Complex regional pain syndrome type II arising from a gunshot wound (GSW) associated with infective endocarditis and aortic valve replacement

A 34-year-old man with a history of gunshot wound (GSW) to the right upper chest developed secondary aortic valve endocarditis (AVE) and was treated with an artificial valve placement (AVP). Three months after, he presented to an outpatient pain management clinic right arm pain and was diagnosed with complex regional pain syndrome type II (CRPS II). The patient underwent a diagnostic sympathetic ganglion block, before undergoing endoscopic thoracic sympathectomy surgery. Successful outcomes revealed decreased pain, opioid utilisation and improved tolerance to therapy and activities of daily living. To our knowledge, this is the first case reporting CRPS II arising from a GSW complicated by AVE followed by AVP, which emphasises how unforeseen syndromes can arise from the management of seemingly unrelated pathology. This case demonstrates the importance of timely and proper diagnosis of uncharacterised residual pain status post-trauma and differential diagnosis and management of chronic pain syndromes.

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Metropolitan W135 meningococcal compressive pericarditis treated with intrapericardial fibrinolysis

Meningococcal pericarditis is a rare but severe form of acute purulent pericarditis. It is a classic complication of Neisseria meningitidis of serotype W135, usually occurring in pilgrims to Mecca and their household contacts. This severe form of meningococcaemia is difficult to diagnose and evolves frequently and gradually towards a tamponade, requiring emergency drainage. We report a case of meningococcal pericarditis caused by N. meningitidis W135 in an immunocompetent patient, without any other organ involvement especially meningeal, requiring pericardium drainage in emergency and then intrapericardial fibrinolysis.

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Rare origin of left main coronary artery from non-coronary sinus with aortic coarctation

Anomalous origin of left main coronary artery from non-coronary sinus (LCANCS) is an extremely rare anomaly. Aortic coarctation in association with LCANCS has not been previously described in literature.

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Fits, feet and HIV: lessons from a case of coexisting epilepsy and neuropathy in a patient with perinatally acquired HIV-1 infection

An 18-year-old black African man with well-controlled perinatally acquired HIV-1 was diagnosed in late adolescence with the unrelated diagnoses of Charcot-Marie-Tooth type 1A (CMT1A), epilepsy due to polymicrogyria and subsequently developed severe depression. The CMT1A diagnosis occurred after transfer of care from a local paediatric HIV service to a tertiary paediatric referral centre and was precipitated by recognition of a history and neurological signs not typically associated with perinatal HIV. The case resulted in the establishment of a quarterly combined paediatric HIV and paediatric neurology multidisciplinary team clinic to assess children and adolescents living with HIV with neurological symptoms.

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A Rare case of recurrent Guillain-Barre syndrome without albuminocytological dissociation

Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy, often preceded by an illness. It is a self-limiting illness in most of the cases, but recurrence is rare and can be seen in about 1%–6% of patients. GBS is characterised by progressive, symmetrical, proximal and distal weakness. Areflexia and sensory disturbances are also common. Patients with GBS usually have albuminocytological dissociation on cerebrospinal fluid (CSF) analysis. This is a case of a 69-year-old woman with recurrent GBS and normal CSF findings.

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Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa

The trigeminocardiac reflex (TCR) is defined as a sudden onset of parasympathetic dysrhythmias during stimulation of the trigeminal nerve. We describe a peripheral variation of TCR during manipulation of the nasal mucosa. A 42-year-old patient suffering from severe obstructive sleep apnoea was scheduled for surgical treatment. After inducted anaesthesia, the surgeon infiltrated the nasal mucosa with a local anaesthetic. The patient immediately showed an asystole and was treated with ephedrine and five chest compressions, despite spontaneous sinus rhythm return after ceasing of manipulation. Treatment with atropine established this TCR episode and ensured an event-free surgery.

The authors present here, for the first time, a prolonged asystole caused by the TCR, triggered by minimal manipulation of the nasal mucosa. This severe manifestation of peripheral TCR demonstrates its importance in daily clinical business. This case was treated according to a modified treatment algorithm for all subtypes of TCR which is presented here.

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Friedreichs sign

Description  

An 82-year-old man with chronic atrial fibrillation treated with anticoagulation was admitted to the hospital for subacute progressive exertional dyspnoea. On examination, the jugular venous waveform was elevated to the mandibular angle with the patient sitting upright. Heart sounds were muffled. Transthoracic echocardiography (TTE) revealed a large circumferential pericardial effusion with early tamponade physiology. Pericardiocentesis yielded a large volume of sanguineous fluid. Following the procedure, there was improvement in jugular venous pressure to 14 cm H₂O. The height of the waveform increased with inspiration (Kussmaul's sign) and there was a prominent y descent, known as Friedreich's sign (see video 1). Repeat TTE revealed thickened pericardium, early diastolic septal bounce and respirophasic changes in early diastolic filling consistent with constrictive pericardial physiology. Friedreich's sign is a physical finding of constrictive pericarditis. The normal jugular venous waveform contains two descents, x and y. The x descent, which corresponds...

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Fungal thyroiditis in a lung transplant recipient

Description  

A 59-year-old man was admitted with 3 weeks of worsening shortness of breath 18 months after receiving a bilateral lung transplant for idiopathic pulmonary fibrosis. His immunosuppression included tacrolimus, everolimus and low-dose prednisone with no antifungal prophylaxis at the time of admission. CT chest revealed multiple, bilateral pulmonary nodules (figure 1—red arrows). CT-guided biopsy revealed fungal hyphae (figure 2). The initial CT and ultrasound of the neck at the onset of sore throat was negative; however, repeat CT neck for evolving neck pain and dysphasia during hospital course showed a mass-like lesion in the right thyroid lobe with extensive surrounding inflammatory changes (figure 3—green arrow). The lesion was also visualised on ultrasound, where it appeared as a hypoechoic solitary nodule (figure 4). Laboratory evaluation revealed hyperthyroidism, with a Thyroid Stimulating Hormone (TSH) of <0.01 µIU/mL (normal: 0.35–4.94 µIU/mL) and a...

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