pyelolithotomy. Later while undergoing open resection of fistula, he was found to have a retained surgical sponge (gossypiboma) near the lower pole of kidney. Gossypiboma is a term used for mass formed around a surgical sponge accidentally left in the body. It is most of the times not diagnosed by radiological imaging and thus results in unnecessary investigations to rule out other causes for the patient's symptoms. Having a high index of suspicion may lead to an earlier diagnosis. But the prevention of gossypiboma is of the utmost importance. A meticulous approach while operating by the surgeon and operating rooms staff is very important in doing so.

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Chronic urinary retention due to diabetic cystopathy masquedering as mesenteric cyst

Description 

A 55-year-old previously diabetic man presented with progressive abdominal distension for the last three months. He denied any bowel/bladder complaints. His medical/surgical history was unremarkable. On examination his vitals were stable and a huge abdominal mass (10x11 cm) was palpable. The mass was having side-to-side mobility. There was no hepatosplenomegaly or clinically significant lymphadenoapathy. On evaluation with ultrasonography of abdomen and CT scan, there was evidence of huge, cystic and homogenous mass (13x11 cm) with clear margins occupying almost entire abdominal cavity (figure 1). There was no evidence of calcification, septations or nodules in the mass, and it appeared to be separate from both the kidneys and bowel. A provisional diagnosis of mesenteric cyst was made, and the patient was taken for laparotomy. A per-urethral catheter was placed intraoperatively and surgery was started. During laparotomy it came as an element of surprise that the swelling was actually chronically distended bladder...

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Fetishism in ADHD: an impulsive behaviour or a paraphilic disorder?

A boy with attention deficit and hyperactivity disorder (ADHD) presented with a fetish for and the subsequent stealing of female undergarments. He was predominantly inattentive and had been a slow learner. Psychological tests showed that he had significant cognitive and inattention problems without significant hyperactivity, and was at risk of dyslexia as well as conduct disorder.

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Pneumonia and bacteraemia caused by Gemella morbillorum in a previously healthy infant: first reported case in literature

A 5-month-old baby presented with a low-grade fever and tachypnoea and was found to have right upper lobe consolidation on chest radiograph. He was admitted with the diagnosis of bronchopneumonia and the treatment protocol for pneumonia was initiated. Blood culture samples were collected, and he was started on a course of intravenous amoxicillin–clavulanate. Blood culture results displayed pansensitive Gemella morbillorum bacteraemia and he was continued on intravenous antibiotic to which he responded in a short period and was discharged in good condition on the fourth day.

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Gastric emphysema secondary to severe vomiting: a comparative review of 14 cases

Gastric emphysema is characterised by the presence of air within the wall of the stomach. The radiographic finding of gastric emphysema with hepatic portal venous gas is classically an ominous sign, associated with a high mortality rate. We report one case from our clinical experience and undertake a review of the previously reported cases of vomiting-induced gastric emphysema retrieved from the PubMed. A total of 14 cases were found to date. The mean age at the time of diagnosis was 45.6 years (range, 9 months to 81 years). Computed tomography abdomen was the frequently used diagnostic modality. Interestingly, conservative treatment led to a clinical cure and resolution of gastric emphysema as well as the associated hepatic portal venous gas in most of the patients. This review illustrates that vomiting-related gastric emphysema entails a more benign course and surgical intervention can be avoided with a prompt aetiology establishment in these patients.

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Aneurysmal dilation of the vein of Galen and straight sinus with resultant obstructive hydrocephalus

Description 

A 20-year-old woman was admitted to the emergency department on a previous occasion with tonic-clonic seizures. Her medical history was significant for headaches and hypertension. The headaches were associated with nausea and vomiting. She had no history of developmental delay or epilepsy. CT scan of the brain showed signs of obstructive hydrocephalus due to venous hypertension as a result of vein of Galen malformation, and hence a ventriculoperitoneal shunt was placed. Now on follow-up, her MRI brain demonstrates a round flow void in the suprapineal cisterns with engorged straight sinus, compatible with vein of Galen arteriovenous fistulous communication and shunting (figure 1). The resultant venous hypertension leads to mild to moderate compensated hydrocephalus.

Figure 1

(A) Axial T2, (B) axial T1 and (C) sagittal T2 MRI brain. MRI brain demonstrates a round flow void in the suprapineal cisterns with engorged straight sinus (green arrow),...

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Lateral Proboscis (Elephant Tusk) with Orofacial Clefts: A Report of a Rare Case

Lateral proboscis is a rare congenital anomaly. Lateral proboscis is a rare craniofacial malformation characterized by a rudimentary tubular, nose-like structure occurring in association with a wide spectrum of other anomalies. We presented a seven-month-old girl's lateral proboscis, cleft lip, and palate. Proboscis was excised by an elliptical incision, and the cleft was repaired at the same surgery.

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Silicone breast implant associated fibromatosis

Abstract

Extra-abdominal desmoid tumors, also known as aggressive or deep fibromatosis, are uncommon soft tissue tumors that rarely involve the breast. Although the exact etiology is unknown, the development of these tumors has been correlated with sites of previous trauma, surgery or in association with familial adenomatous polyposis. Clinically, breast fibromatosis is often mistaken for carcinoma but lacks metastatic potential. It is locally aggressive with high rates of recurrence. The treatment is primarily wide local excision with negative margins. Adjuvant treatments have been suggested and include radiotherapy, chemotherapy and hormonal therapy, however, there are no evidence-based treatment protocols to support their use. Here, we describe a case of fibromatosis that developed within the capsule around a silicone breast implant treated with surgical excision alone. The patient remains recurrence free at 3 months post-operative magnetic resonance imaging.

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