Local anesthetic spread into the paravertebral space with two types of quadratus lumborum blocks: a crossover volunteer study

Abstract

Purpose

Previous work showed that 20 mL of local anesthetic (LA) did not spread into the paravertebral space (PVS) via the intramuscular quadratus lumborum block (QLBi). If spread of LA into the PVS can be achieved by increasing the total LA volume, QLBi can be more effective. We hypothesized that a larger volume of LA for the QLBi would spread into the PVS.

Methods

This crossover volunteer study included five healthy men. For comparison, both the ultrasound-guided QLB type 2 (QLB2) and QLBi were employed on opposite sides of each volunteer, and the spread of LA solution (0.7 mL/kg) mixed with contrast media in the PVS was assessed 1 h after the first injection using magnetic resonance imaging. Sensory loss was evaluated by pinprick 90 min post-injection. Each volunteer underwent both QLB types, and the same procedures were administered on opposite sides 7 days after the first experiment.

Results

In total, 20 QLB blocks (10 QLB2 and 10 QLBi) were performed. LA did not spread into the PVS after the QLBi. The sensory block area included the lower abdomen after the QLB2, but not after the QLBi. The sensory block area did not extend to the upper abdominal region or the midline of the lower abdomen with either block method.

Conclusion

LA administered by the QLB2 spreads into the PVS of T10–T12, resulting in lower and lateral abdominal sensory loss. In contrast, LA administered by the QLBi does not spread into the PVS and results in only lateral abdominal sensory loss.

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Synovial sarcoma of the brachial plexus – a rare tumor in a rare area: a case report

Synovial cell sarcomas are usually seen in a juxta-articular location. However, they occur rarely in the head and neck region.

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Leptomeningeal carcinomatosis as primary presentation of metastatic urothelial cancer

Leptomeningeal spread of carcinoma, referred to here as leptomeningeal carcinomatosis, is an uncommon complication of many cancer types. Its manifestations as the presenting symptoms of a new cancer diagnosis is even less common. This case describes the manifestations of leptomeningeal spread of urothelial carcinoma with review of pathophysiology driving the presenting symptoms of hypertension and headache. In the Discussion section, we address the standard and novel interventions for management of increased intracranial pressure.

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Isolated renal mucormycosis in a patient with Idiopathic CD4 lymphocytopenia

Idiopathic CD4 lymphocytopenia (ICL) is characterised by a low CD4 +lymphocyte count in the absence of HIV or other underlying aetiologies. We report a case of a 17-year-old girl with ICL with autoimmune hepatitis who developed isolated renal mucormycosis, which, to our knowledge, is the first reported case described in literature. Combination therapy with antifungals and surgical resection was done, and the patient improved. This case report illustrates the importance of timely multidisciplinary approach to recognise this highly fatal disease at an early stage.

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Adult intussusception secondary to diverticular disease

Intussusception is the invagination of a proximal segment of bowel into the lumen of an adjacent distal segment. It is a common condition in the paediatric age group although it rarely occurs in adults. Organic lesions in the bowel wall are the primary cause of adult intussusceptions with malignant neoplasms being the most common. However, we present a rare case of a 92-year-old man diagnosed with an intussusception of the sigmoid-rectal colon secondary to a diverticular stricture.

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Rare case of a newborn baby with left-sided Erbs palsy and a contralateral/right-sided paralysis of the diaphragm

Brachial plexus birth injury (BPBI) and phrenic nerve injury can sometimes occur concurrently in neonates following difficult deliveries like breech presentation, shoulder dystocia, forceps or vacuum extraction. Phrenic nerve palsy should be suspected in a newborn with respiratory distress and an elevated hemidiaphragm on the imaging studies in presence of the associated risk factors. The right side is affected more often than the left side and most of it is associated with BPBI. We present here a rare case of a newborn baby with a left-sided Erb's palsy and a contralateral/right-sided diaphragmatic paralysis who recovered from the persistent respiratory distress and feeding difficulties following plication of the diaphragm. The left-sided Erb's palsy also fully recovered at follow-up examination.

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Case of Donath-Landsteiner haemolytic anaemia in an adult female

Donath-Landsteiner haemolytic anaemia (DLHA), also known as paroxysmal cold haemoglobinuria, is a very rare and difficult condition to diagnose as well as treat. Here, we present a case of a 55-year-old Hispanic woman who presented with severe intravascular haemolytic anaemia in the setting of a viral illness 2 weeks prior to presentation. Direct antiglobulin testing revealed mixed results: positive for either complement, IgG or both on various occasions which led to a battery of tests including the Donath-Landsteiner antibody testing which turned out positive establishing the diagnosis of DLHA. She was initially treated unsuccessfully with supportive care in the form of packed red blood cell transfusions and steroids as well as rituximab for about 4 weeks but her condition improved on cyclophosphamide, and she is on the road to recovery after 10 weeks of hospital stay.

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Severe haemophilia A in a neonate presenting as haemopneumothorax after tracheo-oesophageal fistula-oesophageal atresia repair

A male infant with oesophageal atresia and distal tracheo-oesophageal fistula (TEF type C) underwent right thoracotomy and transpleural repair of TEF on day 4 of life. He did not have a family history of coagulation disorders. A preoperative finding of prolonged partial thromboplastin time (PTT)>200 s was overlooked, and he went to surgery. There were no concerns with haemostasis prior to and even during the operation. The prolonged PTT was treated with one 10 mL/kg dose of fresh frozen plasma in the immediate postoperative period. On the fourth postoperative day, the infant developed a right haemopneumothorax, requiring fresh frozen plasma and packed cell transfusions. He was subsequently diagnosed with severe haemophilia A due to intron 22 inversion in the factor VIII gene, with factor VIII level <0.01 IU/mL.

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Hydralazine-associated antineutrophil cytoplasmic antibody vasculitis with pulmonary-renal syndrome

Hydralazine, a vasodilator, is commonly used as an adjunctive treatment for moderate to severe hypertension, heart failure and hypertensive emergencies in pregnancy. Hydralazine-induced lupus was first described in 1953. Clinical presentation ranges from arthralgia, myalgia, petechiae, or rash to single or multiorgan involvement. An occurrence of systemic vasculitis is a rare complication. When presented as the pulmonary–renal syndrome, it could have a rapidly progressive course which can be fatal. Here, we describe a case of hydralazine-associated rapidly progressive glomerulonephritis and pulmonary haemorrhage. We use this case to review the current literature and discuss and highlight the importance of a high degree of clinical acumen, early diagnosis and prompt treatment for better clinical outcomes.

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Rapid detection of Listeria monocytogenes rhombencephalitis in an immunocompetent patient by multiplexed PCR

A 46-year-old previously healthy man presented with 1 week of headache, nausea, vomiting and dizziness. He was found to have cranial nerve deficits, his cerebrospinal fluid (CSF) demonstrated a lymphocytic pleocytosis and brain MRI suggested rhombencephalitis. Although Gram stains and cultures of his CSF did not identify a pathogen, Listeria monocytogenes DNA was detected by the FilmArray Meningitis/Encephalitis panel within 2 hours of performing a lumbar puncture. He was treated with ampicillin and gentamicin and had a near-complete recovery. This case highlights the importance of recognising L. monocytogenes infection as a cause of acute cranial nerve impairment with MRI findings suggestive of brainstem encephalitis. It also highlights the frequently atypical CSF profile and low yield of culture in L. monocytogenes rhombencephalitis and the value of multiplex PCR testing of CSF to rapidly identify this pathogen and permit targeted therapy.

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Dulaglutide-induced cerebral venous thrombosis in a patient with type 2 diabetes mellitus

Though patients with diabetes mellitus are at a high risk of atherothrombotic events, every such event should not be attributed to the disease itself. We present a case of a patient with diabetes with headache and blurring of vision for 3 days. Brain imaging revealed right transverse sinus thrombosis and acute infarct of the right posterior parieto-occipital region, predominantly in the posterior cortical watershed zone. The patient was on subcutaneous dulaglutide for 3 weeks and was having nausea and vomiting. Various causes of cerebral venous thrombosis were ruled out with appropriate laboratory investigations. Finally, cerebral venous thrombosis was attributed to dulaglutide-induced nausea and vomiting which led to severe dehydration.

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Splenic granulomas: a rare manifestation of Mycobacterium avium complex in an immunocompetent host

Infections caused by Mycobacteriumavium complex (MAC) are commonly seen in immunocompromised individuals. Though disseminated MAC infections with splenic granulomas are seen in some patients, MAC infection clinically manifesting as only splenic granulomas is rare. This presentation is even less common in immunocompetent individuals. We report a case of a young adult who presented with fever of unknown origin and was found to have multiple splenic granulomas. Fine needle aspiration cytology and PCR for Mycobacterium tuberculosis of the granulomas revealed a diagnosis of MAC infection. The patient was not found to have any immunodeficiency on investigations. This case is perhaps the first case of MAC clinically presenting as splenic granulomas in an immunocompetent individual.

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Polyglandular endocrine emergency: lessons from a patient, which a book cannot teach

A 30-year-old woman with polyglandular autoimmune type 2 syndrome was found collapsed at home with a cardiac arrest, which required direct current cardioversion. On admission, she was hypothermic, hypotensive and bradycardic. Initial biochemical investigations were consistent with a pre-renal acute kidney injury, metabolic acidosis and a possible sepsis. She had significantly elevated thyroid-stimulating hormone levels on admission with the clinical profile consistent with dual Addisonian and myxoedema crisis. She received intravenous liothyronine and hydrocortisone along with supportive therapy. Echo showed severe left ventricular impairment with apical ballooning although coronary angiogram disclosed nothing abnormal. She made a gradual recovery and was discharged home after 2 weeks. She was diagnosed to have primary autoimmune hypothyroidism, Addison's diseaseand type 1 diabetes and coeliac disease in October 2006, July 2007, May 2010 and September 2016, respectively. Her inability to stick to gluten-free diet at her workplace was considered a significant contributory factor for out-of-hospital cardiac arrest.

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Large anterior urethral calculus masquerading as periurethral abscess

Urethral calculus causes variety of symptoms from simple dysuria to acute urinary retention. The diagnosis is many times not easy. A plain X-ray of the pelvis may aid in diagnosis. Due to variety of symptomatic presentations sometimes it is not the first diagnosis that comes to one's mind. Management is by removal of the calculus via various methods ranging from endoscopic to open surgery. We present the case of an adult male, who was initially thought to have periurethral abscess due to stricture urethra but during investigations was found to have urethral calculus as the cause for his symptoms.

https://ift.tt/2PVvUjr

Heterotopic ossification following anterior shoulder dislocation

Heterotopic ossification (HO) is the abnormal growth of extraskeletal bone. Joint involvement may result in chronic stiffness and pain causing considerable functional impairment and the inability to perform the activities of daily living. HO affecting the shoulder joint is rare and little is known about its clinical course or treatment. Here, we describe the first reported case of glenohumeral HO following anterior dislocation. This occurred in a 70-year-old man following a fall onto outstretched hand. Due to persistent stiffness and pain at 8 months from initial injury, he underwent plain radiographs and MRI scans that confirmed rotator cuff tear and HO. He was managed conservatively with physiotherapy and non-steroidal anti-inflammatory drugs. At 1-year follow-up, the patient maintains a good functional outcome.

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Challenging cause of bullous eruption of the hands in the Arctic

Phytophotodermatitis is caused by deposition of photosensitising compounds on the skin followed by ultraviolet exposure. We present an unusual case of a 29-year-old Australian male visiting Greenland who presented with severe itchy bullous eruption on his hands. The cause was a combination of exposure to lime fruit juice and prolonged sun exposure from the Arctic midnight sun.

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Thoracic splenosis: correct imaging diagnosis prevents invasive procedures like biopsy and thoracoscopy

Description 

A 48-year-old woman presented to the emergency department with acute shooting type of left-sided chest pain. There was no radiation of the pain to the arm, no aggravating or relieving factors. The patient denied cough, haemoptysis or weight loss. Medical history was significant for stage 2 breast carcinoma treated with radical mastectomy and radiotherapy 5 years ago. Since then she was on hormone therapy with tamoxifen. Investigations including routine blood counts, ECG and cardiac enzymes were normal. Chest radiograph did not reveal any abnormalities. CT scan of the chest with intravenous contrast revealed three enhancing pleural  based masses in the left hemithorax, measuring up to 2.6 cm in size. Initial diagnosis was pleural metastases from breast carcinoma and biopsy was considered. But the images also revealed bullet fragment in the thoracic spine and postsurgical changes of splenectomy. This raised the suspicion that the pleural masses could be due...

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Pelvic pain in young girls: not only dysmenorrhoea!

Imperforate hymen is the most frequent cause of haematocolpos, although it is a rare malformation (1:2000). We present two cases of young girls with cyclic abdominal pain and urinary symptoms. At gynaecological examination, they all presented imperforate hymen and ultrasound revealed significant vaginal distension. X-shaped hymenectomy was performed in all patients. The later the diagnosis of imperforate hymen, the higher the risk of complications like haematometra, haematosalpinx, haemoperitoneum and infections such as tubo-ovarian abscesses, peritonitis and endometriosis (retrograde menstruation theory).

https://ift.tt/2PLGNUJ

Phytophotodermatitis: still a poorly recognised diagnosis

Description 

A 30-year-old man, forestry worker, with no medical history, presented acutely with pruritic erythematous streaks and bullae (figure 1) in linear configuration on his arms. On the previous day he had pruned branches from a fig tree and carried them with his forearms wearing a sleeveless shirt. Symptoms gradually resolved over 4 weeks of topical treatment with clobetasol propionate 0.05% cream (figure 2).

Figure 1

Bullae and irregular pigmented lesions on both arms.

Figure 2

Recovered skin 2 months later.

Furocoumarins are botanical phytoalexins found in a wide variety of plants, including the fig tree (Ficus carita; Moraceae family), which may induce a skin photosensitivity reaction following ultraviolet A radiation exposure.1 2 The acute lesions often present with irregular erythematous streaks or bullae with sharp demarcation between lesional and...

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Large mediastinal mass in a 15-year-old boy

Hyperimmunoglobulin E syndrome is a rare multisystem inherited disorder characterised by high serum IgE levels, skin disorder causing eczema, dermatitis, recurrent staphylococcal infections and pulmonary infections and various skeletal and connective tissue abnormalities. Common presentation is with recurrent skin and sinopulmonary infections. Several features unrelated to immune system such as characteristic facial features, hyperextensibility of joints, multiple bone fractures and craniosynostosis have been described in the literature. We describe a rare presentation of this disease with invasive aspergillosis presenting as mediastinal mass with extension to mediastinal structures and pulmonary vasculature.

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De Winter pattern: a forgotten pattern of acute LAD artery occlusion

Description  

The De Winter ECG pattern was reported as an indicator of acute left anterior descending (LAD) coronary artery occlusion and is considered an anterior ST-elevation myocardial infarction (STEMI) equivalent.1 The key diagnostic features include ST-depression and peaked T-waves in precordial leads, and it can be seen in around 2% of patients with anterior myocardial infarction.1 2

We report a case of a 77-year-old woman with history of treated hypertension and hypercholesterolaemia. She presented to the emergency department with a typical acute chest pain, almost 1 hour after symptom onset. An ECG was immediately obtained and revealed sinus bradycardia at 45 bpm, with 1–2 mm ST-depression at the J point that continued into a wide, tall, positive, symmetrical T-wave in leads V2–V6, and a 0.5 mm ST-elevation in lead aVR (figure 1A). She was immediately transferred to our primary coronary intervention (PCI) centre. The...

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Bronchoalveolar carcinoma as an unsuspected cause for worsening shortness of breath in a patient with metastatic breast cancer

A 70-year-old woman with lung metastases from a breast cancer presented with worsening cough and dyspnoea. She recently had a pleurodesis for a malignant pleural effusion. Chest CT scans demonstrated various radiological changes leading to diagnostic challenges. Differential diagnoses included empyema, pleural disease progression, pulmonary oedema, pneumonitis, lymphangitis and atypical infections. She deteriorated despite a multimodality treatment strategy. Postmortem examination confirmed that lung changes were consistent with a bronchoalveolar carcinoma unrelated to the known metastatic breast cancer. The eventual knowledge of this diagnosis was reassuring to the treating medical team and a comfort to the relatives who witnessed the lack of response to standard treatment.

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