American Journal of Case Reports最新文献

BACKGROUND Giant coronary artery aneurysms (CAA) are extremely rare and can mimic cardiac tumors. Therefore, an unidentified mass in the heart requires a multimodality imaging approach for accurate diagnosis and guidance of further management, which for CAAs often include surgical intervention to prevent complications such as thrombosis or rupture. CASE REPORT A 37-year-old man presented with non-specific symptoms. A CT scan revealed multiple bilateral pulmonary embolisms and an indeterminate mass in the right atrium. Transthoracic echocardiography (TTE) showed a suspected cardiac tumor, and further imaging with transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and position emission tomography (PET) indicated a local inhomogeneous mass with arterial perfusion. A preoperative cardiac CT found the mass to be a giant thrombosed CAA in the proximal right coronary artery compressing the tricuspid annulus. The patient underwent successful surgical excision of the CAA along with coronary artery bypass grafting. Postoperative management included lifelong administration of acetylsalicylic acid and a 3-month course of anticoagulant therapy. Histopathology excluded systemic vasculitis, indicating a congenital etiology for the CAA. CONCLUSIONS This case illustrates the indispensable role of coronary CT angiography in accurately diagnosing and managing complex cardiac conditions. Due to the complex and diverse nature of suspected cardiac tumors, cardiac CT should always be added in the diagnostic workup to describe the coronary anatomy in relation to the tumor and to identify a differential diagnosis such as a giant coronary aneurysm.

BACKGROUND Mycobacterium marinum is a slow-growing non-tuberculous mycobacterium that is known to cause skin and soft tissue infections, even in healthy patients, and is commonly associated with fish and aquatic environments. CASE REPORT A 23-year-old man working in aquarium management presented with a chronic progression of multiple skin nodules on his right forearm and thumb. The patient was referred from the Dermatology Department to the Outpatient Clinic due to suspected skin tuberculosis, as indicated by a positive T-SPOT.TB test. A second excisional biopsy tested positive for M. marinum via PCR sequencing by the National Institute of Infectious Diseases, confirming the diagnosis. The initial treatment consisted of rifabutin at 300 mg/day and clarithromycin at 800 mg/day. However, due to liver dysfunction, the regimen was changed to moxifloxacin at 400 mg/day and rifabutin. Moxifloxacin was discontinued due to nausea. Finally, the treatment was adjusted to linezolid at 1200 mg/day and clarithromycin. The patient's skin condition improved, with the nodular lesions showing a trend toward resolution. Culturing is time-consuming, and the sensitivity can be reduced when using N-acetyl-l-cysteine-sodium hydroxide in the pre-treatment process; therefore, caution with its use is necessary. Pathological examination can initially show inflammatory changes, and granulomatous lesions with caseous necrosis are not always present. Antibiotics such as rifampicin, rifabutin, moxifloxacin, and clarithromycin are used, but there is scant evidence for treatment regimens, often resulting in prolonged monotherapy or combination therapy. CONCLUSIONS In cases presenting chronic lesions resembling multiple sporotrichoid forms, repeated biopsies are crucial due to the challenges associated with culturing.

BACKGROUND Small bowel transplantation (SBT) is a rare but life-saving surgery. However, successful full-term pregnancies in individuals with SBT are exceedingly rare due to the nutritional and immunosuppression challenges this transplant poses for pregnancy. Therefore, clear guidelines for treating pregnant SBT recipients are unavailable. Here, we report the second case of a successful pregnancy in an individual with a triple organ transplant, including SBT, highlighting the need for careful immunosuppressive management and multidisciplinary care. CASE REPORT A 20-year-old woman in the third trimester of pregnancy with a history of small bowel, liver, and pancreas transplantation at age 1 year presented with elevated liver function test results. She had been taking tacrolimus, sirolimus, and prednisone before pregnancy, with no signs of organ rejection. While sirolimus and prednisone was discontinued upon conception, laboratory test results at presentation revealed low serum tacrolimus levels. The patient had an acute kidney injury and pulmonary edema during her hospitalization and received a diagnosis of preeclampsia. She underwent a successful cesarean delivery, due to labor induction complications; however, about 1 month after hospital discharge, the patient experienced elevated liver enzymes, which was treated with high-dose steroids and adjusted tacrolimus. Sirolimus was restarted, and the patient's liver enzymes have been normalized to date. CONCLUSIONS Comprehensive multidisciplinary care, as well as monitoring and optimizing immunosuppression, are essential for pregnant SBT recipients throughout the prenatal, perinatal, and postpartum periods to mitigate risks, prevent graft rejection, and ensure positive maternal and fetal health outcomes.

BACKGROUND Obesity-hypoventilation syndrome (OHS), also known as Pickwickian syndrome, is a respiratory consequence of morbid obesity, usually treated with non-invasive positive airway pressure (PAP) therapies and weight loss. This study reports a 53-year-old woman with a body mass index of 49 kg/m² who experienced acute hypercapnic respiratory failure due to OHS. Her treatment involved mechanical ventilation, home oxygen therapy, and long-term weight loss of >30 kg. CASE REPORT A 53-year-old woman (109 kg) presented with acute hypercapnic respiratory failure due to OHS, which improved with mechanical ventilation and diuretics. After discharge from the hospital, she was treated with nocturnal non-invasive positive-pressure ventilation (NPPV) and home oxygen therapy. Over a 5-year period, following loss of >30 kg, she was re-evaluated for the discontinuation of NPPV and oxygen therapy. She was evaluated with various NPPV settings and oxygen doses, monitored by transcutaneous pressure of carbon dioxide (PtcCO₂). On NPPV, PtcCO₂ levels ≥55 mmHg were maintained within 10 min, indicating that the durations of PtcCO₂ ≥50 mmHg were too prolonged for her to be switched to continuous PAP therapy. Nonetheless, oxygen therapy was discontinued because the duration of peripheral blood oxygen saturation <90% was brief. CONCLUSIONS For patients with OHS treated with NPPV and oxygen therapy, weight loss alone may not improve hypoventilation and wean the patient from NPPV. Besides obesity, various factors influence respiratory compromise in OHS; hence, a comprehensive assessment of hypoventilation, including PtcCO₂ monitoring, is essential to determine whether NPPV withdrawal is possible after body weight loss.

BACKGROUND Orbital abscess is a severe infectious condition of the eye that can result in significant complications, including vision loss or fatality. Timely and accurate diagnosis and treatment of this condition are crucial. CASE REPORT A 45-year-old man with exophthalmos, diplopia, and decreased vision was admitted to our hospital. He had a history of chronic sinusitis. Ultrasonography showed a dark fluid area above the superior rectus muscle of the right eye, measuring approximately 5.7 ml. Orbital MRI revealed short T1 and long T2 signal shadows outside the upper muscle cone of the right orbit, with a size of about 13.2 ml. The right eyeball was compressed and moved forward, and the superior rectus muscle was also compressed. Long T2 signal shadows were observed in the right frontal sinus, maxillary sinus, and bilateral ethmoid sinuses, leading to a diagnosis of orbital subperiosteal abscess and sinusitis. We performed a fine-needle puncture and injection of antibiotics into the abscess cavity using a 5-ml syringe under the guidance of B-ultrasound. On the 7th day after surgery, the patient showed clinical improvement with decreased symptoms. His visual acuity improved from 20/40 to 20/20, and diplopia resolved. His sinusitis was treated with medication, and no recurrence of ocular symptoms was observed during the 3-year follow-up. CONCLUSIONS This report highlights the use of ultrasound-guided fine-needle puncture and injection of antibiotics into the abscess cavity for the treatment of an upper-quadrant orbital subperiosteal abscess. Timely surgical drainage and effective antibiotic therapy can help reduce the complications associated with orbital abscesses.

BACKGROUND Detection of episodes of desaturation on pulse oximetry in elderly people in community settings is now a common occurrence. Transfer of such patients to hospital by ambulance has led to a greatly increased exposure to high-dose (FiO₂ > 50%) inhaled oxygen therapy in this group. Current British Thoracic Society (BTS) guidelines recommend administration of oxygen, 15 L/min via a non-rebreather mask (NRB) to acutely hypoxemic patients with an SpO₂ below 85% on room air. In some elderly subjects, such high-dose oxygen therapy induces significant hypercapnia in the absence of an identifiable risk factor for oxygen-induced CO₂ retention. CASE REPORT This case series describes 3 very elderly (>85 years old) female patients developing acute hypercapnia shortly after initiation of high-dose inhaled oxygen therapy. In each of these cases, hypercapnia developed in the absence of an accepted risk factor for oxygen-induced CO₂ retention. In 2 cases, CO₂ narcosis resolved within hours of the establishment of controlled oxygen therapy on bi-level positive airway pressure (BPAP). The possibility of oxygen-induced CO2 retention was not considered by the treating physicians in the acute setting. CONCLUSIONS The possibility of oxygen-induced CO₂ retention should be considered in all elderly patients developing acute type II respiratory failure in the setting of high-dose oxygen therapy. Failure to recognize oxygen-induced CO₂ retention has significant implications for patient outcome and resource utilization.

BACKGROUND Diffuse large B-cell lymphoma is the most prevalent form of non-Hodgkin lymphoma, representing around a quarter of newly diagnosed cases of B-cell non-Hodgkin lymphoma. Diffuse large B-cell lymphoma is a disease that affects mostly older persons, with a median presentation in the 7th decade of life. Clinically, it has a variety of presentations, ranging from constitutional symptoms to local or systemic pressure effects caused by a rapidly growing mass. Only rarely do head and neck lymphomas present as syncopal events. Although diffuse large B-cell lymphoma frequently involves the cervical region, syncope from the condition without cardiac involvement has only been documented in a few cases to date. CASE REPORT A 66-year-old man experienced a sudden onset of recurrent syncopal episodes triggered by neck movement that had been ongoing for 2 weeks before his presentation. A rapidly enlarging left neck mass was first noticed 6 weeks earlier and he was treated with antibiotics. During a workup of the syncope, a diffuse large B-cell lymphoma was discovered to be encasing his left internal carotid artery without obstructing blood flow. Chemotherapy was initiated and resulted in complete neck mass and related syncope resolution. Follow-up positron emission tomography scan after 3 months of chemotherapy revealed an excellent response. CONCLUSIONS Sudden onset of syncopal episodes may be the first or only indication of a neck or head malignancy. As a result, we should be aware of the possibility of an underlying malignancy in individuals with unexplained syncope.

BACKGROUND Anterior hip dislocation is a rare injury that often occurs following high-energy road traffic accidents and accounts for approximately 7% to 13% of all hip dislocations. This report describes the presentation, diagnosis, and treatment of a 44-year-old woman with anterior hip dislocation and multiple comminuted fractures due to a vehicular crush injury. A PubMed search showed no similar cases have been reported in the English literature. CASE REPORT A 44-year-old woman was urgently seen at a local hospital after being run over twice by the rear wheel of a reversing truck while walking. Radiographic examination revealed right obturator-type anterior hip dislocation and multiple injuries. Pelvic external fixation and right femoral supracondylar bone traction were performed. Subsequent to hemodynamic stabilization, the patient was transferred to our hospital. Five days later, open reduction internal fixation was performed. Anterior pelvic ring internal fixation was performed after 20 days. The patient was hospitalized for 33 days. At the 5-year postoperative follow-up, the CT image showed healing. There was no lumbar or hip pain, and the patient had returned to normal life and work. CONCLUSIONS Anterior hip dislocation combined with bilateral obturator fractures, sacral fractures, lumbar fractures, and thoraco-abdominal injuries are rare in clinical practice. It is crucial to correctly handle multiple injuries to achieve enhanced recovery after surgery and prevent complications. The aim of this study is to document the clinical presentation, management, and outcomes of this unique case, highlighting the challenges and potential complications associated with femoral head displacement toward the obturator foramen.

BACKGROUND One percent of paraneoplastic syndromes described in the literature present as cutaneous manifestations such as vasculitis, which may reveal potential initial diagnoses. Leukocytoclastic vasculitis is a subtype of small-vessel vasculitis. It affects the skin and internal organs, and diagnosis relies solely on histopathological examination. The literature on leukocytoclastic vasculitis linked with malignancies is scarce. CASE REPORT We present the case of a 60-year-old man with multiple cardiovascular comorbidities, presenting with dysuria and elevated prostate-specific antigen (PSA) levels. Further investigations led to diagnosis of metastatic prostate adenocarcinoma. Concurrently, he developed non-specific cutaneous lesions. He underwent hormonal therapy and radiotherapy. During initial treatment, the lesions rapidly progressed to necrotic ulcers; therefore, hormonal therapy was withheld. Extensive investigations ruled out potential infectious or rheumatological causes of the lesions, and histopathological analysis was consistent with cutaneous leukocytoclastic vasculitis. The patient underwent systemic corticoid treatment while continuing radiotherapy. Following completion of radiation therapy and a corticosteroid course, the patient showed good clinical response, with decreased PSA level, resolution of urological symptoms, and clinical improvement of the lesions. He was cleared for hormonal treatment continuation. CONCLUSIONS Given the temporal relationship between the onset of vasculitis, its exacerbation during first days of cancer treatment initiation and the rapid resolution following radiotherapy, a paraneoplastic etiology for leukocytoclastic vasculitis can be considered in this case. While the literature on leukocytoclastic vasculitis associated with malignancies is limited, clinicians must maintain vigilance to ensure timely and accurate diagnosis.

BACKGROUND Clavicle fractures are a common injury, and the standard surgical treatment for displaced shaft fractures is plate fixation using a single superiorly-placed plate. However, the use of this technique in dementia patients poses challenges, including increased risk of postoperative complications such as fixation failure, mal-union, and non-union. CASE REPORT This is a case series of 2 patients who had clavicle shaft fracture with dementia. The first was a 90-year-old woman with right clavicle fracture and vascular dementia. She underwent superior locking compression plate fixation, but the plate was pulled out because of her uncooperativeness. Therefore, we performed dual-plate fixation. She did not immobilize her arm after the surgery, but the plate did not pull out and she was doing well without any problems in daily life. The second patient was a 78-year-old man with advanced dementia who had a displaced midshaft clavicle fracture after a fall. Due to his inability to cooperate and follow postoperative instructions, a decision was made to employ a dual plating technique with plates applied anteriorly and superiorly. At 6-month follow-up, he had satisfactory functional outcomes and radiographic evidence of fracture healing. CONCLUSIONS The use of dual-plate fixation in the treatment of clavicle fractures in dementia patients is a viable option that can lead to successful outcomes and no failure-related implants.