New Horizons in Clinical Case Reports最新文献

We report a case of functionally independent and cognitively intact 88-year-old male, suffering from anemia with suspicion for UGI bleeding. Diagnostic evaluation revealed a small bowel tumor as the source of bleeding. Our presentation will include a discussion about small bowel tumors as a relatively rare entity. The patient was operated on and the tumor was diagnosed as a distant metastasis of melanoma. Further evaluation revealed a relatively small primary melanoma tumor on the posterior part of right heel. The patient was not aware of the tumor until the diagnostic investigation. Radical Surgery was proposed as the choice of treatment with high probability of wheelchair-bound state as the functional outcome. Further discussion is related to the dilemma of choosing between aggressive treatments versus preserving quality of life in elderly persons. Modern options of melanoma treatment and their suitability to the elderly patient are presented together with a review of the literature.

Objectives

The nucleoside reverse transcriptase inhibitors (NRTI) have been an important 'back-bone' of an antiretroviral therapy (ART) for HIV-1 infected patients. However, these agents have been associated with both short and long-term toxicity. Therefore, there has been growing interest in evaluating NRTI-sparing regimens. Now we have administered dolutegravir (DTG) and rilpivirine (RPV) to HIV-1 infected patients as a new NRTI-sparing regimen. However, there are few data on the outcome of ART regimen consisting of DTG and RPV. In this study, we examined treatment outcome for this NRTI-sparing regimen in HIV-1 infected patients.

Method

We examined 27 HIV-1 infected patients treated with NRTI-sparing regimen consisting of DTG and RPV in Nagoya Medical Center, Japan. We checked efficacy and safety for this regimen from 2014 to 2015, retrospectively.

Results

Median duration of this NRTI-sparing regimen for 27 Japanese HIV-1 infected patients (26 males, 1 female; mean age 57 years) was 323 days. The reasons for changing to this regimen were pill burden (n=13), lipodystrophy related to NRTI (n=7), myelopathy (n=2), renal dysfunction (n=1), dyslipidemia (n=1), respectively. Finally, 25 patients have continued this regimen. After starting this regimen, HIV viral load were soon less than the detection limit for all patients. Virologic failure and regimen discontinuations by severe adverse reactions were not confirmed for individuals. In addition, abnormal laboratory data (ALT, AST, etc) were not shown for all patients.

Conclusions

Current UK and US treatment guidelines do not recommend NRTI-sparing regimens for people starting ART due to concerns about toxicity, treatment discontinuation, and drug resistance. In this study, 12 patients had been already treated with NRTI-sparing regimen (Raltegravir + RPV). As these patients were elder, it was essential to reduce pill burden. Therefore, a new NRTI-sparing regimen, DTG + RPV, will be available in the future because of reducing pill burden, few drug interactions and low toxicity.

Introduction

Inflammatory local recurrence after breast-conserving therapy is very rare and these patients always have poor prognosis.¹ In common, the recurrence happens in a median of 65 months for lymph node negative patients. Fast recurrence is usually be considered correlated with ER status, lymph node status and tumor size.

Case description

A 70-year-old female patient had left breast conserving surgery in PUMCH on 2016-4-19, pathological results showed an IDC (triple negative) and the margins of the tumor were clear. Then she began chemotherapy (Taxol+CTX, 3 week regimen) on 5-22. At the end of June, she had a skin lesion on the left breast. We continued chemotherapy to 7-22, TC*4 in total. During this, the patient's skin lesion turned bigger and the therapy had no effect on this. We took the skin for biopsy and the skin and lymphatic was filled with breast cancer metastases.

Conclusion

Locally recurrence can happen in patients having had breast-conserving surgery. However, in our case, the patient has rare inflammatory local recurrence after breast conserving surgery very rapidly, even during chemotherapy. Just 2 months after surgery. So we think that the inflammatory skin lesion on breast cancer patients must be taken seriously and do biopsy as soon as possible.

In Poland, sarcomas represent about 1% of all cancer diseases. Every year about 800 new cases are diagnosed. Osteosarcoma is the most frequently recognized primary malignant bone tumor.

Osteosarcomas are diagnosed more frequently in children and adolescent males, whereas in pregnant women they are extremely rare. We present a case of a 29-year-old pregnant woman with a highly diverse osteosarcoma. A patient which was in 23rd week of pregnancy was treated with multiple doses of chemotherapy while fetal health was being monitored.

The plan for a therapeutic process included inducing a pregnancy solution at the moment of the fetus reaching maturity, then continuing oncological treatment.

According to the established protocol of treatment in 34 week pregnancy was completed via cesarean section. The woman gave birth to a daughter in good condition. Surgical treatment was conducted after delivery until complete post-pregnancy healing. There was no reduction of dose or quantity of planned and conducted courses of chemotherapy due to pregnancy.

The paper offers an analysis of diagnosis and therapy of pregnant women with osteosarcoma based on own experience and on the basis of a relevant literature.

Introduction

The Stevens Johnson syndrome is a rare and potentially fatal cutaneous reaction to medicaments or infections. The most common drugs linked to this syndrome are antibiotics (such as sulfonamides, cephalosporines and quinolones), anticonvulsivant drugs (carbamazepine, phenytoin) and nonsteroidal anti-inflammatory drugs (NSAIDs). It is characterized by extensive necrosis with detachment of the epidermis, and the mortality rate rises up to 30%. We present a case of Stevens Johnson syndrome associated with drugs administration during postoperative period.

Case description

A 73-year-old female reported to Department of Hepatic Surgery for a hepatectomy due to colorectal liver metastases. Her oncological history initiated 5 months ago with a colorectal obstructive tumor and liver metastases in both lobes. An emergency Hartmann procedure was performed following adjuvant chemotherapy, with good response. The surgical team decided to perform a two stage hepatectomy. The postoperative period was torpid and a reintervention for bowel obstruction was required, as well as two long stays in the Intensive Care Unit. A month after the first surgery, the patient presented with a reddish maculopapular lesion on the neck that rapidly extended to the back and forearms. An intra-oral erythema and conjunctival ulcerations were also noted. The diagnosis of syndrome was confirmed by the Department of Dermatology with a skin biopsy. Pharmacology and Allergy Departments completed the study and proposed that the syndrome was possibly due to peniciline and NSAIDs. Despite the efforts of the multidisciplinary team, the supportive care, and the early retreat of the possible causing drugs and ciclosporine plus corticosteroids treatment, the patient presented with severe liver failure and finally died after 2 months of hospitalization.

Conclusions

Cutaneous reactions are a very common condition during the postoperative period, most of them are related to habitual drugs regimens. Considering this, it is of paramount importance to keep in mind that the Stevens Johnson syndrome is a rare but severe dermatological pathology in which early diagnosis and treatment is vital.

Introduction

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids: A rare central nervous system inflammatory disorder involving predominantly the pons as a distinct form of brainstem encephalitis centered on the pons, and/or the spinal cord. Usually presented with symptoms/signs referable to brainstem, cranial nerve-and/or cerebellar dysfunction. Symptoms related to long tract affections and/or spinal cord syndrome. Paresis, spasticity, plantar response, hyperreflexia, altered sensation of the extremities, decrease vibration sense, neurogenic bladder and cognitive deficits. Responsive to steroids and long term immunosuppression. MRI with contrast is a useful tool to help for early diagnosis of such cases.

Case description

Here we are going to report a case of a 28-year-old, previously healthy female presented to the ED with a history of blurring of vision, dizziness, headache, and parasthesia of lower limbs, not alcoholic or smoker, no H/O drug intake. No family history of chronic disease. On examination the patient had normal vital signs (Temp. 37.2, RR 18 and SpO2 100%) her ENT examination is unremarkable. Her neck movements are unrestricted. Cardiovascular, respiratory and abdominal examinations are unremarkable. Her pupils are equal and reactive; fundoscopy is normal. She is orientated and follows commands, horizontal Nystagmus, DTRS exaggerated symmetrically, planter reflex down going on the left equivocal on the right, positive Romberg sign to the left and dysdiadochokinesis.

Results and conclusions

Non contrast CT head showed left periventricular parenchyma calcification suspicious of hemorrhagic spots. MRI brain showed multiple punctuate and curvilinear enhancing foci, B/L cerebral scattered ovoid bright signal intensity ring enhancement small nodules workup was done to exclude Meningitis, TB encephalitis, CNS lymphoma, Toxoplasmosis, HIV, Vasculitis and Demyelination. Results were negative. Steroids started and the patient improved.

Take-home message

Careful history taking and a high index of suspicion of central causes of vertigo is needed when a patient presents with dizziness.

With the first recorded medical application of a robot - a CT-based orientation of a needle guide for biopsy of the brain - occurring in 1985, a number of research groups in Asia, Europe, and the USA began investigating other medical applications of robotics. Beside of a big number of research prototypes and scientific outcome, a relatively small number of commercial ventures were resulting from these efforts.

Now, after more than 30 years of activities and compared to many other fields of medical technology, medical robotics still can be considered as of being in its infant state. The number of commercially available setups actually could be increased, but only few of them really have created significant impact. Many research questions have been addressed in order to improve the technology, but the gap between research in laboratories and real use in surgical routine seems to get even bigger. If one looks to the main reasons for this slow adoptation of new technology, it turns out to mostly not being related to technical functioning, but to other factors such as:

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  cumbersome use of robots (complexity, size, missing integration into clinical workflow) which hinders application in clinical routine,

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  high cost for robot system and operational cost (i.e. cost/benefit ratio is not satisfactory in most cases),

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  high setup time and effort (e.g. additional person for operating robot system),

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  limitation in portability and/or mobility,

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  unsolved safety issues.

The presentation will include a short introduction into medical robot systems for surgical applications. Topics include issues such as kinematic configurations, interfaces to existing surgical equipment, but also matters related to standards and regulations. One key aspect for (future) medical robots is related to its main operation principle. Current commercial robot systems are either directly controlled by a human operator or strictly follow a pre-defined path. Automated systems are limited to setups where no direct contact between robot and/or the guided tool takes place, e.g. to compensate (to a certain degree) breathing motion in external radiotherapy or for imaging purposes. On the cognitive side, a long thought-after feature is to estimate what the surgeon would like to do next. This could be taken into account when planning and executing the next movement of the robotized tool or camera. Addition of cognitive capabilities to the robot also has the potential to take a further step toward surgical automation, e.g. for the awareness of the current medical situation and the ability to react in a suitable way. Concrete robot applications - such as for percutaneous placement of needles for tumor