Clinical Medicine Insights. Case Reports最新文献

Introduction: Spontaneous splenic rupture (SSR) is an uncommon and potentially life-threatening cause of acute abdominal pain, often linked to underlying pathology. Because its presentation can mimic more common conditions, diagnosis is frequently delayed. We report a case from a resource-limited setting where SSR initially mimicked peptic ulcer disease, underscoring diagnostic challenges.

Case presentation: A 57-year-old Ethiopian woman with chronic reflux presented after 5 days of severe epigastric pain radiating to the left shoulder, with nausea and vomiting but no trauma or fever. Initial labs showed mild anemia. Abdominal examination revealed localized epigastric tenderness without peritonism. The initial working diagnosis was peptic ulcer disease; proton pump inhibitors were started, and endoscopy was unavailable. After 2 days, she developed hypotension and left upper quadrant pain. Bedside ultrasound (FAST) showed free intraperitoneal fluid, and contrast CT confirmed a ruptured spleen with hemoperitoneum.

Management and outcome: The patient underwent emergency laparotomy, which found a shattered spleen and ~3.5 L of intra-abdominal blood; a splenectomy was performed. She required an intraoperative transfusion and was stabilized. Histopathology confirmed a normal spleen with preserved architecture, supporting a diagnosis of idiopathic rupture possibly related to transient microvascular congestion. Postoperatively, she recovered uneventfully and was discharged on postoperative day 5. She received the vaccinations needed and was counseled about infection risk.

Conclusion: This case illustrates that true spontaneous rupture can occur in a histologically normal spleen and may mimic peptic ulcer disease in presentation. Recognizing atypical features and ensuring timely imaging are crucial, especially in resource-limited settings where delayed diagnosis increases mortality.

Background: Ectopic pregnancy (EP) complicates approximately 1% to 2% of pregnancies. Most EPs implant in the fallopian tube and present in the first trimester; continuation beyond 10 weeks is extremely uncommon.

Case presentation: An 18-year-old primigravida at 12 weeks' gestation presented with acute-onset lower abdominal pain, syncope, and 1 week of dark-red spotting. She was hypotensive (BP 90/60 mmHg) and tachycardic (112 bpm) with pale conjunctivae. Abdominal examination revealed lower-quadrant tenderness; pelvic exam showed a closed cervix and a tender posterior fornix. Transabdominal ultrasound demonstrated an empty uterus, a gestational sac with a fetal pole adjacent to the right adnexa, and moderate free intraperitoneal fluid.

Management and outcome: Emergency laparotomy was performed. Approximately 800 mL of hemoperitoneum was evacuated. The right fallopian tube was found ruptured in the ampullary segment with extrusion of a formed fetus. Right salpingectomy was performed, and hemostasis achieved. The patient received 2 units of packed red blood cells intraoperatively and recovered without complication. A follow-up ultrasound at 6 weeks showed a normal remaining adnexa.

Conclusion: This rare case of a 12-week tubal ectopic pregnancy with an advanced fetus highlights critical diagnostic challenges. Delayed presentation and lack of early prenatal imaging allowed the tubal pregnancy to progress to late gestation. High clinical suspicion and prompt ultrasound evaluation are essential for early detection of atypical ectopic pregnancies, to prevent catastrophic hemorrhage and preserve fertility.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon but potentially fatal hypersensitivity response, commonly triggered by medications such as antiepileptics and antibiotics. It typically presents with rash, fever, hematologic abnormalities, lymphadenopathy, and internal organ involvement-most commonly affecting the liver. We report a case of a 79-year-old woman with hypertension and dyslipidemia who underwent laparoscopic cholecystectomy for acute cholecystitis with early pancreatitis. Postoperatively, she developed persistent cholestatic liver injury without biliary obstruction. Ten days later, she presented with fatigue, a diffuse maculopapular rash, and elevated cholestatic liver enzymes and lipase. Skin biopsy revealed features consistent with drug-induced hypersensitivity. Using the RegiSCAR scoring system, the case met criteria for probable DRESS syndrome (score = 5). Ceftriaxone and metronidazole, the only new drugs introduced perioperatively, were identified as likely triggers using the Naranjo causality scale. The patient was treated with oral prednisone (0.75 mg/kg), with full resolution of clinical and laboratory abnormalities following a 5-week course. This case highlights an atypical presentation of DRESS syndrome mimicking postoperative cholestasis. It underscores the importance of considering DRESS in the differential diagnosis of unexplained cholestatic injury, even in the absence of classical features like fever, eosinophilia, or lymphadenopathy. Early recognition and timely corticosteroid therapy are critical to improving outcomes.

Background: Aconitine, a highly toxic diterpenoid alkaloid derived from the Aconitum genus, continues to be utilized in traditional Chinese medicine. Aconitine poisoning is common in China and often causes malignant arrhythmias and cardiac arrest, with a mortality rate of approximately 15.1%. Using venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in this context has been rarely reported, and associated microcirculatory changes have not been described.

Case report: We present a case of a 59-year-old man who ingested a topical medicinal wine prepared from Aconitum brachypodum Diels. Despite the conventional treatment administered, the patient developed a cardiac arrest 2 hours after admission. VA-ECMO was promptly initiated alongside repeated cardiopulmonary resuscitation and electrical defibrillation. After 6 hours of VA-ECMO initiation, the heart rhythm of the patient stabilized to sinus without further malignant arrhythmias. Microcirculatory monitoring was performed using sublingual microcirculation during VA-ECMO support, which was used for a total of 46 hours. The patient was transferred out of the intensive care unit (ICU) after 7 days of hospitalization and was eventually discharged without any sequelae.

Conclusion: Early initiation of VA-ECMO support may help stabilize cardiac electrical storms in patients with aconitine poisoning. Sublingual microcirculation monitoring may play a role in predicting VA-ECMO weaning success and patient but this requires further investigation.

Background: Takayasu arteritis (TA) is a rare chronic vasculitis primarily affecting the aorta and its major branches, often presenting diagnostic challenges due to nonspecific symptoms, particularly in adolescents. This case highlights a rare adolescent-onset TA with unique vascular findings in Pakistan.

Case presentation: A 17-year-old female presented with a 1-year history of fever, 40 kg weight loss, and vague abdominal discomfort. Physical examination revealed absent left arm pulses, vascular bruits, and asymmetric blood pressure. Laboratory tests showed anemia, elevated inflammatory markers (ESR 62 mm/h, CRP 66 mg/L), and hyperferritinemia. CT angiography confirmed thoracic aortic mural thickening, left subclavian artery occlusion, vertebral steal syndrome, and nonbifurcating carotid arteries. The diagnosis of TA was established using modified Ishikawa and 1990 ACR criteria.

Management and outcomes: The patient received pulse methylprednisolone, monthly cyclophosphamide, and antihypertensives. Symptoms resolved within 3 months, with normalized inflammatory markers and stable vascular status at 1-year follow-up.

Conclusion: This case underscores the importance of considering TA in adolescents with constitutional symptoms and pulse deficits. Early imaging and immunosuppressive therapy led to favorable outcomes. Vertebral steal syndrome and nonbifurcating carotid arteries add educational value, emphasizing clinical vigilance in resource-limited settings.

Background: Pseudoaneurysm of the superior lateral genicular artery (SLGA) is a rare vascular complication following total knee arthroplasty (TKA), with an incidence ranging from 0.03% to 0.2%. Most cases occur in the immediate postoperative period while delayed presentation months after surgery can be often misdiagnosed as infection or hemarthosis.

Case presentation: A 62-year-old male smoker with previous TKA presented to the emergency department with knee pain and a palpable pulsatile mass on the lateral side of the right knee. Clinical evaluation with doppler ultrasonography and CT scan showed the presence of a 1.5 cm pseudoaneurysm of the SLGA. Initial conservative management with manual compression proved ineffective thus given the high risk of rupture, definitive surgical exclusion was performed with no post-procedural complications.

Conclusion: Delayed SLGA pseudoaneurysms typically present with nonspecific symptoms like pain, swelling and limited ROM. Diagnosis relies on imaging while surgical ligation proved to be an effective treatment. Pseudoaneurysm should be considered in post-TKA patients with unexplained knee swelling and pain, even months after surgery. Early diagnosis through second level imaging, multidisciplinary collaboration and timely surgical intervention are crucial for preventing complications.

Introduction: Allergic contact dermatitis (ACD) is a rare but clinically significant hypersensitivity reaction to certain medications, including enoxaparin, a commonly used low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis.

Case presentation: We report the case of a 27-year-old woman who developed pruritic, erythematous eruptions localized to enoxaparin injection sites following sleeve gastrectomy. Symptoms emerged 6 days after initiating enoxaparin and were confirmed as ACD via clinical assessment and histopathological analysis, which revealed spongiotic dermatitis with eosinophilic infiltration. The patient responded well to topical mometasone ointment, with complete resolution of symptoms within 4 weeks.

Conclusion: This case underscores the importance of recognizing enoxaparin-induced ACD and emphasizes the role of histopathology and individualized treatment strategies in optimizing patient care.

Acquired hemophilia A (AHA) is a rare autoimmune coagulopathy disorder characterized by the development of inhibitory autoantibodies against coagulation factor VIII. It often presents with spontaneous or post-procedural bleeding in individuals without prior bleeding history and requires prompt recognition and management. We report the case of a 70-year-old male who developed life-threatening hemorrhagic complications following pancreaticoduodenectomy. Re-laparotomy revealed dehiscence of the pancreaticojejunostomy, which was resected, and a temporary Wirsungostomy was created. The patient was admitted to the Intensive Care Unit (ICU) with progressive anemia, subcutaneous hematomas, and recurrent gastrointestinal bleeding. Laboratory tests revealed isolated activated partial thromboplastin time (aPTT) prolongation, lack of correction in the mixing study, reduced factor VIII activity (15.3%), and the presence of an inhibitor (0.7 Bethesda Units; BU). Based on the above, acquired hemophilia A was diagnosed. Treatment included recombinant activated factor VII (rFVIIa) for 6 days and corticosteroid therapy with methylprednisolone. Clinical improvement and nearcomplete remission were achieved, with normalization of aPTT, restoration of factor VIII activity (99.6%), and persistence of only trace inhibitor levels. This case highlights the diagnostic complexity of atypical postoperative bleeding, underscoring the need for a broad differential diagnosis and a high index of suspicion for rare disorders like acquired hemophilia A to ensure timely, life-saving intervention.

Background: Occipital neuralgia is a relatively frequent but often intractable headache disorder typically arising from trauma or nerve entrapment. While commonly associated with spontaneous or degenerative causes, iatrogenic occipital neuralgia following scalp surgery is rare and underreported in the literature. Reporting this case highlights the diagnostic challenge and surgical relevance of an underrecognized etiology.

Case presentation: A healthy 31-year-old female developed stabbing occipital pain radiating to the forehead after incomplete excision of a left occipital scalp tumor under local anesthesia. Examination revealed paroxysmal pain without sensory loss in the distribution of the greater occipital nerve, associated with dysesthesia and tenderness. A soft residual mass remained near the surgical site. Diagnostic occipital nerve block with lidocaine resulted in temporary pain relief, confirming occipital neuralgia. Surgical excision and neurolysis of the greater occipital nerve were performed. The patient experienced complete resolution of pain, with minimal residual numbness postoperatively.

Conclusions: This case illustrates a rare instance of iatrogenic occipital neuralgia following scalp surgery. It underscores the importance of evaluating prior surgical history in patients with new-onset occipital pain and highlights the utility of occipital nerve block as a diagnostic tool. Greater occipital nerve injury or local inflammatory sequelae may result in persistent neuropathic pain, which can be effectively addressed through decompression or neurolysis. Preoperative knowledge of neuroanatomy and meticulous surgical technique are vital to preventing such complications.

Objective: To present a case of invasive salmonella superinfection of an ovarian endometrioma in a patient with systemic lupus erythematosus, most likely due to exacerbation of a prior infection due to immunocompromised status, and review of literature on the typical and atypical manifestation of salmonella infection.

Design: Case report and mini-review. We used the CARE checklist when writing our report.

Materials and methods: For diagnosis of Salmonella bacteremia, cultures were used. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) was used to further diagnose the patient with Salmonella enterica ssp. diarizonae.

Setting: University-based OBGYN service.

Patient: A 40-year-old G3P3003 female, initially presenting with nausea, non-bloody emesis, watery diarrhea, subjective fevers, and extreme fatigue, was found to have positive cultures for salmonella infection. Cefepime was administered with subsequent marked improvement in symptoms. Patient represented 2 months later with abdominal pain and fever and was confirmed to have a salmonella-infected endometrioma.

Intervention: Explorative laparotomy, right salpingo-oophorectomy, and left adnexal cyst drainage.

Main outcome: Outcome and complication of surgical management of salmonella superinfection of an ovarian endometrioma.

Result: Post-op, the patient experienced post-op fevers until POD7, when her symptoms began to improve significantly. Persistent fevers were attributed to surgical complications involving a cyst rupture during removal. The patient was subsequently discharged with a 6-week course of Ciprofloxacin 500 mg BID and suppressive amoxicillin PO 500 mg BID after completing the Ciprofloxacin regimen due to immunocompromised status.

Conclusion: Assessment for metastasis to other organs is crucial in evaluating immunocompromised patients diagnosed with salmonella infections. Surgical management should be highly considered.