New Horizons in Clinical Case Reports最新文献_第3页

The chemo brain: Severe cognitive decline following chemotherapy of breast cancer 化疗脑:乳腺癌化疗后认知能力严重下降

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.05.001

Wolfgang P. Kaschka , Jürgen Steyer , Iris N. Kaschka , Martin Jandl , Steve Hodgkinson

引用次数: 2

Standard versus minimally invasive transforaminal lumbar interbody fusion: A prospective randomized study 标准与微创经椎间孔腰椎体间融合术:一项前瞻性随机研究

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.018

Gabriel Tender * , Daniel Serban , Anthony DiGiorgio

Introduction

Symptomatic spondylolisthesis patients may benefit from surgical decompression and stabilization. The standard (S) technique is a transforaminal lumbar interbody fusion (TLIF). Newer, minimally invasive (MI) techniques seem to provide similar results with less morbidity. However, prospective studies comparing S versus MI TLIF are rare.

Case description

Patients with at least 6 months of symptoms and image-confirmed low-grade spondylolisthesis (grade 1 or 2) were enrolled, at a single academic institution, between 2011 and 2015. The patients were randomized to either S or MI TLIF. Iliac crest graft, polyether ether ketone (PEEK) interbody cages, and pedicle screw-rod constructs were used in both groups. The primary outcome measure was the Oswestry Disability Index (ODI) improvement at 1 year. Secondary outcome measures included length of operation, estimated blood loss, length of hospitalization, and fusion rates at 1 year. Complications were also recorded.

Results and Conclusions

Forty patients were enrolled in each group. There was no crossover between groups. The age was 50.12+/-11.09 years in the S TLIF group and 51.3+/-9.36 years in the MI TLIF group. There were 23 and 24 females in the S and MI TLIF group, respectively. The mean operative time and estimated blood loss in the S versus MI TLIF group were 297+/-101 versus 323 +/-85 minutes and 417+/-211 versus 351+/-198 ml, respectively. There were 4 transfusions in the S TLIF and 3 transfusions in the MI TLIF group. The patients were discharged after surgery at 4.12+/-0.88 days for the S TLIF group and 1.92+/-0.52 days for the MI TLIF group. The ODI improved from 37+/-6 to 11+/-6 in the S TLIF group (ODI difference: 26+/-7) and from 38+/-7 to 11+/-6 in the MI TLIF group (ODI difference: 26+/-8). The fusion was considered solid (Grade I) in 36 (90%) and partial (Grade II) in 4 (10%) patients at 1 year. There were no reoperations for pseudarthrosis or any other postoperative complication. There were 2 superficial wound infections in the standard TLIF group, which resolved with oral antibiotic treatment alone.

Take home message

In this prospective randomized study, the standard and minimally invasive TLIF in patients with symptomatic spondylolisthesis provided similar clinical and radiological outcomes at 1 year. The patients undergoing MI TLIF had a shorter hospital stay. Both surgical techniques yielded good results at 1 year.

有症状的腰椎滑脱患者可以从手术减压和稳定中获益。标准(S)技术是经椎间孔腰椎椎体间融合术(TLIF)。较新的微创(MI)技术似乎可以提供类似的结果，而且发病率更低。然而，比较S和MI TLIF的前瞻性研究很少。病例描述:2011年至2015年间，在一个学术机构招募了症状持续至少6个月且影像学证实为轻度脊柱滑脱(1级或2级)的患者。患者被随机分为S或MI TLIF组。两组均采用髂骨移植物、聚醚醚酮(PEEK)椎间笼和椎弓根螺钉棒结构。主要结局指标为1年的Oswestry残疾指数(ODI)改善。次要结局指标包括手术时间、估计失血量、住院时间和1年的融合率。并发症也有记录。结果与结论每组40例。两组之间没有交叉。S TLIF组年龄为50.12+/-11.09岁，MI TLIF组年龄为51.3+/-9.36岁。S组和MI组分别有23例和24例女性。S和MI TLIF组的平均手术时间和估计失血量分别为297+/-101和323 +/-85分钟，417+/-211和351+/-198 ml。S TLIF组输注4次，MI TLIF组输注3次。S TLIF组术后4.12+/-0.88天出院，MI TLIF组术后1.92+/-0.52天出院。S TLIF组的ODI从37+/-6改善到11+/-6 (ODI差值:26+/-7)，MI TLIF组的ODI从38+/-7改善到11+/-6 (ODI差值:26+/-8)。1年后，36例(90%)患者被认为是固体(I级)融合，4例(10%)患者被认为是部分(II级)融合。无假关节再手术或任何其他术后并发症。标准TLIF组有2例浅表创面感染，均经单独口服抗生素治疗解决。在这项前瞻性随机研究中，标准和微创TLIF治疗有症状的脊柱滑脱患者1年后的临床和影像学结果相似。接受MI TLIF的患者住院时间较短。两种手术方法在1年后都取得了良好的效果。

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引用次数: 0

Case report: A rare presentation of right illiac fossa pain 病例报告:一例罕见的右侧髂窝疼痛

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.026

Abida Sultana *, Ahmed Saad, Yan Mei Goh, Kyi Toe

Introduction

Duplex appendix is a rare congenital abnormality with an incidence of 2 in 50,000. Incidences of duplex appendicitis are a rare but recognised phenomenon. Unusual presentation of this congenital abnormality can lead to delays in diagnosis and management.

Case description

A 42-year-old male presented with a two-day history of right iliac fossa pain and raised inflammatory markers. He underwent diagnostic laparoscopy where a normal appendix was seen. Laparoscopic appendicectomy was not performed. He represents several years later with similar symptoms and another diagnostic laparoscopy was performed revealing a normal appendix. Subsequent laparoscopic appendicectomy was performed which was histopathology confirmed as a normal appendix. His symptoms did not improve after surgery and he developed localised guarding in the right iliac fossa, low grade pyrexia, tachycardia and raised inflammatory markers. An ultrasound scan was performed which was unremarkable. Computed tomography (CT) abdomen revealed a small collection from which extended a thin tubular structure ending in the terminal ileum. A third diagnostic laparoscopy was performed. The small collection was not identified and conversion to midline laparotomy revealed a second necrotic friable appendix leading to a retrocaecal and retroileal cavity (abscess). This was confirmed on histopathology to be a gangrenous appendix with secondary peritonitis. He was discharged from hospital several days post-operatively. A year later he represented to our services with an incisional hernia which was repaired laparoscopically.

Conclusions

Dual appendix is a well described but rare congenital abnormality that is well described by the Cave-Wellbridge classification. This congenital abnormality is often recognised incidentally at surgery or on post-mortem examination. Radiological studies are often not useful aids in making the diagnosis of duplicate appendix. Hence the possibility of a duplex appendix should be considered and sought during diagnostic laparoscopy performed in patients presenting with recurrent right iliac fossa symptoms.

双阑尾是一种罕见的先天性畸形，发病率为5万分之2。双侧阑尾炎是一种罕见但公认的现象。这种先天性异常的不寻常表现可能导致诊断和治疗的延误。病例描述:42岁男性，右髂窝疼痛2天，炎症标志物升高。他接受了诊断性腹腔镜检查，发现阑尾正常。未行腹腔镜阑尾切除术。几年后，他出现了类似的症状，再次进行腹腔镜检查，发现阑尾正常。随后进行腹腔镜阑尾切除术，组织病理学证实为正常阑尾。手术后症状没有改善，出现右髂窝局部守卫、低度发热、心动过速和炎症标志物升高。进行了超声扫描，没有什么异常。腹部计算机断层扫描(CT)显示一个小集合，延伸到回肠末端的细管状结构。第三次诊断腹腔镜检查。小的收集没有被识别，转换到中线剖腹术发现第二个坏死易碎的阑尾，导致盲肠后和回肠后腔(脓肿)。组织病理学证实为坏疽性阑尾伴继发性腹膜炎。手术后几天他出院了。一年后，他代表我们的服务切口疝是腹腔镜修复。结论双阑尾是一种罕见的先天性畸形，适用于Cave-Wellbridge分类。这种先天性异常通常在手术或尸检时偶然发现。在诊断重复阑尾时，放射学检查往往不能起到辅助作用。因此，在出现复发性右髂窝症状的患者进行诊断性腹腔镜检查时，应考虑并寻求双阑尾的可能性。

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引用次数: 0

Non-union of paediatric carpal fractures: A case report and current concepts review 儿童腕骨骨折不愈合:一例报告和当前概念回顾

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.009

Scarlet Nazarian *, Ashley Simpson, Gavin Schaller, Rajiv Bajekal

Introduction

Paediatric carpal bone fractures are rare, and usually secondary to significant direct trauma. Diagnosis can commonly be missed or the significance of the injury not completely recognised on presentation. During development, the ossification centre of each individual carpal bone is surrounded by a spherical growth plate. This acts as a protective barrier against injury. As the child reaches adolescence the critical bone-to-cartilage ratio is reached, and so, carpal bone fractures start to become more common.

Case description

A 12 year-old boy presented to the emergency department with right wrist pain following a fall from his bicycle while travelling at speed. The impact was sustained directly on to an outstretched hand, resulting in a closed injury. Radiographs demonstrated a dorsally displaced Salter-Harris III fracture of the distal radius with associated displaced fractures of the ulna styloid and lunate. The patient reported reduced sensation and tingling in the thumb, index and radial aspect of middle finger consistent with the distribution of the median nerve. Motor supply was intact. The fracture was initially mobilised with a dorsal plaster slab. The patient was taken to theatre the following morning for manipulation under anaesthetic and plaster immobilisation. Satisfactory reduction of the distal radius fracture was achieved with the lunate and ulnar styloid fractures not addressed. Median nerve symptoms improved somewhat following the procedure but did not completely resolve. At 10 days post-operatively check radiographs demonstrated the distal radius fracture reduction to be maintained and the plaster cast was changed to a lightweight below elbow full cast which remained in situ for 6 weeks. Radiographs at 6 weeks demonstrated union of the distal radius fracture but no signs of healing of the ulnar styloid or lunate fractures. Median nerve sensory symptoms had improved. The cast was removed and range of motion exercises begun. An MRI was performed showing a non-united fracture of the lunate without signs of avascular necrosis. The patient is now 6 months post-op and currently asymptomatic with a full painless range of motion. He has returned to his pre-morbid level of function being actively involved in physical education at school and reports no pain in the wrist or functional deficit. Radiographs continue to demonstrate a lunate non-union.

Results and Conclusions

Paediatric lunate fractures are very rare, and as a result there is very little published literature available. Previous case reports have demonstrated good long-term results from both conservative and operative management of paediatric carpal fractures. A case report by Bhatnagar et al. highlighted a good clinical outcome with non-operative treatment of an active 11-year old boy with multiple carpal fractures. They demonstrated asymptomatic full range of motion of the wrist at 3 years follow-u

小儿腕骨骨折是罕见的，通常继发于严重的直接创伤。诊断通常会被遗漏，或者损伤的重要性在呈现时不能完全识别。在发育过程中，每个腕骨的骨化中心被一个球形生长板包围。这是防止受伤的保护屏障。当孩子进入青春期时，达到了关键的骨与软骨比例，因此，腕骨骨折开始变得更加常见。病例描述:一名12岁男孩在高速行驶时从自行车上摔下，右手腕疼痛，被送往急诊室。撞击直接发生在伸出的手上，造成闭合性损伤。x线片显示桡骨远端背侧移位的Salter-Harris III型骨折伴尺骨茎突和月骨移位骨折。患者报告拇指、食指和中指桡侧感觉减少和刺痛，与正中神经的分布一致。马达供应完好无损。骨折最初用背侧石膏板固定。患者于次日上午被送往手术室，在麻醉和石膏固定下进行操作。桡骨远端骨折复位满意，月骨和尺骨茎突骨折未处理。手术后正中神经症状有所改善，但未完全消除。术后10天检查x线片显示桡骨远端骨折复位得以维持，石膏石膏改为肘部以下轻量全石膏，并保持原位6周。6周的x线片显示桡骨远端骨折愈合，但尺骨茎突或月骨骨折未见愈合迹象。正中神经感觉症状有所改善。拆除石膏，开始进行活动范围练习。MRI显示月骨非愈合性骨折，无缺血性坏死迹象。患者术后6个月，目前无症状，活动范围无痛。他已恢复到发病前的功能水平，并积极参与学校的体育教育，并报告没有手腕疼痛或功能缺陷。x线片继续显示月骨不连。结果与结论儿童月骨骨折非常罕见，因此发表的文献很少。以前的病例报告表明，保守和手术治疗儿童腕骨折的长期效果良好。Bhatnagar等人的病例报告强调了一名11岁多处腕关节骨折的活跃男孩非手术治疗的良好临床结果。随访3年，尽管CT显示钩骨骨折不愈合，但患者的腕关节仍能进行无症状的全方位活动。同样，手术治疗也有良好的临床结果。Kamano等人对一名多发性腕骨折儿童进行钢丝固定治疗，随访至29个月，疗效显著。2009年，Foley等人在一名接受克氏针治疗的10岁男孩身上也证明了类似的结果。该患者骨愈合，随访1年，腕关节无疼痛，活动范围全。在我们的病例中，我们仅根据患者的症状采取保守的治疗方法。然而，仍然存在的问题是:-月骨骨折是否会进展为延迟愈合，我们是否应该随访患者直到这种情况发生?-如果不愈合，这是否会导致手腕功能的长期损害或慢性疼痛?延迟ORIF联合植骨是否应该仅仅为了实现骨愈合而进行，还是应该仅在出现症状时才进行?-初次手术时是否应进行月骨固定?•儿童腕骨骨折是罕见的，通常被忽视和可能被低估。•没有证据表明这些儿童月骨骨折和无症状骨不连的具体治疗方法。•没有长期研究提供儿童腕骨骨折不愈合的可能后遗症。•我们提出了一种基于患者症状的保守治疗方法，这种方法在短期到中期看来是成功的，但我们无法对长期预后发表评论。

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引用次数: 0

Twisted "appendix epiploica" as extraordinary cause of discomfort at the right lower abdomen and rare differential diagnosis of acute appendicitis - a representative case 扭曲的“阑尾”作为右下腹部异常不适的原因和罕见的鉴别诊断是急性阑尾炎的一个代表性病例

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.035

Stefan Schäfer * , Benjamin Garlipp , Cora Wex , Inken Häusler , Stephan Arndt , Björn Friebe , Dörthe Jechorek , Frank Meyer

Introduction

Appendicitis can be considered the most frequent cause of discomfort at the right lower abdomen. Simultaneously, it is the most frequent indication for a surgical intervention. In addition, there is a broad spectrum of differential diagnoses, which can lead to a very challenging finding-specific management in good time as found out in the presented case.

Case description

A 44-year old female patient was transfered to the surgical department because of discomfort of the right lower abdomen with changing intensity which had persisted since the day before. Patient showed a reduced but stable clinical status (normosomic nutritional status; no relevant accompanying diseases). Previous oral nutrition was normal. Clinical examination revealed pain by palpation at the right lower abdomen. Laboratory parameters: White blood cell count, 8.2Gpt/L; CrP, 10.4mg/L; urine with no pathological finding; no increased serum β-HCG level. Transabdominal ultrasound as orienting initial imaging detected free fluid around the cecum and along the right iliac vessels (appendiceal diameter, approximately 6.5mm) – in summary, no sign of appendicitis with certainty. Because of a persisting symptomatology, indication for a surgical intervention was derived (intraoperatively, laparoscopic appendectomy and partial resection of the greater omentum). Postoperative course was uneventful (no general/specific complications, wound healing was properly, initiation of oral nutrition and mobilization were well tolerated). Pathohistological investigation revealed lipofibromatosis of the appendage of the cecum with attached necrotic fat tissue and hemostasis, which can be associated with the diagnosis of a twisted appendix epiploica (no hint for malignant tumor growth).

Results and Conclusions

The finding as presented occurs very rarely (approximately, 0.2%), which was initially misinterpreted as appendicitis with regard to symptomatology, ultrasound and laboratory findings. A definite diagnosis became only possible during the postoperative course by pathohistological investigation (suspicion already raised by intraoperative inspection aspects). Taking the final diagnosis into account, the question of a necessary indication for surgical intervention can be brought up, which can not be circumvented in case of unclear findings and medical history according to the surgical policy (“case of doubt“). However, as a consequence a more intense and extended diagnostic including a well developed clinical experience level as well as the clinical suspicion can be derived and concluded. This was an exciting and instructive case from a didactic point of view (relevant also for medical students) with rare occurrence in daily clinical practice, which includes the whole spectrum of differential diagnoses of i) unclear discomfort at the right lower abdomen in general and ii) acute appendicitis specifically.

阑尾炎被认为是右下腹部最常见的不适原因。同时，它也是手术干预的最常见指征。此外，有一个广泛的鉴别诊断，这可能导致一个非常具有挑战性的发现，具体的管理，及时发现在本病例。病例描述一名44岁女性患者，因自前一天开始持续右下腹部疼痛，且疼痛强度变化，转至外科就诊。患者表现出减少但稳定的临床状态(正常的营养状况;无相关伴发疾病)。既往口腔营养正常。临床检查显示右下腹触诊疼痛。实验室参数:白细胞计数，8.2Gpt/L;10.4 mg / L c反应蛋白;尿无病理表现;血清β-HCG水平未升高。经腹超声定位初步成像发现盲肠周围和右侧髂血管周围有游离液体(阑尾直径约6.5mm) -总之，没有确定的阑尾炎征象。由于症状持续存在，手术干预的指征被导出(术中，腹腔镜阑尾切除术和部分切除大网膜)。术后过程平稳(无一般/特异性并发症，伤口愈合良好，开始口服营养和活动耐受良好)。病理组织学检查显示:盲肠附件脂肪纤维瘤病伴附着坏死脂肪组织及止血，可诊断为阑尾扭曲网膜(未提示恶性肿瘤生长)。结果和结论所呈现的发现非常罕见(约0.2%)，最初根据症状、超声和实验室检查结果被误解为阑尾炎。只有在术后过程中通过病理组织学检查(术中检查方面已经提出怀疑)才能明确诊断。考虑到最终诊断，可以提出手术干预的必要指征问题，如果根据手术政策发现和病史不明确(“怀疑病例”)，则不能回避这一问题。然而，作为一个结果，一个更强烈和广泛的诊断，包括一个良好发展的临床经验水平以及临床怀疑可以得出和结论。从教学的角度来看，这是一个令人兴奋和具有指导意义的病例(也与医学生相关)，在日常临床实践中罕见发生，包括i)一般右下腹部不明显不适和ii)急性阑尾炎的全谱鉴别诊断。

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引用次数: 0

A case report of metastatic renal oncocytoma 转移性肾嗜瘤细胞瘤1例

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.014

Gionathan Amante *, Yan Mei Goh, Henry Andrews

Introduction

Renal oncocytomas are renal tumours that are largely considered to be benign. They represent 5.5% of all renal tumours and the age-standardised incidence is 0.3 per 100,000/year in men and women.¹ Despite this, there have been reported cases where these tumours have developed metastases. We report the case of a patient who had a right radical nephrectomy for renal oncocytoma who then presents nine years later with a pathological neck of femur (NOF) fracture secondary to metastases, suggesting malignant behaviour of the tumour.

Case description

A 62-year-old lady presented in December 2010 with shortness of breath on exertion, frontal headache and malignant hypertension. She was treated with Ramipril and her blood pressure subsided. On discharge she underwent further investigations, including 24hour urine catecholamine test – (normal), and abdominal ultrasound which revealed a mass in the right kidney. Computerized tomography (CT) confirmed a well-defined lower pole right renal solid mass measuring 7.5x5.7cm, extending to the renal pelvis with compression of the vascular pedicle. There was no evidence of extrarenal extension. Renal cell carcinoma stage T2 was suggested. She underwent a right laparoscopic nephrectomy and recovered well from the operation. Histology confirmed oncocytoma with atypical features of extrarenal invasion, absence of Hale’s colloidal blue staining, negativity for cytokeratin 7 and positive vimentin staining. This patient had yearly follow-up CT. Four years after her first surgery, a nodule was noted in the right nephrectomy bed. Surgical excision confirmed recurrent oncocytoma. Two years after this she presented with pathological fracture of her right neck of femur. A bone biopsy confirmed metastatic disease. She had a dynamic hip screw fixation.

Results and Conclusions

The World Health Organization classifies renal oncocytoma as benign neoplasm.² Nevertheless there are case reports of metastatic disease in these tumours. Studies have revealed a classical pattern with typical features of benign neoplasia in 57.5-67% of cases. Malignant features such as atypical histological pattern, focal necrosis, multinucleation, mitotic activity, degenerative atypia and invasion of extrarenal fat have been described in others. Despite this, not all patients with such features progress to developing metastatic disease at 5-year follow-up. In fact only 2 patients out of 42 with atypical features developed metastatic disease.³ This suggests that there is a potential for metastatic transformation of this tumour, especially in the group with features of atypia. There is a however, paucity of information in published literature regarding this. The risk stratification of these atypical features will be a good start. Clearly, further research by way of genetic assessment, including chromosomal and tumour markers is required, as part o

肾嗜瘤细胞瘤是一种通常被认为是良性的肾肿瘤。它们占所有肾肿瘤的5.5%，男性和女性的年龄标准化发病率为每10万人中每年0.3例尽管如此，仍有报道称这些肿瘤发生了转移。我们报告一例因肾癌细胞瘤行右侧根治性肾切除术的患者，9年后出现继发于转移的病理性股骨颈(NOF)骨折，提示肿瘤的恶性行为。病例描述:一名62岁女性于2010年12月以用力呼吸短促、额部头痛和恶性高血压就诊。她接受雷米普利治疗，血压下降。出院时，她接受了进一步的检查，包括24小时尿儿茶酚胺试验(正常)，腹部超声显示右肾有肿块。计算机断层扫描(CT)证实右侧肾下极有一个清晰的实性肿块，尺寸为7.5x5.7cm，延伸至肾盂，压迫血管蒂。没有外翻的迹象。提示肾细胞癌T2期。她接受了右侧腹腔镜肾切除术，术后恢复良好。组织学证实为癌细胞瘤，不典型特征为肾外浸润，未见黑尔胶体蓝染色，细胞角蛋白7阴性，波形蛋白阳性。该患者每年接受CT随访。第一次手术四年后，在右侧肾切除术床上发现了一个结节。手术切除证实复发性癌细胞瘤。两年后，她表现为右股骨颈病理性骨折。骨活检证实有转移性疾病。她有一个动态髋螺钉固定。结果与结论世界卫生组织将肾嗜瘤细胞瘤归为良性肿瘤然而，在这些肿瘤中有转移性疾病的病例报告。研究显示57.5-67%的病例为典型的良性肿瘤。恶性特征，如不典型的组织学模式，局灶性坏死，多核，有丝分裂活性，退行性异型和肾外脂肪的侵袭已在其他人中被描述。尽管如此，并不是所有具有这些特征的患者在5年随访中都进展为转移性疾病。事实上，42例具有非典型特征的患者中只有2例发展为转移性疾病这表明该肿瘤有转移转化的潜力，特别是在具有异型性特征的组中。然而，在已发表的文献中，关于这方面的信息缺乏。这些非典型特征的风险分层将是一个良好的开端。显然，需要通过遗传评估的方式进行进一步的研究，包括染色体和肿瘤标记，作为未来诊断和管理算法的一部分。转移性肾癌细胞瘤极为罕见。对于易引起转移性转化的非典型特征所知甚少。我们的病人在6年后出现局部复发和远处转移病变并股骨颈骨折。我们广泛搜索的文献显示，只有2例转移性癌细胞瘤在骨是胫骨和股骨。股骨骨折患者有多处骨转移灶。需要进一步研究这种极其罕见的疾病的生物学特征和特征。这可能有助于将患者按转移风险潜力进行分层。也许治疗方案可以相应地调整。

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引用次数: 0

Intraosseous lipoma of the calcaneus: The non-stereotypic lesion of the bone 跟骨骨内脂肪瘤:骨的非典型病变

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.03.001

A. Sani,MH, MY Bajuri, MH Shukur

Background

Intraosseous lipoma is one of the rarest benign bone tumour. They have been identified in the tibia, fíbula, metatarsals, and calcaneal. They are easily misdiagnosed as the clinical presentation is nonspecific and can mimic other ligamentous or soft tissue injury.

Case presentation

We described a 40-year-old patient with a chronic dull pain at sole of foot without significant physical findings apart from minimal swelling over the lateral ankle and local tenderness over the anterior talofibular ligament, lateral talocalcaneal joint and minimal pain at the base of left heel. MRI revealed features of suggestive of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) sprain with incidental finding of calcaneal intraosseous lipoma. Intraosseous calcaneal lipoma was treated with surgical curettage and bone graft due to the non-resolving nature of the pain despite conservative effort. Patient was symptom free and bony consolidation was visible in radiographs. No evidence of local recurrence seen and patient able to return to normal daily activities without any restrictions. Intraosseous lipoma of the calcaneus is an even rarer subset of osteolipoma and is often identified incidentally during radiologic examination, having no specific symptoms besides heel pain at the worst. Diagnosis is usually made accidentally on radiographs images. CT or MRI scans are used to confirm the fatty nature of the lipoma.

Conclusions

Intraosseous lipoma of the calcaneal is very infrequent benign tumour-like lesion that can appear with pain but can also be asymptomatic and discovered incidentally by imaging investigation. To reach the diagnosis it is usually enough to have simple x-ray and CT or MRI. It has good prognosis, usually it improves with rest and analgesia. On occasions, excision and curettage of tumour and bone grafting, or cementation can be necessary as treatment modalities in cases that failed conservative management.

背景:骨间脂肪瘤是最罕见的良性骨肿瘤之一。已在胫骨、fíbula、跖骨和跟骨中发现。由于临床表现无特异性，可模仿其他韧带或软组织损伤，故易误诊。病例介绍:我们描述了一位40岁的慢性隐痛足底患者，除了踝关节外侧轻微肿胀，距腓骨前韧带、距跟外侧关节局部压痛和左脚跟底部轻微疼痛外，没有明显的身体表现。MRI显示提示距腓骨前韧带(ATFL)和跟腓骨韧带(CFL)扭伤的特征，偶然发现跟骨骨内脂肪瘤。骨内跟骨脂肪瘤的治疗，手术刮除和骨移植，由于无法解决的性质，尽管保守的努力。患者无症状，x线片上可见骨实变。没有局部复发的迹象，患者可以不受任何限制地恢复正常的日常活动。跟骨骨内脂肪瘤是一种更罕见的骨脂肪瘤，通常在放射检查时偶然发现，除了足跟疼痛外，没有其他特殊症状。诊断通常是在x光片图像上偶然做出的。CT或MRI扫描用于确认脂肪瘤的脂肪性。结论跟骨内脂肪瘤是一种罕见的良性肿瘤样病变，可伴疼痛出现，但也可无症状，影像学检查偶然发现。要确诊，通常只需要做简单的x光片和CT或MRI检查。预后良好，常经休息和镇痛后好转。在保守治疗失败的情况下，切除和刮除肿瘤、植骨或骨水泥可以作为必要的治疗方式。

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引用次数: 5

Perianal mucinous adenocarcinoma presenting as recurrent perianal sepsis 肛周粘液腺癌表现为复发性肛周败血症

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.036

Zulfiqar Hanif *, Kumaran Shanmugarajah, Simon Middleton

Introduction

Mucinous adenocarcinoma can rarely present as recurrent perianal sepsis and may be defined by specific neoplastic involvement of perianal tissue in the absence of rectal mucosal carcinoma. It accounts for less than 5% of tumours in this region. These tumors are usually well-differentiated and present late because of their insidious slow growing nature. These lesions are often mistaken for a benign condition like perianal fistula and abscess. Neoadjuvant radiotherapy and radical resection of mucinous adenocarcinoma with abdominoperineal resection is the treatment of choice. We present such a case along with a review of literature concerning its etiopathology.

Case description

A 68-year-old man presented with 6 episodes of perianal sepsis over the course of a year. He had no history of previous perianal sepsis, diabetes or Crohns disease. His past medical history included ischaemic heart disease. He was a previous smoker, with a 20-pack year smoking history. The patient underwent examination under anaesthetic and incision and drainages of perianal abscesses on multiple occasions. A pelvic MRI scan demonstrated the fistulous tract and a chronic abscess. Initial biopsies taken from the rectal mucosa and fistula tract were unremarkable. However, biopsies taken during his sixth examination under anaesthetic revealed mucinous adenocarcinoma.

Results

Patient had neoadjuvant radiotherapy followed by curative abdominoperineal resection (APR) with satisfactory outcome.

Take home message

Expeditious identification and management is associated with favourable outcomes. In patients presenting with ongoing perianal sepsis, one should have high index of suspicion and the diagnosis of mucinous adenocarcinoma should be considered.

摘要:粘液腺癌很少表现为复发性肛周败血症，在没有直肠粘膜癌的情况下，可以通过特定的肿瘤累及肛周组织来定义。它占该地区肿瘤的不到5%。这些肿瘤通常分化良好，由于其生长缓慢的特性而出现较晚。这些病变常被误认为是良性疾病，如肛周瘘和脓肿。新辅助放射治疗和根治性切除黏液腺癌是首选的治疗方法。我们提出这样的情况下，连同检讨有关其病因的文献。病例描述一名68岁男性在一年的时间里出现了6次肛周败血症。既往无肛周败血症、糖尿病、克罗恩病病史。他的既往病史包括缺血性心脏病。他以前是吸烟者，有20年的吸烟史。患者在麻醉下多次行肛周脓肿切开引流检查。盆腔MRI扫描显示瘘管和慢性脓肿。直肠粘膜和瘘管道的初步活检无显著性。然而，在麻醉下进行的第六次活检显示粘液腺癌。结果患者接受新辅助放疗后行根治性腹会阴切除术(APR)，效果满意。关键信息快速的识别和管理与有利的结果相关联。对于持续出现肛周脓毒症的患者，应高度怀疑，并考虑粘液腺癌的诊断。

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引用次数: 1

Emphysematous pyelonephritis - Is surgery necessary? 气肿性肾盂肾炎-手术是必要的吗?

New Horizons in Clinical Case Reports

Pub Date : 2017-11-01 DOI: 10.1016/j.nhccr.2017.10.024

Joseph Butler, Ree'Thee Bhatt, Gionathan Amante *

Introduction

Emphysematous pyelonephritis is a rare, life threatening acute suppuration of the kidney, characterised by the presence of air in the renal parenchyma, sometimes extending to the surrounding tissue. E. Coli and Klebsiella are the most common causative organisms, but the exact pathogenesis is poorly understood. It carries a high mortality, cited up to 50% and therefore requires prompt diagnosis and management.

Case description

A 52-year old woman presented to A&E with a two day history of severe left-sided abdominal pain, rigors, vomiting and increased urinary frequency. Her past medical history was significant for non-insulin dependent Type 2 diabetes mellitus, a well-established risk factor that is present in 90% of cases. On examination, she had marked left flank tenderness, tachycardia and pyrexia. Bloods showed raised inflammatory markers with a severe AKI.

Results and Conclusions

A CT KUB carried out in A&E showed air bubbles in the parenchyma and calyceal system of the left kidney, which confirmed emphysematous pyelonephritis. As there was no obstruction, the decision was made to manage conservatively. She was started on intravenous empiric metronidazole and tazocin, aggressive fluid resuscitation and close monitoring of her blood glucose. On day 3, initial blood cultures grew ESBL and tazocin was switched to meropenem and amikacin. A repeat CT scan on day 4 showed complete resolution of the parenchymal gas. Nonetheless, she continued to have recurrent pain and pyrexia. She stayed in hospital for a total of 16 days, with conservative management alone significantly improving her AKI and pyelonephritis. She was discharged with analgesia for residual loin tenderness.

Take home message

As portrayed in this case, young diabetic women are predisposed to developing emphysematous pyelonephritis. Nephrectomy remains the treatment of choice in most patients, whilst nephrostomy drainage is required in patients with urinary obstruction. Systematic reviews have indicated that antibiotic therapy with nephrostomy carries a reduced mortality risk in comparison to antibiotic therapy with emergency nephrectomy, though there are currently no guidelines available to optimally manage the condition. Prompt CT diagnosis and targeted antibiotic therapy in the initial assessment of this patient were crucial in preventing her from having to undergo an invasive surgical procedure.

肺气肿性肾盂肾炎是一种罕见的危及生命的急性肾脏化脓，其特征是肾实质中存在空气，有时延伸到周围组织。大肠杆菌和克雷伯氏菌是最常见的致病生物，但确切的发病机制尚不清楚。该病死亡率高，高达50%，因此需要及时诊断和治疗。病例描述:一名52岁女性，因严重左侧腹痛、僵硬、呕吐和尿频增加两天就诊于急诊室。她的既往病史是非胰岛素依赖型2型糖尿病，这是一个确定的危险因素，90%的病例存在。检查时，她有明显的左侧压痛、心动过速和发热。血液显示严重急性肾损伤患者炎症标志物升高。结果与结论a、E区行CT KUB示左肾实质及肾盏系统可见气泡，提示肺气性肾盂肾炎。由于没有遇到阻碍，所以决定保守处理。她开始静脉注射甲硝唑和他唑辛，积极的液体复苏和密切监测她的血糖。第3天，初始血培养培养出ESBL，他唑辛切换为美罗培南和阿米卡星。第4天复查CT显示实质气体完全溶解。尽管如此，她仍然有反复的疼痛和发热。患者住院共16天，单靠保守治疗可显著改善AKI和肾盂肾炎。因腰部残余压痛镇痛出院。正如本例所描述的，年轻的糖尿病女性易患气肿性肾盂肾炎。肾切除术仍然是大多数患者的治疗选择，而尿路梗阻患者需要肾造口引流。系统综述表明，与抗生素治疗急诊肾切除术相比，抗生素治疗肾造口术的死亡风险较低，尽管目前尚无最佳治疗指南。在对该患者的初步评估中，及时的CT诊断和靶向抗生素治疗对于防止她接受侵入性手术至关重要。

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