Journal of medical cases最新文献

Dengue virus infection (DVI) has multiple routes of transmission. Modes of transmission include mosquito bites, perinatal transmission, blood transfusions, organ transplantation, needle stick injuries, or laboratory accidents. DVI in kidney transplant recipients is common in an endemic area. In an endemic area, it is usually caused by a mosquito bite. Solid organ transplantation, including the kidney, has been implicated in the transmission of DVI in the immediate post-transplant period. We describe a case of end-stage renal disease in which the patient got DVI immediately after getting a kidney from a deceased kidney donor. Our patient presented with fatigue and pain around the graft, anemia, thrombocytopenia, coagulopathy, hepatitis, and was found to have a hematoma around the graft. The recipient of the second kidney from the same donor also presented with fever and was found to have dengue. We describe our experience with managing our case, along with a detailed literature review of similar cases transmitted through renal allograft.

Methotrexate is a commonly prescribed immunosuppressant and chemotherapy agent, carefully monitored by healthcare providers due to its potential adverse effects. As a result, methotrexate toxicity is relatively rare. We present the case of a 79-year-old man followed in rheumatology for symmetrical polyarthralgia, who inadvertently took methotrexate 10 mg daily, instead of weekly, leading to methotrexate toxicity. The patient presented with erosive mucositis affecting the lateral tongue, buccal mucosa, and hard palate, as well as pustular lesions on the scalp (occipital and cervical regions) extending to the trunk. Laboratory findings revealed pancytopenia and transaminitis, and upper gastrointestinal endoscopy showed erythema and superficial ulcerations in the oropharyngeal region. Methotrexate was discontinued immediately, and the patient was treated with intravenous fluids, filgrastim, and supportive care. This case highlights the importance of early recognition of methotrexate toxicity, as well as the critical role of patient education. It underscores how easily a medication with numerous therapeutic benefits can cause serious adverse outcomes if not taken as prescribed. Effective communication between healthcare providers and patients is essential to ensure medication safety.

Hypereosinophilic syndrome (HES) is a hematologic disorder characterized by an increased absolute eosinophil count (AEC) that can lead to tissue infiltration and damage. Idiopathic HES (iHES) comprises a subset of patients with HES, in which a reactive cause such as infections or an inflammatory process cannot be identified, and clonality is not demonstrable. iHES remains a challenge to treat since there is no specific mutation to target. Interleukin-5 (IL-5) is a cytokine responsible for the proliferation and maturation of eosinophils. Anti-IL-5 and anti-IL-5 receptor therapies represent recent advancements in the management of these disorders. A 25-year-old female developed transient and recurrent visual deficits lasting several minutes at a time. Marked peripheral blood eosinophilia was noted. Over a year, she developed Loeffler's endocarditis (LE), leading to microvascular ischemic strokes and heart failure due to mitral valve infiltration. The patient needed an urgent mitral valve replacement. Multiple lines of standard eosinophil-lowering agents were tried and appeared ineffective or could not be maximally dosed due to hematologic dose-limiting toxicity. Benralizumab (Fasenra^®) is an IL-5 receptor antagonist indicated for eosinophilic asthma and eosinophilic granulomatosis with polyangiitis (EGPA) but not Food and Drug Administration (FDA)-approved for other HESs. Off-label benralizumab was tried, and her eosinophil count normalized within a week, allowing hemodynamic stability for a mitral valve replacement. After a year of continued bimonthly treatment with off-label benralizumab, her eosinophil count remains within normal limits, resulting in stabilization of her cardiac parameters. Off-label benralizumab treatment was effective in controlling our patient's eosinophilic counts and preventing further cardiac injury. Benralizumab should be considered earlier in the treatment of LE, particularly when rapid control of the eosinophil count is needed.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly with an estimated incidence of 0.008% to 0.043% based on autopsy and echocardiographic studies. Although often asymptomatic, it can lead to progressive aortic regurgitation (AR), left ventricular (LV) dysfunction, and arrhythmias such as atrial fibrillation (AF). Due to its rarity, QAV is often misdiagnosed or discovered incidentally, highlighting the need for advanced cardiac imaging in young patients presenting with unexplained heart failure symptoms and arrhythmias. We present the case of a 41-year-old female patient who was admitted with new-onset dyspnea classified as New York Heart Association (NYHA) class III and palpitations due to persistent AF with a European Heart Rhythm Association (EHRA) symptom class 2b. There was no family history of congenital or structural heart disease, with arterial hypertension being the only identified predisposing condition. Initial transthoracic echocardiography revealed moderate AR, but more detailed transesophageal echocardiography performed before pulmonary vein isolation incidentally revealed a QAV. Further cardiac magnetic resonance imaging confirmed normal aortic root dimensions with early LV remodeling. The patient was managed conservatively with rate control, anticoagulation, and regular follow-up to monitor disease progression. This case highlights the importance of advanced imaging techniques in the diagnosis of rare structural heart abnormalities in young patients presenting with unexplained heart failure symptoms and arrhythmias. Early identification of QAV allows for timely medical intervention, optimal patient monitoring, and prevention of long-term complications. Regular follow-up is essential to monitor disease progression and determine the need for surgical intervention.

Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), is a rare and aggressive subtype of non-Hodgkin lymphoma (NHL) that arises from mature T or natural killer (NK) cells, accounting for about 5% of all NHL cases. While PTCL-NOS typically involves lymph nodes, extranodal sites such as the skin, gastrointestinal tract, liver, and lungs can also be affected. Central nervous system (CNS) involvement is extremely rare, especially at the time of initial presentation. When it does occur, the brain is most commonly affected, followed by the spinal cord and meninges. We present a rare case of PTCL-NOS with secondary CNS lymphoma involving the meninges at initial diagnosis. Our patient is a 75-year-old male with multiple comorbidities who presented with several weeks of intermittent headaches. Imaging showed multiple extra-axial brain lesions with infiltration into extracranial soft tissues, epidural space, meninges, and brain parenchyma. A subsequent lymph node biopsy confirmed PTCL-NOS. He was started on rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), with plans for high-dose methotrexate. Thereafter, the patient was readmitted several times due to various complications and expired approximately 2.5 months after diagnosis. We conclude that secondary CNS involvement in PTCL-NOS is very rare and has a poor prognosis, with a median survival after CNS diagnosis of about 1.1 months. Early diagnosis and tailored treatment strategies, including CNS-penetrating agents, are essential. Continued research is needed to better understand and improve outcomes for this aggressive disease.

Complement-mediated hemolytic uremic syndrome (CM-HUS) is a condition characterized by hemolytic anemia, thrombocytopenia, and renal impairment, typically associated with a chronic dysregulation of the complement system. Few adult cases of CM-HUS triggered by influenza infection have been described. Here we present a case of a 56-year-old female with multiple myeloma receiving cancer treatment who presented with Influenza A H1N1-associated CM-HUS. She was treated with anti-complement therapy and at her 1-month follow-up had complete resolution of renal dysfunction and hemolytic anemia. This case highlights influenza infection as a trigger for CM-HUS in an immunocompromised adult and the role of anti-complement therapies.

Knee septic arthritis caused by Stenotrophomonas maltophilia (S. maltophilia) was very rare in immunocompetent group but was observed in a series of post-arthroscopy patients in our hospital. This study aimed to report the clinical course and treatments of the infections and the investigation of the incidents. One patient who underwent knee arthroscopy exhibited serious knee septic arthritis 17 days postoperatively. Later, three more similar patients were also suspected of knee infection. Investigation was initiated by interviews with personnel and reviews of medical records. All instruments associated with arthroscopy were subsequently sampled and tested. While no abnormalities were revealed in medical personnel and records, positive culture of S. maltophilia was found on one arthroscope, used in all four infected patients. No violations were found in sterilization processes. The contaminated arthroscope was proven loss of airtightness subsequently. For infection treatment, double or triple therapy of levofloxacin, sulfamethoxazole-trimethoprim, and minocycline was administered, with additional debridement performed in one patient. By retrospective survey, another three patients were suspected of infection out of the total 19 patients who underwent knee arthroscopy in last 4 weeks. After intervention, all involved patients recovered. Although S. maltophilia is a rare cause of knee septic arthritis, it can still occur and even lead to nosocomial outbreaks through instrument-related transmission. Sulfamethoxazole-trimethoprim, levofloxacin, and minocycline remain the treatment of choice, despite the rising global resistance rates. Although hydrogen peroxide gas plasma sterilization serves as a fast and effective method for instrument sterilization in arthroscopy, maintaining good arthroscope condition and airtightness ensures success, which warrants periodic checks.

Chronic myelomonocytic leukemia (CMML) is a rare neoplasm that has a roughly 15-30% chance of transforming into acute myeloid leukemia (AML). Acute leukemias have been known to cause pleural or pericardial effusions but having CMML transform into AML while presenting as a cardiac myeloid sarcoma causing pericardial effusions makes this case unique. A 59-year-old patient presented to the emergency room with shortness of breath and was found to be in cardiac tamponade requiring urgent care. The thoracic surgery team performed a pericardiectomy and placed a window drain. Cardiac tissue biopsy proved cardiac myeloid sarcoma with immature blasts and myeloid cells. Initial bone marrow biopsy on admission showed hypercellularity with 19% blasts and abnormal monocytes with multilineage dysplasia on aspirate differential, with positive KRAS and TET2 mutations on next-generation sequencing analysis. There was no evidence of a BCR/ABL1 fusion on fluorescence in situ hybridization (FISH), and chromosomal analysis demonstrated a normal karyotype. At this time, the patient met the WHO criteria for a CMML-2 diagnosis. A follow-up bone marrow biopsy closer to discharge showed a 33% blast count pointing towards a CMML-2 transformation into AML. Remarkably, he was able to improve and was discharged from the hospital. He was admitted again to the hospital to initiate chemotherapy. Such complex cases are rarely reported. Here we discuss the diagnosis and treatment of CMML transformed into AML as well as the rarity of cardiac myeloid sarcomas with an in-depth literature review.

Non-Hodgkin lymphoma (NHL) has many subtypes, with diffuse large B-cell lymphoma being the most common subtype. Typical symptoms of NHL include fever, weight loss, night sweats, and lymphadenopathy. Treatment depends on the subtype of NHL. Our case presents the clinical course of a patient who presented with obstructive jaundice and pancreatitis rather than typical symptoms of NHL. Workup included abdominal imaging showing a pancreatic mass and biopsy ultimately revealed high-grade B-cell lymphoma. This case presents a rare diagnosis of likely primary pancreatic lymphoma.

Intramuscular hemangiomas are rare, benign vascular tumors, with very few reported cases arising in lumbar paraspinal muscles. We describe the seventh documented adult case involving a 39-year-old male presenting with acute severe right-sided S1 radiculopathy. Magnetic resonance imaging (MRI) identified an 8.0 × 3.0 × 3.3 cm lesion within the erector spinae muscles at the L5-S1 level, accompanied by concurrent right-sided L5-S1 disc herniation compressing the S1 nerve root. Conservative treatment initially alleviated radicular pain, but persistent back pain and diagnostic uncertainty necessitated further evaluation. Negative metastatic screening and an inconclusive computed tomography (CT)-guided biopsy led to surgical excision, revealing an intramuscular hemangioma with significant adipocytic stromal components. This case highlights diagnostic challenges and underscores the importance of including vascular lesions in the differential diagnosis of persistent back pain, particularly when coexisting spinal pathologies complicate clinical presentation.