Clinical Medicine Insights. Case Reports最新文献

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.

Uterine fibroids are the most common benign gynecologic tumors; in pregnancy, degeneration may occur but is uncommon, whereas spontaneous rupture is an exceedingly rare complication. We present the case of a 43-year-old woman, gravida 2 para 2, at 17 weeks and 6 days of gestation, who was admitted with progressive abdominal pain and distension. Imaging revealed a large degenerating intramural fibroid with hemoperitoneum and a focal contour defect, raising concern for rupture. Despite stable vital signs, the patient experienced spontaneous abortion during hospitalization. Persistent abdominal pain and imaging findings warranted exploratory laparotomy, which revealed approximately 2 L of hemoperitoneum and a ruptured, necrotic fibroid. A uterine-sparing myomectomy was performed, and histopathology confirmed infarct-type degeneration with extensive hemorrhage and necrosis. The postoperative course was uneventful, and the patient was discharged in good condition. This case underscores that fibroid rupture in pregnancy may evolve subacutely, with preserved hemodynamics, and should be considered in pregnant patients with ongoing abdominal pain and degenerating myomas. Prompt recognition and timely surgical intervention are critical for favorable outcomes and uterine preservation.

The use of the transradial approach for performing coronary angiography is now a trend owing to the low risk of bleeding as well as quick recovery. Rare but life-threatening complications, such as acute compartment syndrome, must be identified promptly. A 60-year-old man presented to the hospital with excruciating pain and swelling in the forearm 2 hours post a transradial coronary angiography procedure. He was later diagnosed with acute compartment syndrome secondary to radial artery injury and managed with emergency fasciotomy, achieving full functional recovery. The transradial approach, while commonly used, can be associated with rare but serious complications such as acute compartment syndrome. In this case, early diagnosis and timely surgical intervention were crucial in preventing permanent damage. Clinicians should remain vigilant to ensure prompt management and favorable outcomes.

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition with a strong genetic basis, and rare X-linked variants may contribute to its pathogenesis, particularly in consanguineous families. We present 2 pediatric cases from related Turkish families carrying a novel hemizygous DRP2 stop-gain mutation (p.Q232X). Case 1, a 5-year-old male, presented with ASD, macrocephaly, hypotonia, chronic otitis media with conductive hearing loss, and a mild demyelinating polyneuropathy confirmed electrophysiologically. Case 2, a 7-year-old male cousin, showed developmental delay, hyperactivity, bilateral cryptorchidism, and recurrent otitis media with hearing loss. Whole-exome sequencing identified the same DRP2 mutation in both patients, classified as likely pathogenic. Case 1 additionally carried heterozygous variants of uncertain significance in COL4A2 and MFN2. Multidisciplinary management included behavioral, speech, occupational, and physical therapies, as well as tympanostomy and orchiopexy. Longitudinal follow-up showed improved communication, motor function, and hearing, with stable neuropathy in Case 1. This report introduces a potentially novel role of DRP2 in ASD, extending its phenotypic spectrum beyond neuropathy, and underscores the need for further cases to define genotype-phenotype heterogeneity. Recognition of this variant is clinically relevant for genetic counseling in consanguineous populations, where risks extend beyond neuropathy to include broader neurodevelopmental outcomes.