American Journal of Case Reports最新文献

BACKGROUND Arterioportal fistulas (APFs) are abnormal connections between the arterial and portal venous systems, leading to portal hypertension (PH) and symptoms such as gastrointestinal bleeding, splenomegaly, and hepatic pain. Symptoms typically appear by the age of 2 years in about 75% of cases. CASE REPORT A 7-year-old boy with an asymptomatic APF developed life-threatening complications following a Clostridium difficile infection. He initially had chronic diarrhea, abdominal pain, weight loss, and anorexia for 3 weeks, despite normal liver enzymes. After antibiotic and antifungal treatment, his condition worsened, resulting in severe anemia and hemorrhagic shock due to variceal bleeding. Further evaluations revealed significant PH secondary to the APF. Intensive care involved blood transfusions, fluid resuscitation, and high-frequency ventilation. Emergency embolization successfully reduced PH and controlled bleeding. After stabilization, the patient was transferred for further care. A week later, a color Doppler ultrasound (CD-US) detected a thrombus in the left portal vein, which decreased by the 19-day follow-up. Spleen size reduction indicated decreased portal pressure. The presence and reduction of the thrombus and alleviation of PH symptoms indicate therapeutic success. Ten months after embolization, the patient remained asymptomatic, with normal liver function and no thrombus on follow-up imaging. CONCLUSIONS Early diagnosis and intervention are crucial in managing congenital APF in children. Severe variceal bleeding triggered by exacerbated PH due to a Clostridium difficile infection demonstrates the complications of APF. Endovascular treatment was highly effective, resulting in significant improvement. The recommended diagnostic approach includes initial computed tomography angiogram and CD-US, followed by digital subtraction angiography with possible intervention, and monitoring with CD-US.

BACKGROUND Open injury of multiple organs in the chest and abdomen, such as the colon, duodenum, kidney, liver and diaphragm, is relatively rare. The rescue of such a patient is difficult, and the results are often unsatisfactory. It is also a challenge for the hospital and doctors. CASE REPORT A 44-year-old man was injured by a heavy falling iron plate on a construction site. The right side of his abdomen was severely lacerated, with a 30-40-cm long wound and multiple exposed abdominal organs. He was send to our Emergency Department within 2 h, with gauze covering the wound. The relevant examinations were completed immediately, and emergency surgery was performed in a multidisciplinary manner. During surgery, we found that the hepatic flexure of colon, right kidney, and descending duodenum was ruptured, there was mild laceration to the liver, and the right diaphragm was ruptured, with hemopneumothorax. The right kidney, right half colon, gallbladder, duodenum, and part of the head of the pancreas were removed. Ileostomy was done, and gastric-intestine, biliary-intestine, and pancreas-intestine anastomosis were done. The liver and diaphragm were repaired. The patient was discharged after 23 days in hospital, without any serious complications. One year later, the ileostomy was closed in our hospital. CONCLUSIONS Multidisciplinary collaboration and adherence to evidence-based guidance are important for rescuing patients with severe chest and abdominal trauma.

BACKGROUND Recent studies have shown that peribiliary glands may be the potential cell origin of cholangiocarcinoma, and that precancerous lesions such as biliary intraepithelial neoplasms and intraductal papillary neoplasms of the bile duct may arise from these peribiliary glands. However, whether and how these precancerous lesions progress to cholangiocarcinoma is controversial. CASE REPORT Herein, an autopsy case of perihilar cholangiocarcinoma, exclusively periductal-infiltrating, is reported. Since repeated transpapillary biopsies and cytology showed no carcinoma cells, the patient was treated for sclerosing cholangitis until death. The findings at cholelithiasis treatment 1 year earlier had not aroused suspicion of the presence of precancerous lesions. The changes in the spread of bile duct stenoses on cholangiography and the unique findings at autopsy, namely (i) the distribution of cancer growing locally within the peribiliary gland compartment without invading the bile duct mucosa and (ii) the existence of in situ-like carcinoma cells replacing the epithelium of the peribiliary glands throughout the extrahepatic bile duct, suggested that cholangiocarcinoma arose from the peribiliary glands in the hilum without a detectable precancerous lesion and then spread to the lower end of the common bile duct via the peribiliary gland network. CONCLUSIONS This case report may help further our understanding of the natural history of cholangiocarcinoma and provide clues about cholangiocarcinogenesis and progression. In addition, histological and cytological diagnosis could be theoretically difficult by sampling tissue from the bile duct lumen in cholangiocarcinoma, as in this case.

BACKGROUND Malignant hyperthermia (MH) and anesthesia-induced rhabdomyolysis (AIR) are rare, yet life-threatening complications that need prompt therapeutic actions and logistic preparedness for treatment success. Both conditions are triggered by general anesthetics, particularly volatiles and depolarizing muscle relaxants. In comparison with MH, which is an inherited pharmacogenomic disease of calcium channel receptor subpopulation and arises only after trigger exposure, AIR has been described mostly in patients with muscular dystrophies. In perioperative settings, rhabdomyolysis is also observed during propofol infusion syndrome, neuroleptic malignant syndrome, and cocaine, heroin, and alcohol intoxication. Despite their diverse etiology, the main clinical manifestations of MH and AIR overlap: a hypermetabolic state, hyperpyrexia, hypercarbia, acute renal failure, and hyperkalemia progressing to cardiac arrest, making the therapeutic approach to the patient extremely difficult. CASE REPORT We present an unenviable and challenging clinical scenario of an obligatory general anesthesia with endotracheal intubation in a patient with difficult airways for breast conserving onco-surgery with simultaneous targeted intraoperative 20 Gy irradiation. The case was complicated even further by coincident suspicious clinical presentation of a mild and self-limited hypercarbia, together with a protracted rhabdomyolysis, without hyperpyrexia. Given the atypical and scarce clinical presentation leading to diagnosis uncertainty of MH or AIR, which was proved only after receiving the genetic results, dantrolene was not administered, and the patient underwent successful supportive treatment. CONCLUSIONS The study points to the diagnostic dilemma - crisis event MH or AIR - and raises issues about possible preoperative preventive measures and treatment options in patients with an uncertain diagnosis.

BACKGROUND Diabetes mellitus is a significant global health issue, affecting millions and costing billions annually in management. A major complication of diabetes is foot ulcers, which heal slowly due to nerve damage (neuropathy) and poor circulation. These ulcers have a high risk of infection and, if untreated, can lead to amputation. The rise of antibiotic-resistant bacteria further complicates treatment, making traditional methods like wound cleaning, dressings, and antibiotics less effective. Cold atmospheric plasma (CAP) therapy is a noninvasive, innovative treatment showing promise in addressing these wounds. CAP generates reactive oxygen and nitrogen species that stimulate cell growth, migration, and proliferation, which are critical for wound healing. It also kills bacteria, including antibiotic-resistant strains, preventing infection and promoting tissue regeneration. Additionally, CAP encourages release of growth factors and cytokines, helping tissue repair and reducing inflammation. Unlike traditional treatments, CAP targets harmful bacteria without harming healthy tissue, making it safer and more effective for treating non-healing wounds. This case highlights a 69-year-old man with a chronic diabetic foot ulcer, previously unresponsive to standard treatments, who experienced successful healing with CAP therapy. CASE REPORT A 69-year-old man with a chronic non-healing diabetic foot ulcer on the plantar surface of his left foot underwent multiple failed treatments over 60 weeks, including traditional wound care and advanced clinical trials, before being treated with CAP, leading to significant wound closure over the course of 15 weeks. CONCLUSIONS This report has highlighted the challenges of managing chronic diabetic foot ulcers and has shown that CAP can promote wound healing.

BACKGROUND Pacemaker implantation serves as a prevalent therapeutic approach for bradycardia or atrioventricular blocks associated with syncope. While generally regarded as safe, this procedure is not devoid of rare yet severe complications. Examples include lead-induced cardiac perforation resulting in pneumothorax or pericardial effusion, which pose life-threatening risks. CASE REPORT This article presents a case study detailing the experience of an 87-year-old patient diagnosed with complete atrioventricular block who underwent permanent pacemaker implantation, complicated by lead displacement and cardiac perforation. Despite the absence of typical post-implantation symptoms, such as backache, chest tightness, shortness of breath, and drops in blood pressure, the electrocardiogram (ECG) revealed a right bundle-branch block pattern. Additionally, bradycardia and occasional pacemaker capture failure were observed the day following pacemaker implantation. Subsequent X-ray and computer tomography examinations confirmed displacement of the ventricular lead and the presence of cardiac perforation and left pneumothorax. Following emergent thoracic drainage and repositioning of the right ventricular lead, the patient was discharged without further complications. CONCLUSIONS This case highlights the importance of thorough post-implantation monitoring, even in the absence of typical symptoms. Early detection through electrocardiogram, X-ray, and CT can facilitate timely intervention, as demonstrated by the successful treatment and discharge of the patient following emergent thoracic drainage and pacemaker lead repositioning.

BACKGROUND Streptococcus pneumoniae is an uncommon but serious cause of infective endocarditis (IE), particularly in immunocompromised individuals, such as those with untreated HIV. When pneumococcal IE occurs, it is associated with high morbidity and mortality due to the high prevenance of complications such as acute valvular destruction and septic embolization. Therefore, early recognition and prompt surgical intervention are paramount to improving outcomes. This case report highlights the complexity of diagnosing and managing pneumococcal IE in the context of concurrent infections and immunosuppression. CASE REPORT We present a rare case of a 37-year-old man with untreated HIV who presented with fever, confusion, and back pain. He had a history of pneumococcal sepsis and meningitis a year prior. This time, he was diagnosed with pneumococcal sepsis, meningitis, and mitral valve infective endocarditis with large vegetations, which triggered the prompt involvement of a multidisciplinary treatment team for further operative management in addition to the indicated antimicrobial therapy. The case was concluded with successful operative mitral valve replacement. CONCLUSIONS Pneumococcal infective endocarditis is an uncommon but potentially fatal complication of pneumococcal bacteremia. In patients with risk factors such as untreated HIV, a high degree of clinical suspicion is required to ensure early diagnosis. Timely surgical intervention, along with targeted antimicrobial therapy, are critical to improving outcomes in these patients. Multidisciplinary collaboration is essential to prevent further complications, making early operative management a key element in the successful treatment of pneumococcal IE. Improving vaccination efforts in vulnerable populations could reduce the incidence of such severe cases.

BACKGROUND Choroid plexus tumors (CPTs) are rare brain tumors that originate from the choroid plexus epithelium and range from low-grade papillomas to overtly malignant carcinomas, and can occur in newborns. According to the World Health Organization's histological classification, atypical choroid plexus papilloma (aCPP) is an intermediate-grade (Grade II) lesion characterized by an increased mitotic rate. It is difficult to distinguish CPTs on imaging during the early stages. The present article aims to increase awareness and vigilance regarding CPTs. CASE REPORT A newborn girl was admitted to the hospital on the day of her birth with suspected intracranial hemorrhage, after visualization of a hyperechoic lesion in the right lateral ventricle the day before delivery. During hospitalization, her neurological examinations revealed no abnormalities. Cranial ultrasound showed that the right choroid plexus was thicker, with stronger echo and more Doppler flow than the left side. MRI revealed an isointense mass located in the right ventricular trigone. She was treated conservatively for suspected intraventricular hemorrhage, and 3 months later, her head circumference increased. A follow-up MRI showed that the lesion had greatly enlarged. Consequently, surgery was performed, and the histopathologic finding showed it was aCPP. CONCLUSIONS CPTs are rare tumors that do not have specific clinical patterns or imaging findings, and they can easily be misdiagnosed as intraventricular hemorrhage. The thickening of the choroid plexus, which presents with a highly echogenic appearance and enhanced blood flow signals, might be an ultrasound feature indicative of CPTs.

BACKGROUND Appropriate recommendations for the management of systemic lupus erythematosus (SLE) should be carefully followed. A significant adverse effect can develop unexpectedly, and off-label drug use may control this adverse effect and other lupus manifestations. The current research in lupus relies solely on multiple composite outcome measures, which vary from one study to another. However, the optimal drug for a particular lupus symptom is presently unclear, requiring additional research for definitive clarification. CASE REPORT Here, we report a typical case of SLE in a 54-year-old Saudi female patient who presented with mucocutaneous symptoms and arthritis. She had a positive serology for antinuclear antibodies and anti-double-stranded DNA. Owing to the failure of conventional drugs, the use of belimumab resulted in significant improvements. She later developed worsening symptoms that progressed from alopecia areata (AA) to alopecia totalis (AT) and alopecia universalis (AU). She partially responded to systemic and local steroid injections. All measures to taper her steroid failed despite the use of azathioprine, methotrexate, and mycophenolate. Belimumab was stopped due to lack of efficacy. She was re-challenged with belimumab after she showed partial response to steroid therapy, but this clearly resulted in worsening of her hair loss to AT. The use of baricitinib following the second discontinuation of belimumab resulted in a significant improvement in AT and arthritis. CONCLUSIONS Our case offers valuable perspectives for future SLE research by concentrating on specific outcomes instead of composite outcome measures. The effectiveness of baricitinib should be investigated further in SLE.

BACKGROUND We present a rare case of an ectopic thyroid nodule hyperplasia, confirmed postoperatively after excision and histopathological examination of a chronic cervical mass. We discuss the different clinical and therapeutic features of this rare thyroid dysgenesis caused by a defect of migration of the gland along its normal way of descent. CASE REPORT A 48-year-old man with a history of hypertension and asthma presented with dysphagia and a progressively growing firm mass at the anterior part of his neck over the past 6 months. Ultrasound and computed tomography suggested that the mass was attached only to the anterior part of the larynx, without connection to the thyroid, and with a multinodular gland in normal position. A complete surgical excision was performed under general anaesthesia through an external cervical approach. The mass, measuring 60×40 mm, was sent for a histological assessment, which concluded a fully encapsulated ectopic thyroid mass attached only to the soft tissues of the anterior part of the larynx, not showing any sign of malignancy transformation. The outcome of the surgery was marked by a quick recovery, with an improvement of the initial symptoms, proper healing of the surgical scar, and durable normal thyroid functioning after a regular follow-up of 6 months. CONCLUSIONS Nonspecific symptoms can reveal ectopic thyroid tissue growth. Appropriate neck imaging combined, when available, with fine needle aspiration help to determine the extent of the mass and predict its nature. Surgical excision and histological analysis are required to confirm the diagnosis and to exclude any thyroid neoplasm.