New Horizons in Clinical Case Reports最新文献

Introduction

Aneurysms are defined as an abnormal dilation of an artery, vein or cardiac chamber. Aneurysms affecting the inferior vena cava (IVC) are rare, with just over 50 cases in the published literature. They are associated with caval thrombosis. We will discuss the aetiology and management of such cases.

Case description

A 14-year-old girl presented to her local hospital complaining of a two week history of worsening back pain, swelling and discolouration of the legs, and reduced mobility. Imaging suggested a psoas abscess, and drainage was arranged at a regional paediatric centre. Upon review, repeat imaging was sought which indicated an IVC aneurysm rather than a psoas abscess. There was thrombosis within the dilatation extending to the femoral veins which accounted for her symptoms.

Results and conclusions

The patient was anticoagulated in the first instance. The duration of the symptoms meant it was too late for thrombolysis, and the occluded segment was considered too long for conventional venous stenting. She has been placed in compression hosiery and referred to the national centre for ongoing management.

Take-home message

Unusual presentations are often caused by rare pathologies. In any patient presenting with bilateral swollen, purple legs; it is imperative to establish if there is any venous occlusion. This was also an important lesson in being wary of draining supposed psoas abscesses in young patients.

Achalasia is a primary esophageal motility disorder of unknown etiology, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter (LES) relaxation. However achalasia is the best characterized esophageal motility disorder, its pathogenesis is still not entirely clarified. Available data suggest that the disease is multifactorial, involving hereditary, autoimmune and environmental factors, such as viral infections, but the exact initiating factors that may play a role in the development of the disease remain unclear. Our hypothesis is that one possible initial insult that leads to the development of achalasia can be the gastroesophageal reflux disease. This theory was first proposed by Smart et al. in 1986. In our case study we report the case of a 65-year-old woman who had typical reflux symptoms with heartburn and regurgitation for about seven years. During the year before her admission to our clinic her reflux symptoms resolved and dysphagia developed. Endoscopy revealed esophageal dilatation with erosive esophagitis, narrowed cardia and hiatal hernia. Biopsies from the distal esophagus showed chronic esophagitis and Barrett’s metaplasia. Barium swallow showed dilated esophageal body with decreased peristalsis, nonrelaxing sphincter and retention of barium. Manometry and 24-hour pH monitoring was performed. The LES pressure was 34.5 mmHg with 11.9% relaxation. 24-hour pH-metry showed acid reflux, with multiple sharp dips characteristic of typical gastroesophageal reflux, with total DeMeester score of 94.6. Using pH 3 as a discriminatory threshold for GERD the reflux score was 64.2. Achalasia and concomitant GERD was diagnosed and the patient underwent laparoscopic surgery. The hiatal hernia was reconstructed and a Heller’s myotomy with a 360 degree Nissen fundoplication was performed. At the 3-year follow-up the patient was symptom free. In summary, based on our experience and the review of the literature we believe that there is a cause-and-effect relationship between gastroesophageal reflux and the development of achalasia. We believe that the development of achalasia in patients with GERD can be a protective reaction of the esophagus against reflux. In these cases the treatment of choice should be different from that of pure achalasia patients: a laparoscopic Heller’s myotomy completed with a 360 degree Nissen fundoplication should be the recommended surgical treatment to minimize the possibility of postoperative reflux disease.

Introduction

Perinatal testicular torsion can be intravaginal or extravaginal. Extravaginal torsion can be managed in an elective manner. Intravaginal torsion needs an urgent operation to maximize the viability of the testis. The history is vital to distinguish between the two diagnoses. We report a case in which a perinatal intravaginal torted testicle was successfully salvaged due to a timely exploration. This was a retrospective review of a case and literature review of perinatal testicular torsion.

Case description

A term baby was transferred to a tertiary pediatric surgical unit in the for surgical management of exomphalos minor. The child was noted to have normal testes. On the seventh day of life, he was noted to have a firm swelling in his right scrotum with purple discoloration. He was promptly reviewed by the surgical team. A perinatal torsion of intravaginal type was suspected and he was booked for emergency exploration. The surgical findings were 1) significant edema of the right scrotal wall, 2) a thickened tunica vaginalis and small volume of hemolyzed fluid, and 3) a bluish and congested torted testicle in intravaginal plane. Testis was de-rotated and color returned within 5 minutes. A three-point testicular fixation was performed bilaterally. He was reviewed in clinic for the following 2 years and found to have equal growth of the testicles, both of which were appropriately positioned within the scrotum.

Results and conclusions

This case highlights the importance of being aware that perinatal torsion can be extravaginal or intravaginal. The patient history is important to distinguish between the two diagnoses as proven by the above case. A positive outcome can be achieved with judicious assessment and emergent management of perinatal intravaginal torsions.

Take-home message

Clinicians should maintain a high level of suspicion of intravaginal torsion in all cases of perinatal testicular torsion.

Introduction

Pneumatosis cystoides intestinalis (PCI) is a rare benign condition, in which gas is found in a linear or cystic form in the subserosa or submucosa. The subserous cysts are most frequently found in the small bowel while the submucous localizations are predominantly seen in the colonic wall. Peritoneal pneumatosis, abdominal gas cysts, cystic lymphopneumatosis, intestinal emphysema or intestinal gas cysts are terms used to describe the occurrence of multiple, gas-filled cysts, of the gastrointestinal tract. Incidence of PCI was reported to be 0.03% in the general population. It is a radiographic finding and not a diagnosis, as the etiology varies from benign conditions to fulminant gastrointestinal disease.

Case description

A 77-year-old patient was admitted in Pauls Stradins Clinical University Hospital with complains of abdominal discomfort and bloating during two years. Blood laboratory tests revealed no changes in the blood count, CRP (C reactive protein) was 77.6mg/l (N<5mg/l). A colonoscopy showed c.sigmoideum, c.descendens submucosal lesion in 10-15cm zone with submucous cystic formations, visually reminiscent of "a bunch of grapes, which are connected to each other", filled with a whitish, in some areas bluish content, with unchanged superficial mucosae.

Results

Since 2011, lesion was increased in size of 5cm. Endoscopic ultrasound showed formation of submucosal anehogenic mass; 11-17mm thick, blurring, palpable densely, minimally vascularized with no signs of malignancy. A computer tomography (CT) scan of the abdomen and pelvic area, and retroperitoneal space revealed infiltrative mass in the wall of the c.sigmoideum. Colonoscopy was performed for tumor location, followed by laparoscopic resection of the tumor mass. Morphological examination of full specimen revealed pneumatosis cystoides intestinalis in size of 11.5x5.6x4cm, with multicore foreign body type gigantic cells on the inner surface of the cysts, and no signs of malignancy.

Take-home message

Our case, pneumatosis cystoides intestinalisis is a rare disease, which is difficult to diagnose by radiology or endoscopy, even for exclusion of malignancy. PCI is an indication for surgery if the lesion is growing in size and may cause the symptoms of colon obstruction.

Introduction

The main pulmonary embolism is a blockage of blood flow to the lungs by a blood clot which is composed of clumped platelets and condensed fibrin lodged into an artery in the lungs. A condition associated with thrombotic events due to loss of endothelium non-thrombogenic protective factors and severe dehydration might occur in the early course of severe dengue, thereby increasing the risk of embolic formation. We report acute pulmonary embolism in a severe dengue patient co-infected with influenza B, which might additionally predispose to an acute embolic event.

Case description

This 71-year-old diabetic woman with hypertension suffered from the dizziness, episodic fever, and general weakness since September 13, 2015. The data of dengue virus IgM, IgG and NS1 antigen were all positive. The presenting platelet count was 11000/uL. She felt worsening malaise, dizziness, anorexia, and newly developed dyspnea. The brain CT did not indicate obvious lesion except mild atrophy. The chest X-roentgenogram (CXR) revealed the opacity in left lower lung field. Abnormal liver function tests were noted, including S-GOT (AST), 1526 U/L; S-GPT (ALT), 709 U/L; total bilirubin, 2.71 mg/dL and direct bilirubin, 1.84 mg/dL. Under the impression of severe dengue with pneumonia, she was admitted for the further management. Antibiotic therapy with cefuroxime was given. However, the patient had worsening dyspnea and tachycardia 5 days later. Laboratory data showed elevated lactate (4.1 mmole/L), hypoxemia with mild decrease PaO2/FiO2 ratio, and elevated D-dimer (3271 ng/m). CXR showed resolution of pneumonia patch. As suspected pulmonary embolism, chest CT was arranged, which revealed partial thrombosis of right pulmonary artery at superior lobar branch. Therefore, she was admitted to the intensive care unit. In addition, the result of rapid influenza diagnostic test for influenza B antigen was positive. A 5-day course of oseltamivir and antibiotic therapy with levofloxacin were given. After treatment, fever subsided and dyspnea was improved. Follow-up platelet count rose to 91000/uL. Then, she was transferred to ward. After heparin therapy, subsequent daily warfarin was titrated to daily 2.5mg to achieve the desired prothrombin time ratio. As stable condition, she was discharged after 16 days of hospitalization.

Conclusion

Pulmonary embolism has been reported in association with dengue fever or severe influenza, particularly influenza A(H1N1). Co-existence of severe dengue, influenza B and acute pulmonary embolism was sparsely reported before. Awareness for these complications should be recommended to all practitioners who treat patients with severe dengue fever, particularly co-infected with influenza.