Journal of medical cases最新文献

Hepatoid adenocarcinoma of the stomach (HAS) is a rare type of gastric cancer with unique clinicopathological features. HAS has a poor prognosis because of early liver, lung, and lymph node metastasis. Owing to its rarity and malignant potential, data on its pathophysiology and management are scarce. Herein, we describe a case of alpha-fetoprotein-producing HAS (AFP-HAS) with metastases to the liver, lungs, and spine. The patient presented with a 3-month history of epigastric pain and intractable emesis, initially thought to be gastroparesis given her uncontrolled diabetes mellitus. Contrast-enhanced computerized tomography (CECT) of the abdomen and pelvis revealed thickening of the gastric wall with hepatic metastases. Upper endoscopy revealed a fungating gastric mass, and the histopathology confirmed AFP-HAS. The patient did not tolerate palliative chemotherapy and died 6 months after her gastric cancer diagnosis.

Catastrophic antiphospholipid syndrome (CAPS) is a rare, severe, and life-threatening form of antiphospholipid syndrome (APS). Early recognition and rapid treatment are of great importance to improve patient outcomes and decrease mortality. Herein, we present a case of lupus and APS with obstetric complications, recurrent thrombosis, and renal and hematological manifestations of APS which showed great response to the treatment.

Unilateral pulmonary hypoplasia (UPH) is a rare congenital disorder that presents rarely in adulthood. Most patients succumb to complications at a young age, and those who survive are rare and susceptible to frequent lifelong pulmonary infections. It has a high infant mortality rate. We present the case of a 66-year-old male with rheumatoid arthritis and severe persistent asthma who first presented to our emergency department in 2013 with worsening shortness of breath. Chest imaging with a computed tomography (CT) scan revealed right hemithorax volume loss with hypoplasia, honeycomb lung formation, and right mediastinal shift. He was treated with prednisone, inhalers, and antibiotics for asthmatic bronchitis. He continued to suffer frequent hospital admissions (56 to our hospital alone) over the next decade for pneumonia and asthma exacerbations. The hypoplastic right lung was deemed to be contributing to recurrent infections/inflammation, and he is currently being re-evaluated for a right pneumonectomy, as surgical resection is an option for localized bronchiectasis associated with recurrent respiratory infections.

Insertion of a peritoneal dialysis (PD) catheter in end-stage renal disease (ESRD) patients with cirrhosis and tense ascites remains a challenge for nephrologists. Ascitic fluid leak at the surgical site, a common postoperative occurrence, leads to the disqualification of many patients who could be otherwise great candidates for PD. The ascitic fluid leak has been described to occur during or immediately after surgery even after the entire volume of ascitic fluid has been drained. In this study, we report a case study of three patients with ESRD, liver cirrhosis, and tense ascites on hemodialysis. The patients required super large volume paracentesis (SLVP), draining 9,000 - 15,000 cc of ascitic fluid twice weekly in an interventional radiology setup. Besides ascitic fluid drainage, the patients needed in-center hemodialysis (ICHD) 3 days a week, leading to their engagement in procedures 5 days a week. In addition, intradialytic symptomatic hypotension, hypoalbuminemia, and other adverse effects of hemodialysis lead to their poor lifestyle. To improve their lifestyle, all patients desired to switch to PD from ICHD. Upon the PD catheter insertion and drainage of the entire ascitic fluid, leaks developed at the insertion site within a few hours. To overcome these leaks, PD catheters of all three patients were attached via a transfer set to a bag for continuous drainage of ascitic fluid for about 2 weeks. No leak or complication was noted, leading to complete healing of insertion site. We recommend, for the patients with tense ascites requiring SLVP, approximately 2 weeks of healing period continuously be performed till initiation of PD training,.

Tyrosine kinase inhibitors (TKIs) have changed the prognosis of Philadelphia-positive B-cell acute lymphoblastic leukemia (ALL); however, relapsed and refractory disease after multiple TKIs continues to be a clinical challenge. Brexucabtagene autoleucel (brexu-cel) is a novel FDA-approved therapy for relapsed and refractory ALL. Given the lengthy manufacturing time, bridging therapy is commonly employed prior to brexu-cel. Here we describe a case of a 75-year-old Hispanic male patient with relapsed/refractory Philadelphia-positive B-cell ALL with extramedullary disease involving abdominal lymph nodes and skin. He was initially treated with chemotherapy in combination with imatinib, and later received dasatinib and subsequently blinatumomab and nilotinib. As the patient progressed, he received ponatinib with low-dose salvage chemotherapy and did not show kinase domain mutation. In a final effort, a novel combination of ponatinib with asciminib was used as a bridge therapy before brexu-cel and later as maintenance therapy after brexu-cel. This novel combination was able to control disease prior to brexu-cel for 2 months and maintained remission for at least 10 months. This report shows that the novel combination of ponatinib and asciminib is tolerable and effective as a bridge and maintenance therapy after brexu-cel.

Femoral fractures are indubitably common injuries that can occur either from high-energy trauma in young patients or due to fragility in the geriatric population. Femoral fractures affecting two or more regions of the femur are exceedingly infrequent injuries, ordinarily caused by high-energy trauma and are considered segmental femoral fractures. We present a rare case of a 33-year-old male patient presented to our Emergency Department with multiple femoral fractures at the subtrochanteric, diaphyseal and supracondylar femoral regions, a condition regarded as double segmental femoral fracture. After assiduous consideration of treatment options, intramedullary nailing was employed for osteosynthesis. Fracture reduction was laborious, as an entirely separated femoral fragment was present between the fracture lines. The reaming process required paramount attentiveness as the middle femoral fragment was prone to rotational displacement by the reamer. Finally, the intramedullary nail was successfully placed, and the patient was discharged without complications after 11 days of hospitalization. Currently, the patient is capable of full weight-bearing without crutches. This paper underlines the challenges that double-segmental femoral fractures' treatment can bring on to the orthopedic surgeon.

Thyrotoxicosis has been associated with several cardiac conditions including atrial fibrillation, congestive heart failure due to left ventricular dysfunction, and cardiomyopathy. However, few cases of ventricular fibrillation as a complication of thyrotoxicosis have been reported. Our case described a 45-year-old male with a history of hypertension and Graves' disease, who presented with 1 week of left-sided chest pain associated with shortness of breath on exertion and occasional palpitations. His workup revealed acute diastolic congestive heart failure secondary to thyrotoxicosis, causing pulmonary hypertension, which led to ventricular fibrillation and cardiac arrest. After being treated with methimazole and metoprolol, the patient's symptoms improved. This case underscores the significance of assertive medical interventions alongside both invasive and non-invasive cardiac procedures. Addressing thyrotoxicosis and ventricular arrhythmia in hyperthyroid patients is crucial to prevent potentially life-threatening complications.

Orogastric tubes (OGTs) are frequently used to administer feeds and medications to critically ill patients. They are inserted blindly, with a low first-pass success rate and frequent benign complications. OGT fractures and ingestion are exceedingly rare, with only two cases reported to date. Herein, we describe a rare case of OGT transection and ingestion in a male patient admitted for hyperacute delirium and complicated pneumonia. The OGT remnant was retrieved using an endoscope without any complications. Clinicians must be aware of this rare but potentially catastrophic complication of OGT use. OGTs must be inspected in the same manner as endotracheal tubes to ensure patient safety.

Hemophagocytic lymphohistiocytosis (HLH), characterized by acute and progressive hyperinflammation, is a rare syndrome documented in a limited number of coronavirus disease 2019 (COVID-19) and human immunodeficiency virus (HIV) cases. While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can provoke extensive immune activation and systemic inflammation, individuals with HIV, susceptible to immune dysregulation, are at heightened risk of severe complications from SARS-CoV-2. We report a case of a 24-year-old male with no significant medical history presenting with fever, weight loss, respiratory symptoms, and acute renal failure. Initial diagnosis revealed HIV with a CD4 count < 20 and concurrent COVID-19 infection leading to development of HLH. Despite aggressive management including antiretroviral therapy (ART), dexamethasone and supportive care, the patient deteriorated rapidly, leading to multiorgan failure. Coinfection with HIV and SARS-CoV-2 presents unique challenges, especially when complicated by secondary conditions such as HLH, which remains a diagnostic and therapeutic dilemma. Prompt recognition and aggressive management are crucial, necessitating a high index of suspicion and comprehensive evaluation including bone marrow biopsy to improve diagnostic accuracy and guide therapeutic interventions in such complex scenarios.

Tumor lysis syndrome (TLS) presents significant challenges in oncology, primarily due to metabolic complications such as hyperuricemia, which can lead to acute kidney injury. Rasburicase, a recombinant urate oxidase, is frequently employed to manage hyperuricemia in TLS patients. However, its use is an absolute contraindication in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency due to the risk of hemolysis. In this case, the patient developed hemolytic anemia post-rasburicase administration even though she had normal G6PD activity, which was confirmed on two separate occasions, including during an acute episode and 3 months later. This case is unique as it documents hemolytic anemia induced by rasburicase in a patient without G6PD deficiency, challenging current understandings of the drug's safety profile. It suggests the need for caution and thorough screening before rasburicase use, even in patients considered low risk for G6PD deficiency. The report highlights the importance of close monitoring for adverse effects and the potential for alternative mechanisms of rasburicase-induced hemolysis.