AME Case Reports最新文献

Background: Paracetamol (PCM), widely used for its analgesic and antipyretic properties, is generally considered safe at recommended doses. However, its metabolism can be significantly altered in chronic alcohol users due to enzyme induction and glutathione (GSH) depletion. While some clinicians maintain that "therapeutic" doses remain harmless in alcoholics, others argue there is no safe threshold. This case report bridges these opposing views by highlighting an atypical presentation of PCM-induced toxicity in a chronic alcoholic. It adds to existing literature by illustrating how severe lactic acidosis may overshadow more typical hepatic symptoms, thereby delaying diagnosis and treatment.

Case description: A 53-year-old male with a 20-year history of alcohol use presented to the emergency department (ED) with sudden-onset dyspnea and profound metabolic acidosis. Initially misdiagnosed as mesenteric ischemia, subsequent investigations revealed strikingly elevated aminotransferases, coagulopathy, and a PCM level above the normal therapeutic range-despite the patient's claim of following standard dosing. Intravenous N-acetylcysteine (NAC) was started, but the patient deteriorated rapidly and succumbed on day 2. Autopsy or long-term follow-up data were unavailable due to the acute course and lack of liver transplantation options. Although previous guidelines have debated whether PCM dosing must be reduced in chronic alcoholics, this case underscores the potential dangers, even within seemingly acceptable intake levels.

Conclusions: Clinicians must maintain a high index of suspicion for PCM toxicity in chronic alcoholics, recognising that atypical presentations-such as isolated lactic acidosis and respiratory distress-can conceal the true aetiology. This case reinforces the need for routine PCM-level checks in unexplained acute liver failure, prompt NAC administration, and a balanced perspective regarding "therapeutic" dosing in alcoholics. The findings underscore the call for more nuanced guidelines and further research to determine appropriate dose thresholds and monitoring strategies for alcohol-dependent individuals. By harmonising these divergent clinical stances, patient safety can be enhanced through tailored, vigilant practice.

Background: Cerebral ptosis is a rare and often under-recognized condition characterized by eyelid drooping due to central nervous system dysfunction, rather than peripheral neuromuscular damage. While typically associated with strokes, tumors, or brainstem lesions, its presence in traumatic brain injury (TBI) remains poorly documented. The clinical implications of cerebral ptosis in neurorehabilitation are underexplored, especially regarding its potential role as a marker of neurological recovery. In particular, transitions in ptosis patterns-such as from bilateral to unilateral-may reflect underlying neural reorganization. This case report aims to highlight the prognostic and rehabilitative relevance of cerebral ptosis in a patient with severe TBI.

Case description: We present the case of a 46-year-old man admitted to a neurorehabilitation unit after sustaining a severe TBI with left-sided epidural hematoma and bilateral mydriasis. Following emergency neurosurgery and prolonged coma, the patient exhibited bilateral cerebral ptosis, minimal responsiveness, and severe cortical dysfunction. Imaging revealed bilateral structural damage including the left temporal and occipito-parietal lobes and the right cerebral peduncle. Over the course of neurorehabilitation, clinical and electrophysiological evaluations documented progressive neurological recovery, coinciding with a shift from bilateral to unilateral ptosis, restoration of right eyelid control, emergence of blink commands, and transition from vegetative state to minimally conscious state.

Conclusions: This case suggests that cerebral ptosis-particularly its transition from bilateral to unilateral-can serve as a dynamic and clinically useful marker of neurological recovery in TBI patients. Careful monitoring of ptosis patterns, in conjunction with neuroimaging and functional assessments, may enhance early detection of consciousness recovery and guide individualized rehabilitation strategies.

Background: Transverse testicular ectopia (TTE) is a rare congenital abnormality, with only approximately 35% of TTE cases being correctly diagnosed preoperatively. TTE is generally not considered a genetic or inherited disease, although it may occur in genetically related individuals. Here, we report two siblings who had a preoperative misdiagnosis of TTE and share our experience with their diagnosis and treatment to enhance the clinical literature on the appropriate management of TTE cases.

Case description: In June 2021, a 1-year-old boy received preoperative diagnoses of right cryptorchidism and left inguinal hernia; however, laparoscopy then corrected the diagnosis and confirmed it as right TTE with persistent Müllerian duct syndrome. Two years later, in August 2023, his younger brother was brought to the hospital and preoperatively diagnosed with right cryptorchidism and left inguinal hernia. Again, the laparoscopic procedure confirmed the diagnosis of right TTE. Both patients underwent transseptal orchidopexy (Ombredanne operation) to fix the testes inside the left and right scrotum. The patients were followed up at the clinic with no issues reported.

Conclusions: Ultrasound is the first diagnostic modality for suspected testicular abnormalities, but TTE can have a preoperative misdiagnosis rate up to 35%. Laparoscopy is recommended for the diagnosis of TTE. Children with a preoperative diagnosis of cryptorchidism should be carefully evaluated to rule out TTE, especially in those with an inguinal mass on the opposite side and those with siblings with TTE. Preoperative planning in children diagnosed with cryptorchidism should also consider the possibility of TTE. Once TTE is confirmed, transseptal orchidopexy (Ombredanne operation) can be performed.

Background: Orbital fractures in children are uncommon. The existing literature shows a wide range of estimates for incidence, etiology, management protocols, and outcomes. Nevertheless, it is widely accepted that orbital wall fractures with extraocular muscle entrapment is a surgical emergency due to the risk of permanent diplopia caused by ischemia and necrosis of the muscle. Pediatric orbital floor injuries have distinct mechanistic features and fracture patterns when compared to adults. As a result, the prevalence, typical presenting signs and symptoms, and management considerations for pediatric orbital floor fractures differ from those for adults.

Case description: We report the case of a 7-year-old boy with a right orbital floor fracture presenting with restricted upward gaze and binocular diplopia. A computed tomography (CT) scan revealed a linear fracture with herniation of orbital contents into the maxillary sinus. Surgical management was performed via a transconjunctival approach assisted by endoscopic lighting, allowing accurate identification and repositioning of the fractured segment. Postoperative recovery was uneventful, with complete resolution of diplopia and restoration of ocular motility.

Conclusions: Endoscopic-assisted repair of linear orbital floor blowout fractures through a transconjunctival approach seems to be a safe and effective method for treating orbital blowout fractures in children. If the bone is not comminuted, the pediatric orbital floor fracture can be repositioned with careful dissection and preservation of the periosteum.

Background: Rectus sternalis (RS) is a rare normal variant of the anterior chest wall musculature; in humans, it is occasionally found while it is part of some animals' musculature. It was first reported in 1604, but it did not catch much attention and was only formally described in 1726. Many names have been used to refer to it, such as RS or musculus sternalis. It is mostly observed in Asians, and in Saudi Arabia, the prevalence was found to be 4%. It can be confused with tumors of the anterior chest wall during routine mammography. Also, it can affect the radiation field after surgery and can be utilized in reconstructive surgery. So, we believe that it is important for oncology surgeons, radiologists, radiation oncologists and reconstructive surgeons to have the knowledge of this rare anatomical variation.

Case description: We report two cases of RS muscle discovered in Saudi Arabian females during modified radical mastectomy for breast cancer, paying special attention to its correct identification, its clinical importance, and its impact on treatment of breast cancer. The first case is a 47-year-old female with bilateral RS who underwent mastectomy for inflammatory breast cancer, while the second is a 50-year-old female with a unilateral muscle who underwent mastectomy for invasive ductal carcinoma.

Conclusions: Surgeons should be knowledgeable of such variation as the muscle can be a differential diagnosis, may affect the management of breast cancer, and can be used in reconstructive surgery.

Background: The gemcitabine plus S-1 (GS) regimen is a first-line chemotherapy for unresectable locally advanced or metastatic pancreatic cancer (PC), a disease associated with high mortality. However, severe adverse events associated with the standard GS (gemcitabine plus daily S-1) regimen adversely affect treatment adherence and clinical outcomes. Recent studies suggest that modified GS regimens may improve tolerability without compromising efficacy in select populations. Here, we report a case demonstrating that an adjusted GS (gemcitabine plus alternate-day S-1) regimen could represent a viable alternative first-line chemotherapy for patients with standard GS protocol intolerance.

Case description: In January 2020, a 61-year-old female with upper abdominal pain was diagnosed with unresectable locally advanced pancreatic ductal adenocarcinoma (PDAC) confirmed by biopsy (T3N0M1). She received one cycle of standard GS chemotherapy but developed severe toxicity (grade 3 neutropenia and stomatitis). Given the intolerance, the patient was transferred into an adjusted GS regimen (gemcitabine 1,000 mg/m² on days 1, 8; S-1 80 mg/m² on alternate days) in March 2020. The patient tolerated this adjusted GS regimen well, achieving partial remission with reduced carbohydrate antigen 19-9 (CA19-9; from >1,000 to 85.3 U/mL) and decreased tumor size (59 mm × 20 mm to 25 mm × 18 mm) within 14 months. She completed 12 cycles of adjusted GS regimen, followed by S-1 monotherapy. At 58-month follow-up, she remained alive with controlled disease (stable tumor size) and preserved quality of life.

Conclusions: This case highlights the potential of an adjusted GS regimen to achieve prolonged disease control and manageable toxicity in patients with standard GS intolerance. This modified approach may serve as a potential alternative to the standard GS regimen for select patients who experience intolerance to conventional therapy. A future multicenter randomized controlled study will investigate the efficacy and safety of this adjusted GS treatment strategy.

Background: Hepatic pleural effusion is a common complication in patients with cirrhosis. The diagnosis of hepatic pleural effusion is limited by many factors. There are advantages and disadvantages to using radioisotope examination, contrast-enhanced ultrasound and video-assisted thoracoscopy surgery in detecting diaphragmatic defects. We reported that methylene blue injection was injected into the peritoneal cavity, and pleural effusion was turned pale blue with methylene blue. We inferred diaphragmatic rupture in patients with hepatic pleural effusion. Methylene blue injection staining is a supplementary method for the diagnosis of diaphragmatic rupture in patients with hepatic pleural effusion.

Case description: The patient is an 83-year-old patient who was admitted to hospital with respiratory failure. The ultrasound showed a large right pleural effusion and ascites. A computed tomography scan showed no lung infection. The patient has cirrhosis for 20 years. We performed endotracheal intubation and mechanical ventilation. A drainage tube was placed in the patient's right pleural cavity. We injected 2 mL of methylene blue into the patient's peritoneal cavity. After 2 hours, the right pleural cavity drainage appears light blue. Based on this, we assume the patient's diaphragm ruptured. The patient was diagnosed with hepatic pleural effusion. We did a comprehensive treatment for the pleural effusion. Repeated increase of pleural effusion. The patient died 62 days after admission.

Conclusions: Methylene blue injection staining is a supplementary method for the diagnosis of diaphragmatic rupture in patients with hepatic pleural effusion. It is suitable for areas lacking detection methods.

Background: The incidence of incorrect nasogastric tube (NGT) insertion into the trachea or distal airways is approximately 2%. When an NGT penetrates the visceral pleura and enteral feeding products are inadvertently administered into the lungs or thoracic cavity, severe chemical pneumonia and empyema can develop. Thus, confirming the NGT placement site before initiating feeding is crucial. Chest radiography (CXR) remains the gold standard for confirming NGT placement. However, enteral feeding products are often administered without prior CXR, leading to complications. This report describes two cases of iatrogenic empyema caused by incorrect placement of NGT in the thoracic cavity.

Case description: Case 1 was a 70-year-old man with a history of cerebral hemorrhage sequelae who was receiving NGT feeding. Routine NGT replacement was performed without CXR. Dyspnea developed following the administration of an enteral feeding product. Emergency CXR revealed incorrect NGT placement in the right thoracic cavity. The patient's circulation was stable, and he was managed with chest drainage. Case 2 involved a 95-year-old woman who was debilitated due to advanced age and was receiving NGT feeding. Routine NGT replacement was performed without CXR. Subsequently, she developed dyspnea and hypotension after the administration of an enteral feeding product. Emergency CXR and computed tomography revealed NGT placement in the right thoracic cavity, accompanied by a right pneumothorax and pleural effusion. As the patient was in shock, emergency surgery was performed following chest drainage. Both patients recovered successfully.

Conclusions: Iatrogenic empyema induced by NGT feeding is a severe complication often resulting in respiratory failure. Prompt management with chest drainage is critical, and emergency surgery should be considered in cases of circulatory failure. To prevent such events, accurate evaluation of NGT placement via CXR before commencing feeding is imperative. Additionally, the indications for NGT insertion should be carefully assessed on a case-by-case basis.

Background: Harrington rod instrumentation used to treat idiopathic scoliosis wasn't able to correct the sagittal balance or the rotation of the vertebrae and can lead to secondary problems below the achieved fusion.

Case description: We present a patient who presented to the Department of Orthopaedics and Traumatology in Infant Jesus Clinical Hospital with worsening symptoms of back pain and numbness radiating to the left lower extremity and claudication. The patient was previously treated with Harrington rod for adolescent idiopathic scoliosis. X-rays showed progression in the spinal deformity with a thoracolumbar curvature of 54° Cobb's angle and significant vertebral rotation. She was diagnosed with type 2 adult scoliosis and qualified for surgery. She underwent a Th9-L4 posterior instrumented spinal fusion with correction and derotation; however, the first follow-up 3 months post-surgery revealed dislodgement of the instrumentation. Therefore, revision surgery had to be performed to replace the loose pedicle screws. At follow-up, the patient showed significant improvement with Cobb's angle decreased to 42°, decreased pain with no radiation and improved gait and movement.

Conclusions: The presented case report indicates that patients with fusion and secondary changes after unilateral instrumentation should receive surgery as soon as they meet the criteria, as it can greatly improve their symptoms and quality of life.

Background: Spontaneous bladder rupture (SBR) is a rare but life-threatening condition that typically occurs in the setting of bladder pathology, infection, or increased intravesical pressure. This case report aims to describe a rare presentation of spontaneous extraperitoneal bladder rupture in an elderly, immunocompromised, bedbound female-highlighting potential contributing factors such as Candida dubliniensis infection and chronic bladder dysfunction due to neurological impairment.

Case description: We present a case of an immunocompromised patient who developed SBR in the absence of prior urinary catheterization or overt bladder obstruction. Imaging revealed bladder wall rupture with bilateral hydronephrosis and free air loculus on the posterior of the bladder. Notably, the patient was found to have an occipital stroke, raising the possibility of an underlying neurogenic component contributing to chronic bladder dysfunction and subsequent rupture. Urine culture grew Candida dubliniensis, suggesting a potential role of fungal infection in bladder wall fragility, although definitive causation remains unclear. The patient's condition deteriorated despite multidisciplinary care, ultimately resulting in mortality.

Conclusions: This case underscores the diagnostic challenges of SBR in medically complex patients and highlights the importance of early imaging, particularly retrograde cystography, for prompt diagnosis. It also raises awareness of neurological impairment as a potential contributor to bladder dysfunction and rupture, necessitating vigilance in at-risk populations. Furthermore, the presence of Candida dubliniensis in a patient with SBR suggests a potential but unconfirmed role in bladder wall compromise. Clinicians should consider fungal infections and neurogenic bladder dysfunction in immunocompromised patients with unexplained bladder rupture, while recognizing the need for further research to determine causality.