Journal of Medical Case Reports最新文献

Background: First- and second-generation anti-epithelial growth factor receptor tyrosine kinase inhibitors have shown great efficacy in the treatment of advanced adenocarcinoma with epithelial growth factor receptor mutations, but this efficacy is limited by certain resistance mechanisms, in particular the T790M mutation, which must be screened before second-line treatment with osimertinib is indicated. The search for this mutation is sometimes difficult, especially in cases of intracranial relapse, through this case report we attempt to discuss the possibility of initiating treatment with osimertinib despite an unknown T790M mutation in such situation.

Case report: We present the case of a 70-year-old Moroccan male patient diagnosed with non-small cell lung carcinoma initially metastatic to the pleura with an epithelial growth factor receptor mutation who received gefitinib in first line with a complete response, he subsequently presented with cerebral oligo-progression with extra cranial stability. The patient was started on osimertinib with unknown T790M status, as it was impossible to perform a cerebral biopsy, the evolution was characterized by a partial response followed by stereotactic radiotherapy then a complete response for 2 years.

Conclusion: We can discuss osimertinib as an option for patients with stage IV non-small cell lung cancer with brain oligo-progression on prior tyrosine kinase inhibitors and unknown T790M status, further studies are needed in this area.

Background: Spontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assisted thoracoscopic surgery.

Case presentation: A 19-year-old Japanese male was diagnosed with left pneumothorax and underwent chest tube drainage. A total of 10 hours after admission, the patient developed dyspnea, chest pain, and sudden massive bloody effusion. Contrast-enhanced computed tomography revealed contrast extravasation near the left lung apex, and spontaneous hemopneumothorax was diagnosed. Angiography revealed bleeding from a branch of the subscapular artery and transcatheter arterial embolization was performed. The patient underwent video-assisted thoracoscopic surgery and recovered uneventfully.

Conclusions: Anesthesiologists involved in urgent surgeries must be aware that a patient with spontaneous pneumothorax can develop a hemopneumothorax, even when full lung expansion has been obtained following chest tube drainage, owing to latent aberrant artery disruption. Interprofessional team engagement is essential for spontaneous hemopneumothorax management.

Background: Syndrome of apparent mineralocorticoid excess (AME) is characterized by excessive MR stimulation despite low levels of aldosterone. 11Beta-hydroxysteroid dehydrogenase-2 (11βDSH-2) inactivates cortisol to cortisone, preventing cortisol-induced MR activation. Genetic defects in 11βDSH-2 cause AME through accumulation of cortisol in the distal nephron, leading to MR activation induced hypertension, hypokalemia and metabolic alkalosis. Acquired AME can occur due to the ingestion of glycyrrhizic acid, found in licorice root, which inhibits 11βDSH-2 and has additional effects on cortisol homeostasis through inhibition of 11βDSH-1.

Case report: We present a case of acquired AME with a hyperadrenergic symptoms induced by ingestion of Advanced Liver Support, a nutritional supplement produced by Advanced BioNutritionals^(R), in a 65-year-old Caucasian female who presented with accelerated hypertension, hypokalemia, metabolic alkalosis and adrenergic symptoms. Cessation of the licorice-containing supplement resulted in complete resolution of the patient's hypertension, symptoms and abnormal lab values. To our knowledge this is the first reported case of AME from this supplement, and the first to describe accompanying hyperadrenergic symptoms.

Conclusions: Glycyrrhizic acid is increasingly being found in unregulated nutritional supplements and has the potential to induce a reversable syndrome of AME. Acquired AME should be suspected in individuals who present with hypertension along with hypokalemia, metabolic alkalosis and low plasma renin and serum aldosterone levels.

Background: Both dengue and Leptospira infections are endemic to tropical and subtropical regions, with their prevalence increasing in recent decades. Coinfection with these pathogens presents significant diagnostic challenges for clinicians due to overlapping clinical manifestations and laboratory findings. This case report aims to elucidate two clinical scenarios where the coinfection of dengue and leptospirosis complicates the disease course, creating a diagnostic conundrum.

Case presentation: We present the clinical scenarios of two Bangladeshi males, aged 25 and 35 years, who were admitted to our hospital with acute febrile illness. The first patient exhibited hepatic and renal involvement, while the second presented with symptoms initially suggestive of meningoencephalitis. Both cases were initially managed under the presumption of dengue infection based on positive serology. However, further evaluation revealed coinfection with Leptospira, complicating the disease course. Both patients received appropriate treatment for dengue and antibacterial therapy for leptospirosis, ultimately resulting in their recovery.

Conclusion: These case scenarios underscore the critical importance for clinicians in regions where dengue and Leptospira are endemic to consider both diseases when evaluating patients presenting with acute febrile illness.

Background: Heterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointestinal bleeding, and even peritonitis, leading to death.

Case presentation: This case report focuses on a 12-year-old Middle Eastern boy who presented with hematochezia and abdominal pain for a couple of days. A tagged Red blood cell (RBC) scan and Technetium scan revealed gastrointestinal bleeding at the lower abdomen, highly suggestive of the diagnosis of Meckel's diverticulum. Subsequently, exploratory laparotomy revealed contiguous and scattered mucosal lesions with multiple polyps of various sizes in the terminal ileum. Meckel's diverticulum was absent, and the patient was treated with resection and primary anastomosis. The resected tissue revealed extensive ectopic gastric mucosa and polypoid tissues. The patient recovered uneventfully and was discharged four days after the surgery. The symptoms did not recur within six months after his surgery.

Conclusion: Our case demonstrated that despite the rarity of multiple polypoid gastric heterotopias in the terminal ileum, it should be considered as one of the differential diagnoses of gastrointestinal tract bleeding.

Background: Abducens nerve palsy is the most common isolated ocular cranial nerve palsy. In adults, nontraumatic etiologies of isolated sixth cranial nerve palsy can include vascular disease, inflammation, tumors, and a prior history of infection.

Case presentation: We present a case of a 52-year-old Asian male who developed acute abducens nerve palsy after vaccination with the AstraZeneca coronavirus disease 2019 vaccine. A complete workup including magnetic resonance imaging of the brain and orbits revealed no abnormalities. The patient experienced a gradual recovery over 10 weeks through alternative eye patching. The abducens nerve palsy is postulated to be correlated with the coronavirus disease 2019 vaccine.

Conclusion: Despite the recognized efficacy and cost benefits of coronavirus disease 2019 vaccines, clinicians should be aware of the possible association between cranial nerve palsies and coronavirus disease 2019 vaccines.

Background: Invasive Aspergillosis is a fungal infection caused by Aspergillus species, typically posing life-threatening risks to immunocompromised individuals. While occurrences in immunocompetent hosts are rare, a recent case report documented fulminant pulmonary aspergillosis in an immunocompetent patient during autopsy. Here, we present a case of invasive aspergillosis in an immunocompetent woman, manifesting with disseminated lesions.

Case presentation: A 29-year-old Asian woman presented to our hospital in March 2022, reporting chest pain and shortness of breath persisting for two months. Upon examination, she appeared thin and unwell, with no notable abnormalities otherwise. Radiographic imaging revealed an ill-defined lesion in her left lung. Subsequent bronchoscopy and lavage were performed, followed by initiation of empirical antibiotic therapy. Lavage results were negative for gram staining, culture, and ZN staining for AFB, but revealed numerous septate hyphae on fungal smear. Histopathological examination indicated chronic granulomatous inflammation with septal fungal hyphae, indicative of aspergillosis. Subsequent culture confirmed Aspergillus species, prompting initiation of voriconazole therapy. Remarkably, the patient exhibited significant improvement, with weight gain and restored appetite observed within a short period. Within 2 months of treatment, her symptoms resolved, and she resumed near-normal daily activities.

Conclusion: This case highlights the diagnosis of aspergillosis in an immunocompetent individual presenting with disseminated nodular lesions across the lungs, mediastinum, and abdomen. Clinicians should maintain a high index of suspicion for aspergillosis in cases of non-resolving pneumonia and disseminated nodular lesions, even in patients lacking traditional predisposing factors.

Introduction: Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have described anesthesia methods.

Case presentation: We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed.

Conclusion: Cesarean section was safely performed for a pregnant woman with renal and heart failure using combined spinal and epidural anesthesia.

Introduction: Morbidly obese patients occasionally have respiratory problems owing to hypoventilation. Airway pressure release ventilation is one of the ventilation settings often used for respiratory management of acute respiratory distress syndrome. However, previous reports indicating that airway pressure release ventilation may become a therapeutic measure as ventilator management in morbid obesity with respiratory failure is limited. We report a case of markedly improved oxygenation in a morbidly obese patient after airway pressure release ventilation application.

Case report: A 50s-year-old Asian man (body mass index 41 kg/m²) presented with breathing difficulties. The patient had respiratory failure with a PaO₂/F_IO₂ ratio of approximately 100 and severe atelectasis in the left lung, and ventilator management was initiated. Although the patient was managed on a conventional ventilate mode, oxygenation did not improve. On day 11, we changed the ventilation setting to airway pressure release ventilation, which showed marked improvement in oxygenation with a PaO₂/F_IO₂ ratio of approximately 300. We could reduce sedative medication and apply respiratory rehabilitation. The patient was weaned from the ventilator on day 29 and transferred to another hospital for further rehabilitation on day 31.

Conclusion: Airway pressure release ventilation ventilator management in morbidly obese patients may contribute to improving oxygenation and become one of the direct therapeutic measures in the early stage of critical care.

Background: Crossed fused renal ectopia (CFRE) is a common congenital anomaly where one kidney is positioned abnormally on the opposite side of the midline, often fused with the other kidney. However, single ureter draining crossed fused renal ectopia is a rare occurrence.

Case report: Here, we report a case of crossed fused renal ectopia with a single ureter in a 46-year-old Nepali male who presented with history of lithuria. Computed tomography revealed that the left kidney was situated on the right side and fused with the right kidney. The renal pelvises of both kidneys were fused, and a single ureter, located on the right side, was draining both kidneys into the bladder. The patient was advised to have regular follow-ups.

Conclusion: Crossed fused renal ectopia with a single ureter represents a rare renal anomaly. Asymptomatic patients can typically be managed conservatively. Regular follow-up is recommended to monitor renal function, calculus formation, infections, and malignant changes.