Journal of medical cases最新文献

Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.

A 67-year-old man was found to have a pancreatic head mass on abdominal ultrasound. He had compensated liver cirrhosis due to hepatitis C. The fine-needle aspiration (FNA) biopsy of the mass reported an adenocarcinoma of the pancreas, while the subsequent histopathology report of the supraclavicular lymph node showed features of hepatocellular carcinoma (HCC). A second read and additional stains on the FNA specimen confirmed a hepatoid (hepatocellular) carcinoma of the pancreas. He received atezolizumab and bevacizumab and had a good response. Tumors with features of HCC outside of the liver rarely occur and even more rarely in pancreas, with less than 50 cases reported so far. Pure HCC-like morphology is the most common histological form among four subtypes and has a relatively better prognosis. Surgical resection is considered the treatment of choice if amenable and variable outcomes are reported with different chemotherapies. Challenges exist in the diagnosis and the management of this rare and intriguing entity, and the potential misdiagnosis can have grave consequences as the management is completely different for a pancreatic adenocarcinoma and hepatoid carcinoma. We report a case with a challenging diagnosis of metastatic pancreatic hepatoid carcinoma which was treated as unresectable HCC with immunotherapy and the patient had a good response.

[This corrects the article DOI: 10.14740/jmc3490.].

Spiders are the most numerous arthropods of the arachnid class. More than 45 thousand species of spiders have been identified, and only a few are dangerous to humans. Among them, the "violin spider" or "brown spider" of the genus Loxosceles (family Sicariidae) has a worldwide distribution, and its bite can cause loxoscelism. Initial treatment of a Loxosceles spider bite includes application of local cold, rest, elevation of the extremity if possible, and systemic pharmacotherapy with antihistamines, corticosteroids, antibiotics, polymorphonuclear inhibitors, and analgesics or nonsteroidal anti-inflammatory drugs. During cutaneous or systemic loxoscelism, administration of Loxosceles antivenom (immunoglobulin (Ig)G F(ab')2 fragments) may be indicated to prevent progression to severe systemic phases. In this manuscript, we present three cases of patients with loxoscelism treated with the fabotherapeutic Reclusmyn^®, developed and manufactured in Mexico. Two patients had a satisfactory outcome without severe skin or systemic damage. Only one patient with loxoscelism, despite early initiation of antivenom, had extensive skin lesions that healed satisfactorily, leaving only a non-disabling scar. Due to the global presence of this clinical problem, further studies are needed to establish local and general guidelines for the treatment and prevention of loxoscelism. This will allow health professionals to provide more efficient and higher quality medical care and feel supported in their decisions.

TAFRO syndrome, a rapidly progressive and fatal disease, is rare, and its etiology remains unknown. It is characterized by thrombocytopenia, anasarca (edema, pleural effusion, and ascites), fever, reticulin fibrosis (or renal insufficiency), and organomegaly with Castleman disease (CD)-like histological features in the lymph nodes. CD is a rare, indolent, lymphoproliferative disorder with no established curative strategies. Most idiopathic multicentric CD cases are controlled with anti-interleukin (IL)-6 therapy (tocilizumab and siltuximab) and/or rituximab. However, it is unclear whether these therapies can be directly applied to treat TAFRO syndrome. Here, we describe stepwise immunotherapy (rituximab induction therapy and cyclosporine maintenance therapy) for two cases of steroid-refractory TAFRO syndrome. A 32-year-old man visited a local hospital with sudden onset of fever and epigastralgia. The diagnosis of TAFRO syndrome was established based on the diagnostic criteria. After rituximab administration, C-reactive protein and IL-6 levels were normalized. However, the ascites persisted, with increased resistance to rituximab. Tocilizumab was also ineffective; therefore, cyclosporine was administered. After the initiation of cyclosporine treatment, the ascites decreased and ultimately disappeared. Twelve months after immunotherapy, the patient remained asymptomatic under cyclosporine maintenance therapy. Similar stepwise immunosuppressive therapy was administered to a 72-year-old man with TAFRO syndrome complicated by renal failure. After rituximab infusion, C-reactive protein was decreased. Although methylprednisolone, rituximab, tocilizumab, and cyclosporine were administered, other laboratory data and clinical symptoms remained unchanged. His level of consciousness subsequently deteriorated due to herpes zoster encephalitis, and he died. We consider the combination of rituximab induction therapy and cyclosporine maintenance therapy to be effective for TAFRO syndrome if initiated at an early stage.

Crohn's disease is an inflammatory disease that typically affects the bowels but can also have many different extraintestinal manifestations. One of those complications is immunoglobulin A nephropathy (IgAN), which is one of the most encountered renal lesions in the setting of Crohn's disease. Another point of focus for Crohn's patients is the risk of cancer, with a higher risk of colorectal cancer but also extraintestinal neoplasia such as hepatobiliary, hematological, and urinary tract neoplasia. We present the case of a young patient suffering from long-term Crohn's disease and subsequent IgAN leading to end-stage kidney disease and hemodialysis. The patient was diagnosed young and had undergone multiple surgeries and different treatments in various countries. He then presented in our center already with advanced chronic renal failure from IgAN that was unknown due to poor multidisciplinary follow-up. Shortly after starting hemodialysis, he developed a large abdominal mass, first thought to result from Crohn's-related fistula. This mass turned out to be a urachal adenocarcinoma, a rare type of bladder cancer with an especially poor prognosis. It is not known whether this type of cancer is associated with either Crohn's disease or IgAN, and no such association has been previously described. The treatment of urachal cancer usually relies on surgery, with the addition of chemotherapy in some cases. Unfortunately for our patient, his case was already so advanced at the moment of diagnosis that he was excluded from curative treatment and quickly passed away thereafter. This case illustrates many important aspects of the rigorous follow-up that is needed for Crohn's patients, with regular check-ups, screening investigations, and the need for multidisciplinary evaluation. Furthermore, it describes the development of a rare type of cancer in the setting of Crohn's disease and IgAN, with no prior established link between these different pathologies.

The erector spinae plane block (ESPB) is increasingly gaining popularity in pediatric anesthesiology as it provides an alternative to neuraxial anesthesia in those with relative and absolute contraindications. Recent studies show craniocaudal spread in cadavers and multi-level spread impacting neural structures in live subjects. We present a case report of a pediatric patient with a history of abdominal surgeries, contraindication to neuraxial anesthesia, and thoracic vertebrae fractures. Bilateral ESPB catheters were initially placed but the left catheter was accidentally dislodged. Each ESPB catheter was initially programmed to flow at rate of 2 cc/h of ropivacaine 0.1% for a max combined rate of 4 cc/h. Once the left ESPB catheter was dislodged, the right ESPB catheter was programmed to flow at 4 cc/h which surprisingly continued to provide adequate bilateral analgesia for the patient without the need for additional narcotics. In cases where a unilateral ESPB catheter is the only option due to catheter displacement or contamination, administering a higher volume of local anesthetic may still yield satisfactory pain relief for managing postoperative discomfort following abdominal surgery.