Journal of Medical Cases最新文献

Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy or "broken heart syndrome", is characterized by acute transient regional left ventricular systolic dysfunction in the absence of obstructive coronary artery disease or acute plaque rupture. Atypical forms and rare anatomical variants can have different presentations; hence, recognition becomes more important. Prognosis is much more favorable if managed appropriately. An equally infrequent cause of cardiac arrest is commotio cordis (CC). This is defined as sudden cardiac death secondary to a blunt chest wall impact leading to ventricular arrhythmias. We report a case with findings of TCM and/or CC in a patient with a blunt chest trauma in the setting of motor vehicle accident.

Malignant hyperthermia (MH) is an acute hypermetabolic crisis, triggered in susceptible patients by the administration of succinylcholine or a volatile anesthetic agent. When providing anesthetic care for MH-susceptible patients, a total intravenous anesthetic technique with propofol or other sedative hypnotic is frequently chosen. Remimazolam is a novel benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5-10 min and a limited context sensitive half-life. We present anecdotal experience with its use as an adjunct to propofol anesthesia in a patient with a suspected family history of MH. Previous reports of the use of remimazolam in MH-susceptible patients are reviewed and its potential role in such patients discussed.

Pyomyositis is a clinical condition classically associated with tropical climates, but there are an increasing number of reports in temperate climates. We present a diabetic patient, who presented with gastrointestinal symptoms and right foot ulcer. He was found to have methicillin-resistant Staphylococcus aureus (MRSA). Initial computed tomography (CT) scan of abdomen and pelvis was negative for any abscesses, but after persistent bacteremia developed pyomyositis being on appropriate antibiotic therapy. This case may make physicians aware that initial negative test results do not always preclude the presence of pyomyositis in the presence of risk factors.

Primary rectal melanoma (PRM) is an uncommon malignancy whose etiology remains unknown. Most patients present with rectal bleeding. Distant metastasis is commonly seen in the lung and liver. The incidence rates for locoregional lymph node metastases on initial presentation are almost 60%. Histology and immunochemistry are useful and are the gold standard for diagnosis. The prognosis is very poor due to the late presentation of patients. Optimum surgical treatment remains controversial. Abdominoperineal resection was considered traditionally but over time, has been found to have no survival benefit. Current literature and studies, therefore, recommend wide local excision. The beneficial effects of chemotherapy versus radiotherapy use are still debatable. Herein, we discuss a case of a 72-year-old Caucasian male with rectal bleeding found to have metastasized PRM.

Open fractures that produce an extruded long bone diaphysis, such as this case, are an exceedingly rare incident, with even fewer cases documented, leading to difficult medical decision-making for the operative management of such situations. Options for operative management include replantation following sterilization of the extruded fragment, bone transport, a vascularized fibular graft, and even allograft reconstruction. Each option is associated with high and variable levels of risk. The authors report a case study of a 35-year-old female, status post motor vehicle collision (MVC), who sustained a fracture and expulsion of her humeral diaphysis during the incident. She presented to the emergency department by ambulance after colliding into a light post at 50 miles per hour. Upon presentation and examination, the patient scored 14 on the Glascow Coma Scale (GCS) with a positive Focused Assessment with Sonography in Trauma (FAST) exam, consistent with splenic and hepatic injuries. In addition to this, the patient exhibited a flaccid left upper extremity combined with an absent left radial pulse and a small puncture wound on the left anterolateral antecubital area. Radiographic imaging revealed a 6-inch fragment of mid to distal humeral diaphysis missing. Moments later the initial Emergency Medical Services (EMS) crew returned from the scene of the accident with the missing 6-inch fragment of humerus contained in an emesis bag, which was found on the floorboard of the patient's vehicle. This fragment was preserved at -20 °C for 2 days and later used as an autograft in an open reduction internal fixation surgery. This case highlights and details the techniques for proper storage, treatment, and sterilization of the bone fragment during the period of patient stabilization following trauma, to optimize the replantation and union of the fragment. This includes contrasting the different techniques that could be utilized to preserve and sterilize bony fragments, such as autoclaving, gamma radiation, chemical sterilization with iodine, or deciding whether the fragment needs to be discarded altogether with the utilization of allograft.

The rates of nontypeable Haemophilus influenzae (NTHi) invasive disease have been increasing since the introduction of the Haemophilus influenzae type b (Hib) vaccine, but its significance in adults is unclear. A 33-year-old man with human immunodeficiency virus (HIV) was admitted for fever and acute confusion. The day prior to admission he presented to another emergency department for nausea, vomiting and diarrhea where he was thought to have food poisoning and was sent home. Ten days prior to admission, his primary physician thought his nasopharyngitis symptoms were due to the common cold. The patient's HIV had been controlled on antiretroviral therapy for the past 3 years; 1 month prior to admission his viral load was undetectable. Laboratory evaluation on admission was significant for elevated lactic acid and CD4⁺ cell count of less than 200. A head computed tomography (CT) was unremarkable, but a lumbar puncture was consistent with bacterial meningitis. Neisseria meningitidis was suspected and the patient was placed on empiric antibiotics. Shortly after admission the patient was intubated and suffered a cardiac arrest. The patient was placed on vasopressor support after circulation returned; a repeat head CT showed increased swelling of his brain. An electroencephalogram (EEG) indicated complete suppression of activity and the patient expired on day 2 of hospitalization. After the patient's death, cerebrospinal fluid (CSF) cultures reported as positive for Haemophilus influenzae (H. influenzae) and sent to the state lab where it was further classified as NTHi, biotype I. NTHi strains can cause invasive disease in adults and should be considered as a potential pathogen for meningitis and bacteremia.

Dysphagia lusoria (DL) is a rare clinical entity caused by compression of the esophagus by an aberrant right subclavian artery. It is coined from the Latin word meaning freak or jest of nature, with an estimated prevalence of approximately 0.5%. Before the term DL was known, the artery abnormality was referred to as luxus nature. Most patients are asymptomatic. In 30-40% of cases, DL results in tracheoesophageal symptoms like dysphagia to solid foods, chest pain, cough, and Horner's syndrome. Symptoms presenting later in life have been linked to arteriosclerosis and diminishing esophageal compliance resulting in compression. Another reason why people become symptomatic is due to Kommerell's diverticulum, a disorder that was first described by Kommerell, a German radiologist in 1936. It is also known as lusoria diverticulum, remnant diverticulum or lusoria root. This disorder represents a remnant of the left dorsal arch which forms a vascular ring behind the esophagus, leading to external compression. The key to diagnosis of DL is a barium esophagogram which may show extrinsic compression. Computed tomography or magnetic resonance imaging can be used for definite delineation of the vascular anatomy. Treatment approach is dietary modification or surgical intervention for unresponsive cases. Here, we present cases of dysphagia in two middle-aged women caused by compression effect on the esophagus by an aberrant right subclavian artery who did not respond to dietary modification.

Serratia marcescens (S. marcescens) is a gram negative bacterium rarely associated with cases of infective endocarditis (IE). Involvement of three cardiac valves, as evidenced by echocardiography, is uncommon as well. S. marcescens IE and tri-valvular endocarditis have been rarely described in literature. We report a unique case of S. marcescens tri-valvular IE in a 42-year-old female with sudden altered mental status and no underlying structural heart disease complicated by embolic infarcts in both cerebral and cerebellar hemispheres, and a sub-arachnoid hemorrhage. To our knowledge, this is the first reported case of tri-valvular S. marcescens IE. We believe this report will add to the growing literature of rare bacterial IE and considering this in the differential in the right clinical scenario.

QT prolongation is present in 26-52% of cases of Takotsubo cardiomyopathy (TCM). It has been postulated to result from reduced cardiac repolarization reserve and reflects the transient myocardial insult observed in TCM. Bradycardia-induced QT interval prolongation is amplified by the occurrence of TCM, a combination that potentially carries a significant risk for torsade de pointes (TdP). We present a unique case of an 80-year-old female with TCM-related cardiac arrest. The patient had acquired long QT syndrome in which TCM myocardial insult led to the precipitation of a third-degree atrioventricular (AV) block and subsequent bradycardia-induced TdP. Due to the lack of robust literature, there is no clear guideline in the management of third-degree AV block in the setting of TCM. In our case, because of recurrent ventricular tachycardia (VT) and ventricular fibrillation (VF) arrest, we opted for temporary pacing at a high ventricular rate, followed by a biventricular implantable cardioverter-defibrillator (BiV/ICD). Follow-up 3 months later revealed improvement of left ventricular (LV) dysfunction and resolution of QT prolongation. However, the noticed AV conduction defects persisted. In the available literature, we identified five reported cases that bear similarity with our patient's presentation. The identified cases were middle-aged to elderly females with no significant cardiac history, who exhibited a similar triad of TCM associated with high-grade AV block, acquired long QT syndrome, and a rapid progression of bradycardia-induced TdP, resulting in a near cardiac arrest within the first 24 - 48 h of admission. It is crucial to monitor corrected QT (QTc), correct electrolyte abnormalities, and minimize QT-prolonging medications in patients with TCM. The recognition of AV conduction defects in patients with TCM is critical, especially if it is associated with significant QT prolongation. Such situations are underrecognized, and are potentially fatal, necessitating close monitoring and timely intervention.

Fitz-Hughs-Curtis syndrome is a manifestation of pelvic inflammatory disease (PID) which begins with sexually transmitted organisms such as Chlamydia trachomatis (C. trachomatis) and, less commonly Neisseria gonorrhoeae. The infection is hypothesized to disseminate into the peritoneum via lymphatic, hematogenous, or ascending spread of the organisms. Progression of the disease can result in liver capsule inflammation (perihepatitis) and adhesion formation between organs. This case presentation illustrates a female who presented with symptomology consistent with small bowel obstruction (SBO) and acute appendicitis. The patient was incidentally found to have Fitz-Hugh-Curtis syndrome during laparoscopic surgery, as noted by adhesions on peritoneal organs. These findings prompted a sexually transmitted infection (STI) screening which confirmed a C. trachomatis infection, completing the clinical picture for Fitz-Hugh-Curtis syndrome. This case report highlights the need for an increased index of suspicion for Fitz-Hugh-Curtis syndrome in a young female who presents with right upper quadrant (RUQ) pain in order to prevent future complications of PID, including infertility.