World Journal of Clinical Cases最新文献

Background: Collision tumors of the thyroid are rare entities, defined by the coexistence of two histologically distinct tumors within the same organ, separated by intervening normal tissue. Graves' disease (GD) is a well-known risk factor for papillary thyroid cancer but has not been associated with thyroid collision tumor or medullary thyroid cancer (MTC).

Case summary: A 37-year-old female presented with palpitations, weight loss, and tremors. Thyroid function tests showed suppressed thyrotropin and slightly elevated free thyroxine. A thyroid ultrasound was performed with a report of a nodule in the right thyroid lobe. Thyroid scintigraphy revealed a goiter with increased radiotracer uptake. Ultrasound-guided fine needle biopsy suggested an MTC, Bethesda VI. Immunohistochemistry was positive for synaptophysin and negative for thyroglobulin. Calcitonin levels were elevated. Total thyroidectomy with central lymph node dissection was performed. Pathological exam revealed a medullary carcinoma in the right thyroid lobe and a 3-mm papillary microcarcinoma in the left lobe. Lymph nodes showed reactive hyperplasia without evidence of tumor involvement. The final diagnosis was synchronous medullary thyroid carcinoma and papillary thyroid microcarcinoma, staged as T1N0M0. Sequencing of the rearranged during transfection (RET) oncogene revealed no pathogenic variants, and multiple endocrine neoplasia was ruled out.

Conclusion: Collision tumors are rare entities but thyroid collision tumors in GD are even more infrequent despite the known association between GD and differentiated thyroid cancer. The mechanisms by which this clinical entity occurs are unclear. Because it is a rare pathology, there are currently no guidelines for its treatment. Treatment must be guided separately or based on the more aggressive neoplasm.

Background: Buried or submucosally embedded double-J (DJ) stents present a rare but technically demanding challenge in endourology, particularly in patients with malignant ureteral obstruction and prior instrumentation. We describe the case of a 72-year-old woman with metastatic bladder cancer who presented with urosepsis and right hydronephrosis. During attempted bilateral stent exchange, the left ureteral orifice and distal stent curl were completely obscured by fibrotic tissue. A combined antegrade-retrograde approach was employed: A guidewire was advanced from the nephrostomy under fluoroscopy, while controlled transurethral resection of the obstructed ureteral orifice permitted exposure and retrieval of the buried stent. A new stent was subsequently placed without complications. This hybrid technique offers an effective solution in cases where traditional retrograde stent retrieval is impossible.

Case summary: A 72-year-old woman presented to the emergency department with a 2-day history of fever, nausea, and worsening malaise. She described progressive left flank discomfort and suprapubic pressure. Her medical history included muscle-invasive bladder carcinoma with metastatic spread to the vertebral column, pelvic bones, and sacrum. She was receiving immunotherapy and had undergone multiple prior chemotherapy cycles. Bilateral ureteral DJ stents had been placed several months earlier due to malignant ureteral obstruction, and a left nephrostomy tube had subsequently been inserted following a prior obstructive episode. On examination, she was febrile and clinically unwell, with left costovertebral angle tenderness. Laboratory tests revealed elevated inflammatory markers and leukocytosis. Computed tomography (CT) imaging demonstrated right-sided hydronephrosis despite the presence of a DJ stent, with the left kidney adequately decompressed through the nephrostomy tube. Urine and blood cultures were obtained, and intravenous antibiotics and hydration were initiated. Despite 48 hours of conservative treatment, the patient showed no clinical improvement. Given the persistent hydronephrosis and the need for source control, the decision was made to perform bilateral stent exchange.

Conclusion: On examination, she was febrile and clinically unwell, with left costovertebral angle tenderness. Laboratory tests revealed elevated inflammatory markers and leukocytosis. CT imaging demonstrated right-sided hydronephrosis despite the presence of a DJ stent, with the left kidney adequately decompressed through the nephrostomy tube. Urine and blood cultures were obtained, and intravenous antibiotics and hydration were initiated. Despite 48 hours of conservative treatment, the patient showed no clinical improvement. Given the persistent hydronephrosis and the need for source control, the decision was made to perform bilateral stent exchange.

Background: Melioidosis, caused by Burkholderia pseudomallei (B. pseudomallei), is endemic to Southeast Asia and northern Australia, with clinical manifestations ranging from localized infection to life-threatening disseminated disease. Mycotic aneurysm is a rare but serious complication of disseminated melioidosis, associated with high morbidity and mortality.

Case summary: We describe a case of a 67-year-old man with diabetes mellitus who presented with B. pseudomallei bacteremia complicated by multiple deep-seated abscesses and multifocal mycotic aneurysms of the descending thoracic aorta. Despite appropriate antimicrobial therapy, serial imaging demonstrated progressive aneurysmal enlargement. Surgical repair was recommended but declined by the patient. He was managed conservatively with prolonged antimicrobial therapy and close clinical and radiological monitoring.

Conclusion: This case illustrates the aggressive nature of disseminated melioidosis with vascular involvement and highlights the need for early diagnosis and multidisciplinary management to improve outcomes.

Background: Multidrug-resistant organisms (MDROs) pose a major threat to hospital care, with antimicrobial resistance contributing to an estimated 4.95 million deaths globally in 2019 (including 1.27 million directly attributable deaths). India carries a particularly high burden.

Aim: To evaluate clinical outcomes associated with MDRO isolation in a tertiary-care center and identifies actionable signals to strengthen infection prevention and targeted antimicrobial stewardship.

Methods: We conducted a cross-sectional analysis of culture-confirmed MDRO infections treated as pathogens at All India Institute of Medical Sciences Rishikesh from May 2021 to November 2024 using E-Hospital records. Incomplete datasets were excluded. Associations between isolation practices and clinical outcomes-including mortality, length of stay (LOS), and intensive care unit (ICU) utilization-were assessed using χ ² tests and Mann-Whitney U tests (P < 0.05).

Results: A total of 1598 MDRO infected patients were included (mean age 42.8 years; 58.5% male). Overall mortality was 20.8%. ICU care was required in 439 patients (27.5%), and 29.2% had at least one comorbidity. Among ICU patients, 143 (32.6%) were isolated and 296 (67.4%) were not. Mortality did not differ significantly between isolated (46%) and non-isolated (54%) groups (χ² = 2.4; P = 0.12). However, isolated ICU patients had significantly longer ICU LOS (20.5 ± 18.4 days vs 16.4 ± 14.4 days; U = 244157.5; P < 0.001) and hospital LOS (33.7 ± 22.8 days vs 26.9 ± 21.8 days; U = 238460.5; P < 0.001). Most MDRO cases originated from internal medicine (16.3%), general surgery (14.7%), and trauma surgery (13.8%). Duration of antibiotic therapy varied significantly across departments (F = 5.03; P < 0.001). Quarterly trends demonstrated significant fluctuations in MDRO prevalence, hospital LOS (χ² = 200; P < 0.001), and antibiotic utilization (χ² = 252; P < 0.001).

Conclusion: MDRO infections are associated with substantial mortality and prolonged ICU and hospital stays. Marked interdepartmental variability in antibiotic use highlights the need for strengthened infection-prevention practices and targeted antimicrobial stewardship, including de-escalation, intravenous-to-oral switching, and optimized treatment durations to reduce selection pressure. Limited culture availability during 2022 was a key constraint. The associations observed between isolation status and clinical outcomes further highlight the importance of reinforcing infection-control strategies and stewardship efforts in high-risk departments.

This letter to the editor highlights the importance of considering potential cumulative contributions among human leukocyte antigen (HLA) alleles in shaping the clinical manifestations of primary biliary cholangitis. Complementing the overview by Curto et al, which focused on non-HLA candidate genes, this paper emphasizes that specific haplotypes of HLA-DRB1, HLA-DQA1, and HLA-DQB1, as well as HLA-G*01:01:01:08/UTR-1, may modulate disease heterogeneity, predisposition to primary biliary cholangitis and autoimmune hepatitis overlap syndrome, disease progression, and poorer therapeutic response. A comprehensive understanding of these HLA polymorphisms and their interactive effects is essential for improving risk stratification and guiding personalized management of this complex autoimmune liver disease.

Background: Endoscopic vacuum therapy (EVT) has emerged as a secure and efficient organ-preserving option for gastrointestinal perforations, leaks, and fistulas, with high closure rates and low mortality.

Case summary: A 41-year-old woman with a history of Roux-en-Y gastric bypass and diaphragmatic repair with biological mesh developed a left-sided empyema due to a gastric pouch fistula complicated by pulmonary abscess and rib osteomyelitis. Multiple thoracic surgical interventions failed, leading to severe malnutrition and persistent pleural drainage. A complex gastro-pleuro-broncho-cutaneous fistula was diagnosed, and salvage EVT was performed using a staged approach, including percutaneous and transluminal EVT combined with bronchial endoscopic treatment. Complete fistula closure was achieved, with restoration of oral intake and significant weight gain at two-month follow-up.

Conclusion: This case highlights the successful use of a staged multimodal EVT strategy to achieve definitive closure of a complex gastro-pleuro-broncho-cutaneous fistula.

Background: Ectopic varices present diagnostic and management challenges when encountered unexpectedly in clinical practice. Given their potential for fatal outcomes, with mortality rates reaching 40%, it is essential to discuss their clinical manifestations as well as current management guidelines.

Case summary: We report the case of a 56-year-old male patient with a history of liver transplantation and segmentectomy for hepatocellular carcinoma with underlying liver cirrhosis and chronic hepatitis B virus infection. He had previously undergone gastrojejunostomy for a perforated duodenal ulcer. The patient presented to the emergency department with hematochezia that began two days prior to his visit, shortly after discharge following recovery from upper gastrointestinal bleeding caused by an anastomotic ulcer at the gastrojejunostomy site. Initial esophagogastroduodenoscopy showed a healing anastomotic ulcer without active bleeding but revealed several hyperemic spots suggesting angiodysplastic changes near the anastomosis. Argon plasma coagulation was performed for cauterization of these microvascular changes. During admission, recurrent bleeding occurred, and abdominal computed tomography revealed portal vein (PV) and superior mesenteric vein (SMV) thrombosis, as well as a varix in the third portion of the duodenum. The patient successfully achieved hemostasis through a combination of embolization and surgical PV-SMV bypass.

Conclusion: A systematic approach is essential for diagnosing and managing ectopic varices. Further, evidence-based studies are needed to improve outcomes.

Background: Cefepime is a fourth-generation cephalosporin antibiotic widely used to treat a variety of serious bacterial infections, including febrile neutropenia, pneumonia, complicated intra-abdominal infections, urinary tract infections, and skin infections. It possesses broad-spectrum action against both gram-positive and gram-negative bacteria, with favorable pharmacokinetics and clinical efficacy, making it a cornerstone in the management of infections, especially in the hospital setting, where resistant organisms are prevalent. Well-known adverse effects include local reactions, gastrointestinal symptoms, and neurologic complications. However, instances of liver injury are rare.

Case summary: We report the case of a 73-year-old male who presented to the emergency department (ED) with a 1-week history of productive cough, shortness of breath, and fatigue. Laboratory findings in the ED included leukocytosis, hyponatremia, and elevated procalcitonin. Computed tomography chest without contrast showed a new right-sided pleural effusion and worsening consolidative opacities in both lungs. He was admitted and started vancomycin and cefepime for infected bronchiectasis. Liver function tests subsequently worsened and improved with the discontinuation of cefepime. The patient ultimately died from acute hypoxic respiratory failure two weeks after hospitalization.

Conclusion: This case report highlights a rare adverse effect of a commonly used antimicrobial in the hospital setting for various bacterial infections. Prompt cessation of the medication is the primary treatment in cefepime-induced liver injury, and most cases resolve without complications.

Background: Hospital-acquired functional decline (HAFD) is a poor prognostic factor in older patients who have undergone cardiovascular surgery.

Aim: To develop a model to predict HAFD and to identify its associated factors.

Methods: This retrospective observational study included 144 patients who underwent cardiovascular surgery between May 2019 and December 2023. HAFD was defined as a change in the preoperative and pre-discharge short physical performance battery score. Seven machine learning models were constructed, and their performance was evaluated using the area under the receiver operating characteristic curve (AUC) values. The models were further interpreted using SHapley Additive exPlanations (SHAP) values.

Results: Among the 144 participants, 41 (28.5%) experienced HAFD. Of the 7 machine learning models, the extreme gradient boosting model (XGBoost) achieved the best performance, with an AUC of 0.87. SHAP analysis revealed that being female and having a slower preoperative walking speed markedly impacted HAFD occurrence.

Conclusion: We developed a high-accuracy model to predict HAFD in older patients who have undergone cardiovascular surgery and identified key associated factors, informing preoperative evaluations and interventions in clinical practice.

Background: Conjunctival melanoma is rare and prone to local recurrence, and optimal surveillance imaging of the ocular surface and periocular skin is not standardized. We report the use of ultra-high-frequency ultrasound (UHFUS) to map multiple clinically subtle recurrent nodules in a previously treated conjunctival melanoma (Co-M) patient undergoing immunotherapy. This case supports incorporating UHFUS into multidisciplinary follow-up, showing how it can non-invasively detect occult recurrence and guide staging and treatment planning.

Case summary: A middle-aged patient with a history of conservatively treated left Co-M was referred for suspected local recurrence, reporting a new palpable subcutaneous lump near the lateral orbital rim and a pigmented lesion at the medial canthus of the same eye. Clinical examination confirmed a periocular nodule suggestive of relapse. Cervical lymph node ultrasound showed no suspicious lymphadenopathy. UHFUS (48 MHz) with Doppler of the periocular region revealed epidermal thickening at the medial canthus and three subepidermal nodules in the lower eyelid and lateral canthus, with irregular morphology and increased vascularity, highly suggestive of recurrent melanoma and satellite lesions. The patient was already receiving first-line anti-programmed cell death 1 immunotherapy; high-frequency ultrasound findings refined local staging, confirmed absence of nodal involvement, and supported multidisciplinary planning and imaging-based follow-up.

Conclusion: UHFUS can non-invasively detect and map recurrent Co-M, improving local staging and guiding multidisciplinary follow-up.