Journal of Medical Case Reports最新文献

Background: Thrombotic microangiopathy (TMA) is a rare, life-threatening disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end-organ damage. Atypical hemolytic uremic syndrome (aHUS) is even less common, comprising less than 10% of hemolytic uremic syndrome (HUS) cases. aHUS in postpartum is associated with poor maternal outcomes, with the majority of cases resulting in end-stage renal disease. aHUS, unlike other types of TMA, is related to complement dysregulation. Thus, the current treatment of choice for aHUS is complement blockade, which limits unregulated activation of complement and complement-mediated end organ damage.

Case presentation: We present a rare case of a previously healthy, postpartum, 20-year-old Hispanic female patient who underwent a laparoscopic cholecystectomy and subsequently developed complement-mediated TMA, successfully treated with eculizumab. Unique to our case was renal failure owing to multiple insults and partial resolution of hematologic TMA findings prior to initiation of eculizumab.

Conclusion: Our case emphasizes the importance of clinicians possessing a high degree of clinical awareness and judgement surrounding complement-mediated TMA, aHUS and its subsets, and surgery as a precipitator, regardless of safety, particularly during the postpartum period.

Background: Sleep disorders are a common health problem that can be classified into many types that are distinguished by their history and characteristics. In this case report, we discuss a case of a patient suffering from recurrent unusual prolonged sleep attacks lasting up to 9 days that responded excellently to levetiracetam.

Case presentation: An 18-year-old Syrian male patient presented to the neurology department complaining of recurrent prolonged sleep episodes lasting for 9 days. Although Kleine-Levin syndrome was suspected, the history and investigations ruled it out. The patient was then treated with levetiracetam as a trial, and the response was excellent.

Conclusion: This case is a rare and unusual sleep disorder that does not match any of the known sleep disorders. What makes the case unique is the unexpected response to levetiracetam.

Background: NeoDura (Medprin Biotech Gmbh) is an absorbable dural repair patch consisting of degradable poly-L-lactic acid and porcine gelatin that provides a hermetic closure of the dura mater (Medprin Biotech. Neodura. Dural Repair Patch [Brochure]. 2016. https://irp.cdn-website.com/762563d2/files/uploaded/a-NeoDura-Broschüre.pdf . Accessed 24 Sep 2022.). It can be used after resection of a meningioma. If overlying bone and skin structures are absent, an additional flap reconstruction is usually considered, resulting in extensive surgery. However, this study is the first to describe a case of healing by secondary intention over NeoDura as the most superficial layer.

Case presentation: A 48-year-old Caucasian woman had been treated with surgery and whole brain radiotherapy for medulloblastoma in 1976. As radiotherapy-related consequences she developed blindness and multiple secondary tumors (meningioma, basal cell carcinoma). After resection of a large parasagittal meningioma, wound infection and healing problems occurred. The skull flap (10 cm in diameter) had to be removed, and two latissimus dorsi reconstructions failed. As the dura closure using NeoDura appeared watertight, it was decided to attempt healing by secondary intention using vacuum assisted closure, and later, with local wound dressings. This resulted in a complete skin closure after almost 1 year. No local or neurological complications occurred. The tissue was sufficiently resistant to avoid the "syndrome of the trephined," a well-known complication in patients without bony reconstruction after craniectomy.

Conclusion: This is the first description of healing by secondary intention over a craniectomy wound where the normal dura was also removed and replaced by NeoDura. This treatment could be an alternative for extensive reconstructions in patients who are not fit to undergo reconstructive surgery or after failure of reconstruction.

Background: Klinefelter syndrome is considered one of the most common sex chromosome disorders affecting males. The presence of an extra X chromosome can alter the tendency to develop various cancers, including lymphomas. Lacrimal gland lymphoma is a disease of the elderly, with a median age of presentation of 70 years.

Case presentation: In this article, we report a case of a 35-year-old Arabian Saudi male with a known case of Klinefelter syndrome who presented to oculoplastic clinic complaining of progressively growing superior-temporal mass in the left eye. After evaluation and imaging, an incisional biopsy from the lacrimal gland mass was obtained and histopathological evaluation showed atypical lymphoproliferative infiltrate consistent with extranodal marginal zone lymphoma of mucosa associated lymphoid tissue. The mainstay treatment was external beam radiotherapy, which showed significant improvement in the case.

Conclusion: This is considered the first reported case of lacrimal gland lymphoma in young patient with Klinefelter syndrome, which increases the association between Klinefelter syndrome and lymphomas.

Background: Systemic lupus erythematosus is a multi-organ autoimmune disorder that is treated by immunosuppressive agents that weaken the immune defense against opportunistic pathogens and latent infections such as strongyloidiasis. Herein, we report the case of a 43-year-old woman known to have systemic lupus erythematosus who presented with gastrointestinal symptoms, edema, and bone pain 2 months after receiving immunosuppressive treatment.

Case presentation: A 43-year-old Iranian female known to have systemic lupus erythematosus and antiphospholipid syndrome presented with abdominal pain, nausea, vomiting, and generalized edema. She was on CellCept, prednisolone, and hydroxychloroquine. The vital signs were within the normal range. On physical examination, no rash was observed on the skin. There was only a mild tenderness in epigastric region. The results of blood analysis revealed hypochromic microcytic anemia, normal leukocyte count with mild eosinophilia. Liver enzymes as well as renal function tests were within the normal range. Stool examination was negative for trophozoites, ova, or cysts of parasites. Endoscopic findings included a generalized nodular appearance of duodenum with an infiltrative mucosa in the wall of duodenum, suggesting lymphoma. The pathology report determined the diagnosis of strongyloidiasis. Cap albendazole 400 mg was administered twice a day for 2 weeks. Abdominal pain was completely relieved 1 week after starting the treatment. The patient was eventually discharged after 10 days.

Conclusion: The significance of this case report is the necessity to send complete blood count and serologic assays to screen latent strongyloidiasis before receiving immunosuppressive agents in patients with systemic lupus erythematosus.

Background: Angiosarcoma is a rapidly proliferating vascular tumor that originates in endothelial cells of vessels. Rarely, it can be associated with consumptive coagulopathy due to disseminated intravascular coagulation eventually leading to thrombocytopenia and microangiopathic hemolytic anemia. This specific manifestation is termed Kasabach-Merritt syndrome. Patients usually present with manifestations related to the primary diagnosis of angiosarcoma depending on the organ it is involving. However, if Kasabach-Merritt syndrome has occurred, it will present with manifestations such as bleeding and thromboembolic phenomenon. To date, no favorable outcomes have been documented, and the overall prognosis remains grim.

Case presentation: A 44-year-old male patient of Afghan origin developed typical signs and symptoms of pulmonary tuberculosis, that is, fever, cough, hemoptysis, weight loss, and night sweats. He was initially managed in an Afghan medical facility where workup for tuberculosis was done but came back negative. He empirically received anti-tuberculous therapy owing to typical presentation and tuberculosis being endemic in the area. The condition of the patient worsened, and he presented to our facility (Shifa International Hospital, Islamabad, Pakistan). Workup led to the diagnosis of a metastatic vascular neoplasm, which was further complicated with consumptive coagulopathy, and microangiopathic hemolytic anemia. This presentation is known as Kasabach-Merritt syndrome. Multidisciplinary team discussion was called, and it was decided to proceed with palliative chemotherapy with paclitaxel.

Conclusion: Although a patient may present with typical signs and symptoms of, but negative workup for, TB, if there is a high index of suspicion and the patient is receiving empirical treatment for pulmonary tuberculosis, clinical worsening should alert to think about differential diagnosis. In our case, histopathological analysis of lymph node and radiological findings led us to the diagnosis.

Background: The sunken flap or sinking skin flap syndrome is a complication that can be observed following decompressive craniectomy. More rare, sinking skin flap syndrome can occur as an iatrogenic complication of pleural effusion evacuation via chest tube placement in the presence of ventriculopleural shunt.

Case presentation: We report the case of a Hispanic male patient in his 20s who presented to the emergency department after sustaining a penetrating gunshot wound to the head. In addition to undergoing an emergent decompressive craniectomy, a ventriculopleural shunt was subsequently placed as a treatment for hydrocephalus. Two days after shunt placement, the patient developed significant hydropneumothorax that did not respond to observational management. Owing to the severity of his hydropneumothorax, a chest tube was placed for evacuation, but he developed a sinking skin flap at the craniectomy site. The suction function of the chest tube was discontinued, and the ventriculopleural shunt pressure was increased. Within 24 hours, the skin flap reexpanded. We hypothesize that the inherently negative pressure of the pleural space combined with significant suction effect from chest tube evacuation placed him at risk of sinking skin flap syndrome despite having an antisiphon device.

Conclusion: Our case highlights the importance of understanding cerebrospinal fluid hydrodynamics with shunt presence and suggests a potential treatment framework for iatrogenic sinking skin flap syndrome in the presence of ventriculopleural shunt.

Background: Ketamine treatment presents a novel approach for addressing refractory conditions, such as major depressive disorder, suicidal ideation, and posttraumatic stress disorder, which often co-occur and pose significant challenges for clinicians. This study explores the clinical and electrophysiological outcomes of ketamine treatment in two cases, shedding light on its potential efficacy and mechanisms of action.

Case presentation: The first case involves a 56-year-old Caucasian male with chronic posttraumatic stress disorder and suicidal ideation, and the second case involves a 52-year-old Caucasian female with treatment-resistant major depressive disorder. Both patients opted for ketamine treatment after years of unsuccessful interventions. The male patient received nine ketamine infusions over 18 months, while the female patient received five infusions over one month. Symptom improvement was accompanied by distinct electrophysiological changes, as observed through electroencephalogram and evoked electroencephalogram responses. These changes persisted for several months post-treatment, offering hope for individuals grappling with challenging chronic conditions.

Conclusion: Ketamine infusions resulted in significant and sustained symptomatic improvement in both cases, accompanied by distinct electrophysiological changes indicative of altered brain function. These findings highlight the potential of ketamine as an alternative treatment for refractory conditions, such as major depressive disorder and posttraumatic stress disorder, offering relief and functional recovery for certain patients. Further research is warranted to elucidate the underlying mechanisms and optimize treatment protocols.

Introduction: Traumatic obturator-type anterior dislocation of the hip with an ipsilateral subtrochanteric fracture is rarely encountered in clinical practice. This case presentation described a trauma patient with such a rare scenario.

Case report: This paper reports a case of a 20-year-old Amhara ethnic male patient who had a traumatic anterior dislocation of the hip associated with an ipsilateral subtrochanteric femur fracture after a truck rolled over. There was diffuse swelling of the proximal thigh, and the lower limb was externally rotated. Radiographic examination shows right femur subtrochanteric fracture with ipsilateral obturator-type anterior hip dislocation. Emergency open reduction of the hip dislocation and antegrade intramedullary nailing of the subtrochanteric fracture performed. Subsequent clinical and radiologic follow-up demonstrated good outcomes.

Conclusion: The main peculiarity of the presented case is the association of obturator hip dislocation with ipsilateral femur shaft fracture. Early and stable reduction of the dislocation and firm internal fixation of the fracture as soon as possible will allow early rehabilitation and prevent late complications. At the 4th week of operation, he started non-weight-bearing mobilization.

Background: Congenital scoliosis with progressive potential is a controversial subject in early-onset spinal deformities. The presence of a hemivertebra may produce severe spinal deformities. The evolution of a scoliotic curve in these cases is unpredictable and requires careful follow-up dependent on multiple variables, such as the location of the hemivertebra, the age of the patient at the time of diagnosis, and the degree of deformity already present in both sagittal and frontal planes. A segmented hemivertebra is an obvious cause of spinal deformity owing to its high progressive potential. A semi-segmented hemivertebra may induce severe deformities and surgery may be required, depending on the patients' age, current deformity, and progressive potential. The age of 1.5-6 years is ideal to obtain an excellent surgical result. Prophylaxis of a predicted severe scoliotic curve owing to a semi-segmented hemivertebra requires a strategic surgical approach. While there are multiple surgical treatment options available nowadays, the current gold standard is the resection of the hemivertebra via a single posterior approach with limited fusion.

Case description: A 5-year-old Caucasian male child with congenital scoliosis owing to a semi-segmented hemivertebra at the thoracolumbar junction and a synchondrotic vertebral body bridge below the hemivertebra. The particularity of the hemivertebra consisted in the fact that it involved the L1 thoracolumbar transition area. The architecture of the upper part of the deformity resembled a T12-like deformity while the lower part was L1-like. Hemivertebra resection was performed by posterior approach and a short segmental fusion. The complete resection of the hemivertebra corrected the scoliotic curve and improved spinal balance. The patient was allowed to ambulate independently 3 days postoperatively while wearing a protective brace. Unrestricted daily activity was permitted 3 months after surgery. No complications were noticed until now.

Conclusion: Extensive clinical and imaging examination of the congenital malformation should be performed in all cases of congenital scoliosis owing to semi-segmented hemivertebra, especially if surgery will be performed. Proper diagnosis, age at surgery, and appropriate surgical technique ensure good results. Establishing which part of the involved spinal segment, including the semi-segmented hemivertebra, must be resected is essential to obtain a good correction with the shortest possible spinal fixation.