American Journal of Case Reports最新文献

BACKGROUND Necrotizing fasciitis is an aggressive type of skin and soft tissue infection that results in necrosis of subcutaneous tissues, including muscle and fascia. Mixed bacteria, including gas-forming organisms, are usually identified. This report describes a 55-year-old male diabetic patient with herpes zoster involving the thoracic dermatomes complicated by skin infection, necrotizing fasciitis, chest wall abscess, and sepsis. CASE REPORT A 55-year-old man with diabetes mellitus presented with thoracic herpes zoster, initially treated with acyclovir and topical agents. He developed swelling, pain, and fever over the left chest, which was unresponsive to topical treatment. Investigations revealed elevated white blood cells and gas on chest X-ray. Computed tomography confirmed a 13×6×11-cm abscess with gas between the latissimus dorsi and serratus anterior muscles, suggesting necrosis. He received intravenous amoxicillin/clavulanic acid and metronidazole and underwent urgent surgical drainage, yielding 200 mL of pus. Cultures identified antibiotic-sensitive Staphylococcus aureus and Clostridium perfringens. Histopathology confirmed necrotizing tissue with acute bacterial inflammation. He was treated postoperatively with dressings and vacuum-assisted closure, followed by sutures, and was discharged in good condition after 16 days. CONCLUSIONS This case underscores the aggressive nature and potential complications of necrotizing soft tissue infections in patients with diabetes mellitus and herpes zoster. Prompt recognition, early intervention with appropriate antibiotics, and surgical drainage are crucial in managing such infections effectively. The successful use of vacuum-assisted closure therapy underscores its role in facilitating wound healing after debridement. Clinicians should maintain vigilance for necrotizing infections in similar high-risk patients to ensure early intervention and improve clinical outcomes.

BACKGROUND Angioedema is characterized by localized self-limiting edema of the deep dermis, subcutaneous, and submucosal tissues. Acute episodes often involve the skin of the face, lips, tongue, limbs, and genitals, as well as internal areas of the body and respiratory and gastrointestinal mucosa, which could be life-threatening. Histamine and bradykinin are the most recognized vasoactive mediators in the pathophysiology of angioedema. Tissue plasminogen activator (tPA) is a fibrinolytic that is commonly used for the treatment of cerebrovascular accidents. Angioedema is a rare adverse effect of tPA, with an estimated incidence of 0.02% in patients with myocardial infarction or pulmonary embolism and 0.2% to 5.1% in patients with stroke. We report a unique case of tPA-associated angioedema with 24-h management. CASE REPORT A 79-year-old male patient presented to the Emergency Department with acute onset right-sided weakness, right-sided facial droop, and speech difficulties. Following the initial evaluation, it was determined that he was a candidate for receiving tPA therapy. On arrival at the Intensive Care Unit, he was noted to have right upper and then lower lip swelling. The patient was asymptomatic and did not show any signs concerning airway compromise. Treatment included systemic corticosteroids and antihistamines. The progression of the angioedema was further described with sequential images. The angioedema was completely resolved with treatment. CONCLUSIONS Angioedema is a rare but potentially life-threatening adverse effect of tPA. Although it generally has a mild self-limiting course, it can cause life-threatening airway compromise.

BACKGROUND Infection control and reconstruction of bone and soft tissue are essential for treating infected nonunion. Continuous local antibiotic perfusion (CLAP) is a drug delivery system that continuously delivers antibiotics at the required concentration, area, and duration. This case report describes the instance of infected nonunion in which infection eradication and bone union were achieved using CLAP and synthetic bone grafting while retaining the implant. CASE REPORT The case was a 31-year-old woman with an infected nonunion. After she underwent osteosynthesis using nail for open fractures of tibia and fibula, bone union remained unachieved, and she exhibited skin defects and draining of pus. Following the removal of the infected granulation tissue from the bone defects, 2 bone marrow needles, serving as intramedullary antibiotic perfusion (iMAP) pins, were inserted into the medullary cavity tibia. A double-lumen tube was placed in the subcutaneous pocket as the intra-soft tissue antibiotic perfusion (iSAP) tube. No bone mobility was observed around the bone defect and nail, and replacement of the implant was not necessary. Beta-tricalcium phosphate was transplanted to the bone defect, and negative pressure wound therapy was applied. Gentamicin was injected continuously through iMAP and iSAP. Finally, the infection was eradicated, and cortical bone bridging was observed without additional surgery or adverse effects. CONCLUSIONS CLAP emerges as a viable treatment option for infected nonunion, as it enables the delivery of antibiotics at a concentration sufficient for infection control while providing the surgeon with flexibility to design the area, dosage, and duration of antibiotic delivery.

BACKGROUND Polycythemia vera (PV) is a myeloproliferative neoplasm (MPNs) marked by elevated hemoglobin and hematocrit, which can lead to thromboembolic events and progress to myelofibrosis or acute myeloid leukemia (AML). MPNs, including PV, are relatively rare in Malaysia, and there is currently no recent published data reporting the demographics and outcomes of PV patients in the country. In Western countries, routine annual blood tests are standard, whereas this practice is less common in Malaysia, underscoring the need for improved awareness and accessibility to ensure timely diagnosis of PV. CASE REPORT This report presents a case of a 55-year-old Malaysian woman in a primary care setting, initially misdiagnosed with benign conditions due to atypical presentations of recurrent bilateral eye redness and dizziness. Persistent symptoms led to further evaluation by primary care and hematologist, which revealed elevated hemoglobin, hematocrit, leukocytosis, JAK2 V617F mutation, and low serum erythropoietin levels, confirming PV, even without proceeding with a bone marrow biopsy. Treatment with phlebotomy, hydroxyurea, and aspirin resulted in significant improvements in ocular symptoms and hematological parameters within 60 days. CONCLUSIONS This case underscores the critical role of primary care in the early detection of polycythemia vera. Timely identification and appropriate referral from primary care settings are essential to avoid diagnostic delays and ensure effective management, improving patient outcomes and preventing complications.

BACKGROUND Eagle syndrome is an uncommon medical illness that can manifest as neck pain in primary care. It results from an abnormally unilateral or bilateral long styloid process that may compress and affect adjacent structures, which leads to the symptoms. Classical Eagle syndrome has been commonly reported, but this case highlights the uncommon involvement of autonomic nerve dysfunction. CASE REPORT This case report details a 43-year-old woman with chronic neck pain for 5 years who saw numerous medical professionals and underwent 8 physiotherapy sessions. Marginal improvement of her neck pain and recent development of imbalance and a floating sensation prompted escalation of radiological imaging that eventually led to the diagnosis of Eagle syndrome. She was subsequently subjected to tonsillectomy and styloidectomy to address the sources of her neck pain. CONCLUSIONS Neck pain is a common complaint in primary care, but Eagle syndrome is often overlooked due to its complex symptoms, which mimic other conditions resulting in missed diagnoses and prolonged diagnostic evaluations. To improve patient care and outcomes, primary care physicians should consider Eagle syndrome when evaluating neck pain. This involves taking a detailed clinical history, conducting a thorough physical examination, using appropriate imaging techniques, and knowing the treatment options. By considering this potential diagnosis, primary care physicians, other healthcare professionals, and physical therapists play an important role in referring these patients to an otorhinolaryngologist or a maxillofacial surgeon for a comprehensive evaluation and management.

BACKGROUND Muscle hernias are an uncommon condition typically found in the extremities; masseter muscle hernia is even rarer. However, it is important for clinicians and radiologists to be aware of this possibility. Intramuscular venous malformation (IMVM) is also uncommon and mostly found in the head, neck, and extremities. The simultaneous presence of both conditions is extraordinary uncommon, and, to our knowledge, this has not been reported before in the masseter muscle. Due to their rarity, vague presentation, and inaccurate clinical diagnosis, radiological evaluation is needed to avoid inappropriate surgical planning. CASE REPORT A 12-year-old boy had a long-standing focal left cheek swelling exacerbated by teeth clenching. Lateral X-ray revealed a round calcification over the left mandibular region. Ultrasonography indicated a bulky left masseter muscle with focal heterogeneous structure and 2 rounded calcified foci. During teeth clenching, ultrasonography detected focal muscular herniation through the left masseter muscle facia that reduced with rest. The patient was diagnosed with left masseteric muscle hernia coexistent with IMVM. Surgical excision of the IMVM was performed, and the hernia defect was repaired. Histopathology confirmed the diagnosis, and the patient was discharged without postoperative complications on short-term follow-up. CONCLUSIONS Despite their rarity, masseter hernias and IMVMs should be considered in the differential diagnosis of any masseter lesion, especially in children. We reported a very rare coexistence of both pathologies. Comprehensive diagnosis can be achieved through a combination of clinical examination, X-ray, and ultrasound assessments.

BACKGROUND Anifrolumab, a monoclonal antibody targeting the type 1 interferon (IFN-I) signaling pathway, holds promise as a therapeutic intervention for systemic lupus erythematosus (SLE). However, its use is associated with an increased risk of infections, particularly viral infections like herpes zoster (HZ). Results from the clinical trials on anifrolumab show yearly rates of upper respiratory tract infections of 34% and HZ of 6.1%. An increased frequency of other specific viral infections, including herpes simplex virus (HSV), was not reported. CASE REPORT Here, we present 2 cases of patients with SLE treated with anifrolumab, both experiencing severe adverse reactions in the form of disseminated herpesvirus infections, specifically disseminated HSV-2 and varicella zoster virus (VZV, HZ encephalitis). To the best of our knowledge, no previous reports of severe disseminated HSV-2 or HZ have been published in anifrolumab-treated patients. The patient in case 1 experienced a primary HSV-2 infection following anifrolumab treatment, potentially explaining the severity of the infection. The patient in case 2 had a history of previous HZ skin infections, which may have increased her risk of disseminated infection. Both patients recovered from the infections with minor sequelae, but they still require prophylactic antiviral treatment. These cases highlight the critical role of IFN-I immunity in protecting against herpesvirus infections. CONCLUSIONS Thorough risk assessment before anifrolumab initiation, considering the patient's viral infection history, vaccination status, and potential exposure risks, is essential. Administration of recombinant zoster vaccine before anifrolumab therapy may benefit susceptible individuals.

BACKGROUND Pheochromocytoma, a rare catecholamine-secreting tumor, often presents with paroxysmal or sustained hypertension, tachycardia, headache, and diaphoresis. Timely diagnosis is essential to prevent adverse complications. Less common presentations include pheochromocytoma crisis, with severe neurological and cardiac complications. CASE REPORT We report a unique case of a 25-year-old woman who initially presented with pheochromocytoma-induced hypertensive encephalopathy and acute coronary syndrome. Echocardiography revealed takotsubo-like cardiomyopathy, and magnetic resonance imaging of the brain revealed posterior reversible encephalopathy syndrome. Initial treatment focused on controlling her blood pressure and supporting cardiac function. Due to her recovering from immediate crisis and absence of further symptoms, the patient refused further follow-up. However, she eventually experienced another episode of hypertensive crisis 2 years later. Subsequent investigations with 24-h urine tests revealed elevated vanillylmandelic acid levels (7.93 mg/24 h), normetanephrine (2638.72 µg/24 h), and nor-metanephrine to creatinine ratio (3546.67) and normal urine metanephrine levels (195.92 µg/24 h) and metanephrine to creatinine ratio (263.33). Contrast-enhanced computed tomography of the abdomen revealed a 4.3×3.1×4-cm mass in the right adrenal gland. A DOTATATE positron emission tomography scan revealed a 3.9×4.3×2.7-cm localized right adrenal pheochromocytoma. Biochemical testing and adrenal imaging revealed a previously undiagnosed pheochromocytoma. Following targeted medical therapy and right adrenalectomy, the patient achieved complete resolution of her hypertension and associated symptoms. CONCLUSIONS Our case is a unique simultaneous presentation of posterior reversible encephalopathy syndrome and takotsubo-like cardiomyopathy, highlighting the importance to consider pheochromocytoma in acute neurological and cardiac presentations, even in the absence of typical symptoms.

BACKGROUND Pheochromocytomas, rare tumors arising from the adrenal medulla, can present with highly variable symptoms; therefore, pheochromocytomas frequently remain undiagnosed, leaving the potential for physiological complications. Acutely, these complications include pheochromocytoma crisis, in which high levels of catecholamines are released and cause a life-threatening hypertensive emergency. Over time, undiagnosed pheochromocytomas can lead to cardiovascular damage and end-organ disease related to chronic exposure to elevated blood pressure. CASE REPORT We share a case of pheochromocytoma in a 45-year-old woman who presented with gastrointestinal symptoms of intractable nausea, vomiting, and abdominal pain. Imaging revealed an adrenal mass that had radiographic features that were most consistent with myelolipoma. Before exposing the patient to anesthesia and endoscopy for further diagnostic workup of her gastrointestinal symptoms, which can trigger a catecholamine surge in individuals with a pheochromocytoma, further biochemical testing was performed. Testing of plasma and urine confirmed pheochromocytoma, and surgical resection was performed for definitive treatment. Ultimately, the patient had resolution of her symptoms following the removal of the tumor. CONCLUSIONS The resolution of symptoms following surgical resection suggests that symptoms may have been related to the mass effect of the tumor or as an atypical manifestation of increased catecholamine levels. Additionally, by screening for pheochromocytoma, the patient was able to avoid potential complications that can result from common gastroenterological diagnostic procedures. This case report highlights the potential benefit for screening for pheochromocytoma when faced with symptoms that may be non-specific or related to mass effect upon surrounding organs.

BACKGROUND The pediatric population, due to its distinct anatomy and physiology, often presents with unique mechanisms of trauma, leading clinicians to encounter diverse and sometimes unexpected injuries. Whether these injuries result from blunt or penetrating trauma, they may involve intra-abdominal organs in pediatric patients. Additionally, there are occasional occurrences where injuries affect rare sites such as the pylorus in an isolated manner within this age group. Clinicians must be prepared to address a wide range of injury patterns to ensure optimal outcomes for pediatric patients experiencing trauma to intra-abdominal structures such as the pylorus. CASE REPORT We report a 19-month-old boy who presented with abdominal pain, crying, and repeated vomiting of gastric contents after a wardrobe fell on his upper torso. His vital signs were stable except that he was tachycardiac. Upon investigation, abdominal computed tomography (CT) revealed pneumoperitoneum, free peritoneal fluid, and inflammatory changes in the intestinal wall, suggesting hollow viscus injury. Exploratory laparotomy was performed, and complete transection of the pyloric area of the stomach was identified. The pancreatic and biliary ducts were intact. On postoperative day 5, an upper gastrointestinal (UGI) contrast study prior to initiating oral feeding was done and showed normal findings with no contrast leakage. His postoperative course was unremarkable. CONCLUSIONS Isolated pyloric injuries following blunt trauma are rare with no known case reports in pediatric age group. High morbidity and mortality rates can result from traumatic gastrointestinal injuries including the involvement of pylorus. Therefore, accurate diagnosis and prompt management are essential for an improved outcome.