New Horizons in Clinical Case Reports最新文献

Introduction

Cytomegalovirus (CMV) pneumonia is an important cause of morbidity and mortality in transplant recipients, hematological malignancies on chemotherapy, and HIV-infected patients. Invasive pulmonary aspergillosis (IAP) occurs primarily in patients with severe immunodeficiency. Both infections have dramatically increased in the patients with impaired immune state associated with critically ill patients and those with chronic obstructive pulmonary disease.

Case description

The 93-year-old diabetic woman was admitted to the intensive care unit (ICU) due to urosepsis. Antibiotic therapy with piperacillin-tazobactam was given. As clinical progression to profound shock and multiple organ failure, high-dose vasopressors, hydrocortisone and fluid resuscitation were given. After short course of continuous venovenous hemofiltration was used, the hyperkalemia and metabolic acidosis were improved. The patient was maintained on regular haemodialysis. However, active gastric and duodenal ulcers with bleeding were identified by endoscopy. Hemostasis and high-dose pantoprazole infusion were given. As stable condition after ICU stay for one month, she was transferred to respiratory care center for weaning ventilator. However, CXR showed partial consolidation over bilateral lung, favoring inflammatory process. The sputum culture showed Acinetobacter baumannii and Aspergillus species. Meanwhile, the results of CMV-PCR for serum and sputum samples were positive. Blood CMV virus load was 8140IU/mL. In spite of one week therapy with imipenem and ganciclovir, the sepsis and pneumonia did not improve. The CXR still showed severe pulmonary edema and high airway pressure was noted. The serum Aspergillus galactomannan (GM) antigen revealed >5.59 index (normal, <0.5). As rapid deterioration of clinical conditions, the families agreed palliative treatment and she died after 43 days of hospitalization.

Conclusion

Early diagnosis and treatment of CMV infection is important in view of the poor prognosis of established infection. Strategies include pre-emptive therapy when viral load increases or CMV-PCR becomes positive on serial monitoring. As cultures for Aspergillus spp are positive only in few cases, serum GM assay is useful for early diagnosis of IPA even before the clinical symptoms and signs becoming obvious. Old age, diabetes, hemodialysis, steroid use and prolonged ICU stay might predispose our patient to develop IPA and CMV pneumonia. Voriconazole was not given for our patient in time, which also highlighted the importance of early diagnosis and therapy.

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

Skene`s gland also known as paraurethral glands are bilateral prostatic homologues glands. It was first discovered and described by Alexander Johnston Chalmers Skene in 1880. Paraurethral glands are located posterolaterally to the urethra. Embryologically derived from the urogenital sinus. Skene`s gland secretes a small amount of mucoid material which has a role in sexual stimulation and lubrication. The etiology of paraurethral cysts remains unknown. The obstruction of Skene's ducts as a result of infection or inflammation usually in response to skenitis, of which gonorrhea is the most common cause, or cystic degeneration of embryonic remnants of the paraurethral glands, have been assumed to be possible causes of paraurethral cysts. The distinguishing features of paraurethral cysts are the displacement of urethral meatus by the mass and a cyst containing milky fluid. Thus, we report a case of Skene's duct cyst in a female which presented with acute urinary retention secondary to the lateral displacement of meatus.

Case description

A previously healthy female presented to casualty with gradual onset of suprapubic pain, associating with a sudden onset of the inability to void for 6 hours. The patient was complaining of obstructive lower urinary tracts symptoms for 2 weeks. She had 3 uncomplicated normal full term vaginal deliveries with an unremarkable past medical or surgical history. Examination of the external genitalia revealed an ovoid, fluctuant, tender swelling located just inferior to pubic symphysis and completely displacing and stretching the external urethral meatus to the opposite side. Compression of the swelling did not result in fluid extravasation through the urethra. Vaginal patency was also verified. Insertion of 14 Fr foley’s catheter was managed with difficulty and drained 600cc clear urine. MRI showed normal kidneys, ureters and urinary bladder with a simple 2.1x2.7x3.3cm lower vaginal cyst with high protein/hemorrhagic content mostly a paraurethral gland duct cyst. Patient underwent examination under anesthesia, cysto-urethroscopy and skene’s duct cysts excision was done. Histopathology examination displayed the presence of benign cystic lesion lined by transitional and squamous epiltleium with focal surface ulceration; thereby confirming the diagnosis of paraurethral cyst. Foley’s catheter was removed after 5 days and she voided freely.

Results and conclusions

Skenes gland cyst should be listed in the differential diagnosis of a female patient who comes with an acute urinary retention.

Introduction

Marcus Gunn Syndrome, also known as Jaw Wink Syndrome or trigemino-oculomotor synkinesis, was first reported in 1883. It typically presents at birth with unilateral ptosis and eyelid elevation on jaw opening. Pathophysiology is explained by an oculofacial synkinesis. There is an aberrant connection of the oculomotor nerve and the mandibular branch of the trigeminal nerve resulting in eyelid elevation on mouth opening. The typically congenital syndrome is exceptionally rare. It is often diagnosed in infancy with complete ophthalmic examination and ptosis evaluation. This syndrome does not often require surgical intervention but it may still have an impact in clinical management.

Case description

A 32-year-old male presented in the OMFS outpatient clinic in Countess of Chester Hospital for extraction of his lower third molars. His past medical history included a known diagnosis of Marcus Gunn Syndrome but he was otherwise fit and well. He had resting ptosis of the left and elevation of the left eyelid on jaw protrusion.

Results and conclusions

Third molars were removed uneventfully under local anesthesia and no further treatment was required. Literature suggests that patients with Marcus Gunn Syndrome may have an atypical oculocardiac reflex during their surgical procedure and patients are at increased risk of malignant hypothermia. In this case, the procedure was performed under local anesthesia but this condition may impact on surgical planning if general anesthesia was to be considered.