Ileal schwannoma causing intussusception in an adult

Ileal schwannomas are extremely rare tumours. Very few cases have been previously reported. Most cases present with abdominal pain and gastrointestinal bleeding; intussusception is a rare presentation. Due to limitations in imaging modalities, arriving at a diagnosis preoperatively can be challenging. The only reliable method of diagnosis, and treatment, is resection of the tumour, followed by histological and immunohistochemical testing. This report details the rare case of intussusception as the presenting feature of an ileal schwannoma.

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Infected and obstructed kidney secondary to sloughed necrotic renal papilla

Description  

A 66-year-old Afro-Caribbean woman presented with a 1-day history of sharp left flank pain. This was associated with nausea and diarrhoea, without fever or urinary symptoms. Her medical history includes type 2 diabetes mellitus on insulin therapy but with suboptimal control (haemoglobin A1c 80 mmol/mol or 0.23 g/dL glucose levels) and related complications including chronic kidney disease, retinopathy, peripheral neuropathy, hypertension, sickle cell trait, obesity and osteoarthritis. Blood investigations demonstrated leucocytosis (white cell count 12.7x10⁹/L) and deranged renal function (creatinine 150 µmol/L; baseline 110 µmol/L). Urine dipstick test was positive for nitrites, ketones and glucose and urine culture isolated mixed growth of bacteria with Candida.

A CT abdomen/pelvis, initially planned on the working diagnosis of acute diverticulitis, revealed a mild left-sided hydroureteronephrosis associated with perinephric inflammatory stranding. Left posterolateral bladder wall thickening and left distal ureteric enhancement were also highlighted (figures 1 and 2). The patient was...

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Salmonella Enteritidis breast abscess: an unusual cause of breast abscess in the UK

Breast abscess is a common clinical condition mostly caused by Staphylococcus aureus. However, infections due to mixed organisms are observed in non-lactational women, mostly in smokers. Salmonella infection causing breast abscess is extremely rare in developed countries. We report a case of Salmonella enterica subsp enterica (I) serovar Enteritidis breast abscess in a 48-year-old woman, a UK citizen, who had recently travelled abroad. She was treated successfully with a combination of surgery and ciprofloxacin. Unusual causative organisms should be kept in mind in patients with recent travel abroad and pus should be sent for microbiology. Mastitis caused by Salmonella spp can present with a severely indurated area that may take a few weeks to resolve. Complete assessment with biopsy of the indurated area and breast imaging is mandatory to exclude malignancy.

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Linezolid-associated serotonin toxicity after escitalopram discontinuation: concomitant drug considerations

We report a case of a hospitalised patient who developed probable serotonin toxicity shortly after the initiation of linezolid in whom the selective serotonin reuptake inhibitor (SSRI) escitalopram had been recently discontinued. On day 2 of linezolid administration, the patient reported severe anxiety and was observed to have full body jerking and twitching motions without mental status change. Notably, the patient was concomitantly receiving the antidepressant, trazodone and the benzodiazepine, clonazepam possibly affecting the severity and manifestations of serotonin toxicity. Linezolid was discontinued after 5 days and the patient's symptoms resolved. Serotonin toxicity can present with an array of symptoms and be life threatening if left unrecognised. This report highlights the clinical lessons that discontinuation of an SSRI upon initiation of linezolid does not eliminate the risk of serotonin toxicity and that other concomitant medications may worsen or improve some of the symptoms lending delay and uncertainty to the diagnosis.

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Neurocysticercosis: a reversible and rare cause of seizure in the developed world

Description 

A 22-year-old man, originally from India, presented to an emergency department in Canada with a new-onset seizure and collapse associated with a few seconds of right eye and tongue deviation. This event occurred following 6 weeks of difficulty concentrating and unilateral left-sided headache. On examination, no focal neurological deficits were found. A non-contrast CT head was requested which showed a left-sided occipital lesion. A follow-up brain MRI revealed the 'hole-with-dot' lesion pathognomonic for neurocysticercosis (NCC).

NCC is caused by the tapeworm Taenia solium and is the most common parasitic infection of the central nervous system, endemic to many low-income countries worldwide. T. solium is transmitted among humans via the faecal–oral route, with pigs acting as an intermediate host. Humans are a definitive host for the intestinal tapeworm which produces eggs containing an infective embryo (oncosphere). This embryo can actively cross the intestinal wall into the blood stream and deposit in...

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Adjacent schwannomas originating from intercostal and sympathetic nerves

Description 

Schwannomas are the most frequent type of intrathoracic neurogenic tumour, but the presence of multiple simultaneous schwannomas is a rare occurrence. We experienced a patient initially thought to have a single schwannoma based on preoperative imaging, but who was subsequently found to have two adjacent schwannomas arising from different nerves.

A 48-year-old woman showed an abnormal shadow on chest X-ray during a medical examination. CT-guided biopsy did not provide a definitive diagnosis, and she was therefore referred to our department. Her general condition was good and her neurological findings were normal. No skin pigmentation or subcutaneous nodules were observed. Chest CT revealed a 5.5 cm segmental lobular tumour in the right posterior mediastinum (figure 1A) and chest MRI showed that the tumour continued from the right intervertebral foramina (figure 1B). We suspected schwannoma of the intercostal nerve, and performed video-assisted thoracoscopic surgery in the...

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Association between intraoperative phenylephrine administration and umbilical artery pH in women with hypertensive disorders of pregnancy: a retrospective cohort study

Abstract

Purpose

In healthy pregnant women undergoing Cesarean section, treatment of post-spinal hypotension (PSH) with phenylephrine is reportedly more efficacious than ephedrine in preventing a decline in umbilical artery pH (UApH), which is an indicator of fetal acidosis. However, phenylephrine has the potential to reduce placental blood flow and consequently decrease UApH in women who develop hypertensive disorders of pregnancy (HDP), due to decreased cardiac function and placental vascular abnormalities. We aimed to verify the association between decreased UApH and phenylephrine administered before delivery to treat PSH in women with HDP.

Methods

This single-center retrospective cohort study was conducted between April 2008 and October 2016 by assessing the records of pregnant women with confirmed or suspected HDP who underwent Cesarean section under spinal anesthesia. The association between phenylephrine and the primary endpoint of decreased UApH was investigated using logistic regression analysis and propensity score matching.

Results

In the original cohort of 107 pregnant women with HDP, neither univariate nor multivariate analysis indicated a significant association between phenylephrine treatment and decreased UApH [crude odds ratio (OR) = 2.26; 95% confidence interval (CI) 0.75–6.77; P = 0.14], (adjusted OR = 1.80; 95% CI 0.55–5.93; P = 0.33). Thirty patients each who were not treated with phenylephrine (control group) and were treated with phenylephrine (phenylephrine group) were matched by propensity score analysis. UApH [median (interquartile range)] was not significantly different between control and phenylephrine groups [7.30 (7.25–7.35) vs. 7.27 (7.25–7.30); P = 0.14].

Conclusion

Intraoperative phenylephrine administration to treat PSH in women with HDP was not associated with decreased UApH.

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Making a difference in gender disparities

Across the globe, women are made vulnerable by modifiable determinants in their homes, communities and cultures. In "Barriers to healthcare for female patients in Papua New Guinea," Klaver and Coe address some of this risk. The authors present the case of a 25 year old woman who had complaints of abdominal distension, exertional dyspnea and amenorrhea. Despite trying to address these symptoms early on, she "had been turned away… [d]ue to limited resources and high levels of tribal fighting in the area…. The closest hospital where elective surgery was available was a 10-hour journey by dirt road for which she had neither transport nor funds to allow her to travel." Her husband had left her and taken a second wife due to her illness, and she had moved back to her family and was raising her child alone. "She currently had no contact with or financial support from her husband." She was diagnosed with HIV, treatment was initiated, and three months later had an ovarian cyst of 5.3 kg (12% of her body weight) removed in an uneventful elective surgery.

While there are multiple reasons for her delayed presentation to care and the severity of her symptoms, the authors make clear that tribal violence in the highlands of Papua New Guinea was a major factor in her delayed presentation. First, "Women are commonly targeted in the tribal fighting and subjected to rape and sexual violence as part of the conflict." Second, "Due to high levels of trauma and significant numbers of patients requiring emergency surgery… [the hospital] did not undertake elective procedures." Both of these facets of the tribal violence conspired against this patient to ensure she would remain in poor health.^[1]

Papua New Guinea is the only country in the pacific where women have a lower life expectancy than men. As described by the authors, "Many women are only allowed to attend… hospitals with the permission of their husbands, and any surgical procedure would certainly require… [his] consent." Many women in abusive relationships have no other options but to return to their abuser.^[2] Her amenorrhea caused her husband to abandon her for a second wife, and she was forced to provide for herself despite her condition. The author's hypothesize, "Had [her ill health]… not prevented her from working, she would likely never have voluntarily attended the hospital." These gender disparities are worsened in diseases associated with cultural stigma, such as HIV.^[3]

While the outcome from this case can be construed as positive, this woman still suffered for years because of discrimination against her gender. This is not only a problem in Papua New Guinea, but worldwide. Health professionals can act as advocates for these patients by ensuring they receive the proper care, being aware of the gender biases present in each culture, and fighting for their patients on a local, national and global level.

BMJ Case Reports invites authors to submit global health case reports that describe the disparities of healthcare based on gender. These cases could focus on:

-The factors contributing to these disparities

-The methods used to ensure equal care for all

-The unique contributions made by female practitioners in areas of gender disparities.

 

Manuscripts may be submitted by students, physicians, nurses and allied health professionals to BMJ Case Reports at www.bmjcasereports.com. For more information, review our guidance on how to write a global health case report and look through our online collection

 

To read more about gender disparities at BMJ Case Reports, please review:

-'The more we change, the more we remain the same': female feticide continues unabated in India

– Barriers to safe abortion access: uterine rupture as complication of unsafe abortion in a Ugandan girl

-HIV in India: the Jogini culture

 

To read more about gender disparities globally from other cited sources, please review:

^[1]ICRC report, 2016. The old ways are gone: Papua New Guinea's tribal wars become more destructive. Available at https://medium.com/@ICRC/the-old-ways-are-gone-papua-new-guineas-tribal-wars-become-more-destructive-ade38205196f

^[2]MSF, 2016. Papua New Guinea Report- "Return to abuser". http://www.msf.org/sites/msf.org/files/msf-pngreport-def-lr.pdf

^[3] Wardlow H. The (extra)ordinary ethics of being HIV-positive in rural Papua New Guinea. J R Anthropol Inst 2017;23:103–19.doi:10.1111/1467-9655.12546

 

The post Making a difference in gender disparities appeared first on BMJ Case Reports blog.

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Challenges and hurdles for patient safety in obstetric anesthesia in Japan

Abstract

The use of pain relief for labor has gained popularity in Japan. However, its acceptance is still low among laboring women: only 6.1% of Japanese parturients receive labor analgesia, in contrast with the United States, where approximately 70% receive labor analgesia. Unfortunately, several maternal deaths associated with labor analgesia have been reported in recent years in Japan and how to achieve safer obstetric care is a pressing concern. In this review, we focus on current approaches to labor analgesia in the United States as they compare to existing practices in Japan. We discuss challenges for the introduction and implementation of standard anesthesia practice into the Labor and Delivery Room (LDR; i.e., labor and delivery ward), aiming to secure safety for both mothers and fetus in every part of Japan in the near future.

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Dengue shock syndrome complicated with acute liver failure and kidney injury, infective endocarditis, and deep vein thrombosis: a case report

Dengue fever is a mosquito-borne viral disease with a very high incidence in Southeast Asia. Most patients with dengue fever recover following a self-limiting febrile illness, while a small proportion may prog...

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