American Journal of Case Reports最新文献

BACKGROUND Choroidal melanoma is the most common primary intraocular tumor in adults. Most primary choroidal melanomas are unilateral and unifocal. Bilateral primary choroidal melanomas are considered to be a rare occurrence. Ocular melanocytosis, especially when it is bilateral, increases the incidence of bilateral primary choroidal melanoma. CASE REPORT Our patient was a 78-year-old man who presented to the Emergency Department with floaters and a reduction in visual acuity in his left eye, with an onset 7 days prior. Upon macroscopic examination, the patient displayed bilateral pigmentation on the sclera, which was consistent with ocular melanocytosis. Fundoscopy revealed a large choroidal melanoma, situated superior and nasally of the posterior pole of the left eye, and a smaller choroidal melanoma, located inferonasally, in the right eye. Ultrasonography, optical coherence tomography, fundus autofluorescence, fundus fluorescein, and indocyanine green angiographies were performed, confirming the diagnosis of simultaneous bilateral primary choroidal melanomas. CONCLUSIONS This was a rare case of bilateral ocular melanocytosis, which increased the probability of bilateral primary choroidal melanoma. To the best of our knowledge, this is the first case in Greece to be reported. This case illustrates the necessity of always examining the fellow eye on initial presentation and over a long follow-up. We should always bear in mind that choroidal melanoma can be a bilateral disease, albeit very rarely.

BACKGROUND Retained products of conception (RPOC) is a rare complication following second-trimester delivery or pregnancy termination, often leading to significant hemorrhage. Diagnosed via ultrasound or CT, RPOC requires surgical intervention based on endometrial thickness. Risk factors include second-trimester abortion and use of placental forceps. We report a case of RPOC diagnosed 1 month postpartum after using a Bakri balloon for atonic hemorrhage during full-term delivery. CASE REPORT The patient, a 32-year-old woman with a history of 4 pregnancies and 3 births, conceived via frozen embryo transfer, which was her first infertility treatment. At 36 weeks of gestation, blood tests revealed a hemoglobin level of 10.4 g/dl. She delivered vaginally at 38 weeks 2 days, but postpartum uterine contractions were poor, leading to significant bleeding. Oxytocin administration and uterine massage failed to improve contractions, so a Bakri balloon was inserted. The total blood loss was 2263 cc, and 6 units of RBCs were transfused. The next day, the Bakri balloon was removed, and ultrasonography confirmed the absence of retained placenta before discharge on postpartum day 5. However, at her 1-month checkup, a retained placenta was diagnosed, requiring further intervention. The patient declined follow-up. CONCLUSIONS We encountered a case of RPOC 1 month after using a Bakri balloon. Although the relationship between the 2 remains unclear, it may be preferable to avoid such treatment in the future.

BACKGROUND Extracorporeal shockwave lithotripsy (ESWL) is a common procedure, and splenic rupture is a rare complication of ESWL. Depending on the stage of injury and patient's condition, treatment options include non-operative management (NOM) and emergency splenectomy. Diagnosis is not difficult with symptoms such as deteriorating hemodynamic and hematologic indices, localized physical signs of peritoneal irritation in the left hypochondriac region, and confirmation provided by signs of free fluid (hemoperitoneum) seen on ultrasound or computed tomography (CT). Prompt diagnosis and treatment are essential for patient survival. If NOM is not feasible, emergency laparotomy with splenectomy is standard procedure. CASE REPORT A 72-year-old man with a medical history of arterial hypertension and cardiac arrhythmia was emergently admitted 1 day after undergoing ESWL for bilateral nephrolithiasis. He presented with abdominal pain, nausea, vomiting, and anemia. Urgent CT confirmed a splenic rupture, with intraperitoneal fluid. He underwent emergency splenectomy 24 h after ESWL. Complete splenic rupture (grade IV) was identified, accompanied by significant blood loss of 2000 mL. The postoperative course was uneventful, and he was discharged on postoperative day 7, with primary wound healing. CONCLUSIONS Splenic injury following ESWL is a rare but serious complication. Our case underscores the importance of monitoring for splenic injury following ESWL. Management should be multidisciplinary, considering physiological, anatomical, and immunological aspects. While splenectomy is the standard treatment, NOM can be considered for hemodynamically stable patients to avoid complications following splenectomy. Recent treatment protocols have improved stone breakage and reduced tissue damage, suggesting long-term adverse effects can be minimized or eliminated.

BACKGROUND Neuropathic pain symptoms caused by neuromas impose physical burdens and affect patients mentally and socioeconomically. Surgical intervention offers more promising outcomes than do conservative approaches. An accessible and cost-effective surgical treatments is neuroma excision, coupled with nerve wrapping flaps. However, few reports have detailed the outcomes of this approach. In this study, we report 4 patients who underwent neuroma excision and nerve wrapping with vein autographs. CASE REPORT We present 4 patients who experienced persistent neuropathic pain and did not respond to conservative treatment for more than 6 months. Three patients had upper limb neuromas in continuity and 1 patient had a stump femoral neuroma. Surgical intervention involved neuroma excision, nerve grafting, and the application of nerve wrapping flaps at the site of anastomosis. Evaluation of our patients included neuroma pain scores and the Weber 2-point discrimination test. Follow-up assessments demonstrated significant clinical improvement, with all patients showing up to 60% reduction in pain and an average improvement of 5 mm in 2-point discrimination. No recurrence or need for further surgery was observed. CONCLUSIONS Surgical intervention was superior to conservative treatment in patients with painful neuromas. Nerve wrapping flaps, one of the surgical procedures for neuroma management, represents an effective surgical option for neuromas in continuity and stump neuromas. This is related to the more physiological nerve regeneration process when nerve ends are closed. The use of autograft veins as one of the materials for closing nerve ends is advantageous owing to its affordability and versatility in accommodating nerves of varying sizes.

BACKGROUND Giant cell tumors of bone typically occur in early adulthood, when the growth plate has closed. The distal radius is the second most common location affected, accounting for 10% to 12% of cases. Complications of poor soft tissue healing are rare in the distal radius, owing to its rich blood supply. However, the curettage procedure and use of bone cement and external fixation can affect the local blood supply. CASE REPORT We present a rare case of a 24-year-old woman with no significant medical history who underwent surgery at a local hospital to treat a giant cell tumor of the radius. During postoperative wound dressing changes, a 4×3-cm area of flushed skin color with a small blister and reduced local sensation was found on the dorsal side of the wrist. The skin condition worsened despite treatment at the surgical outpatient clinic, leading to referral to scar specialist outpatient treatment. Examination revealed a well-healed surgical scar on the palmar side of the wrist, but a skin defect with necrotic tissue and tendon exposure on the dorsal side. The diagnosis was postoperative soft tissue necrosis of the skin with a giant cell tumor of the bone. CONCLUSIONS This case report discusses the management of chronic non-healing postoperative wounds in giant cell tumors of the distal radius. It emphasizes the importance of appropriate dressing changes, selecting suitable dressings, nutritional support, and effective nurse-patient communication. The case serves as an example of best practices for managing these types of wounds.

BACKGROUND Conjoined twins are a rare congenital anomaly with various types, depending on the connection site. Managing these cases requires a structured approach leading to separation surgery. This report provides a detailed description of the anesthetic strategies and challenges of pygopagous conjoined female twins who underwent 2 surgeries before separation at 17 weeks of age. CASE REPORT The female twins were conjoined at the sacral level (S4), with fused thecal sacs at L5 and cord tethering, with the conus terminating below L3 in both patients. They had separate rectal ampullae that fused into a single anal canal in the midline in a Y formation. The babies underwent 2 surgeries prior to separation: meningocele repair for twin B and anal canal dilation and sphincter mapping for both twins, followed by a ventriculoperitoneal shunt insertion for twin B. The separation surgery included dividing the bony vertebral fusions and dural sacs, untethering the spinal cords and nerves, and correctly allocating the intrapelvic muscles, guided by sphincter muscle mapping. Anesthesia was managed by 2 distinct teams each time, with duplicated equipment and color-coded medications to prevent errors. Due to the critical condition of twin B, general anesthesia was administered to her first. The report also addresses the challenges faced during the 3 surgical procedures. CONCLUSIONS Anesthetic management for pygopagus twins presents complex challenges. Despite limited experience with similar cases, successful management was achieved through planning, effective communication, and rehearsal of unfamiliar setups. Attention to detail and involvement of highly experienced teams were crucial to the success of the procedures.

BACKGROUND The extraction of impacted supernumerary teeth requires precision and accuracy to mitigate iatrogenic damage to crucial anatomical structures during dental surgical procedures, thereby enhancing postoperative healing outcomes. Dynamic navigation systems (DNS) have been applied in dentistry in maxillofacial fractures, orthognathic surgery, root canal treatment, and endodontic surgery. CASE REPORT A 22-year-old female patient visited our department to assess and manage unerupted third molars. An initial cone beam computed tomography (CBCT) scan was obtained. Radiographic and clinical examinations showed the presence of a supernumerary tooth impacted on the lingual side between the root of the lower second premolar and the lower first molar and bilateral lower impacted third molars. The patient agreed to removal of these teeth. To perform the treatment planning of this case and to guide the surgeon intraoperatively, a dynamic surgical navigation system was recommended for surgical extraction of a supernumerary tooth and the impacted third molars. CONCLUSIONS The dynamic navigation system coupled with a high-speed contra-angle handpiece for the extraction of supernumerary teeth is a personalized, digitally-driven, precise, minimally invasive, and efficient treatment approach. In this case, the DNS and the high-speed contra-angle handpiece were seamlessly integrated to facilitate visualization of the surgical procedure, thereby safeguarding of surrounding vital anatomical structures while enhancing patient comfort.

BACKGROUND Hyperthermia is strongly associated with a worse neurological outcome in traumatic brain injury (TBI) and can be exacerbated by shivering. However, effective treatments for uncontrolled shivering have yet to be established. We successfully treated a patient with severe TBI and repeated episodes of shivering using dantrolene sodium hydrate (dantrolene). CASE REPORT A 28-year-old healthy male sustained an acute subdural hematoma with a midline shift following a traffic accident. He underwent emergency evacuation of the hematoma and craniectomy and was admitted to the Intensive Care Unit. The patient experienced severe shivering on the first day of hospitalization. Neuroprotective drugs were administered, and targeted temperature management at normothermia was initiated, initially controlling the shivering. On day 9 of hospitalization, shivering recurred, with a high fever. Despite the reintroduction of general anesthesia and targeted temperature management, the shivering was intractable. We administered dantrolene, which successfully eliminated the shivering. After the intervention, the patient's body temperature and intracranial pressure were well managed. The patient was subsequently transferred to a rehabilitation hospital, with a favorable neurological outcome 70 days after the injury. CONCLUSIONS This case report demonstrates that dantrolene is an effective option for managing uncontrollable shivering in the context of intracranial pressure control after severe brain injury. This finding suggests the potential for the broader use of dantrolene in similar clinical scenarios and supports further investigation of its efficacy and mechanisms of action in TBI care.

BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome that can occur either in genetically predisposed individuals (primary HLH) or in particular conditions in immunocompromised patients (secondary HLH). Secondary HLH is very rare among solid organ transplant recipients, especially in lung transplant recipients, for whom its prognosis is dismal. CASE REPORT We report an exceptional case of HLH occurring unusually late following lung transplantation. At 11 years after transplantation, the patient, aged 67 years, presented with pancytopenia, fever, hyperferritinemia, and hypertriglyceridemia, along with splenomegaly. Exhaustive serological and PCR tests ruled out active infection. Bone marrow aspirates showed signs of hemophagocytosis, and bone marrow biopsy was suggestive of post-transplant lymphoproliferative disorder (PTLD). Timely treatment with etoposide and corticosteroids led to a transient improvement in the patient's clinical condition, and rituximab was initiated as a treatment for PTLD. Unfortunately, pancytopenia persisted for weeks, and the patient died from refractory septic shock, despite appropriate intravenous antibiotics. Autopsy revealed lymphoid infiltration of the mediastinal lymph nodes, liver and bone marrow, with some lymphocytes expressing CD3. A final diagnosis of Ann-Arbor stage IV non-EBV-mediated monomorphic T-cell PTLD was established. CONCLUSIONS This case report highlights a very unusual and fatal presentation of HLH in a lung transplant recipient, secondary to a T-cell PTLD. Indeed, HLH is typically seen as infection-related and reported to occur in the initial months following transplantation. To date, no guidelines or consensus exist regarding the management of immunosuppression regimen in solid organ transplantation.

BACKGROUND Managing unique anatomical structures, such as the nasopalatine canal, remains key for successful implant placement and long-term functionality. Topical oral oxygen therapy (TOOT) has gained attention for its antibacterial, regenerative properties, and ability to accelerate wound healing. This report presents a case of postoperative palatal necrosis successfully treated with TOOT oxygen-active gel (blue®m) CASE REPORT A 33-year-old male patient presented with the primary concern of needing rehabilitation of the anterior maxillary region. Clinical and imaging examinations revealed a deficient maxillary ridge and an enlarged incisive foramen. The treatment plan involved nasopalatine deflation with guided bone regeneration using particulate synthetic bone graft and a collagen membrane. Seven days after surgery, he returned with minimal pain but had necrotic tissue on the palate. The necrotic tissue and a portion of the contaminated biomaterial were removed, and the area was thoroughly cleansed with a saline solution. A thick layer of active oxygen gel (blue®m) was then applied to the palatal lesion. The patient was instructed to apply the gel 3 times daily for 30 days and attended follow-up appointments every 2 days. After 12 days, rapid healing and significant clinical improvement were observed, with the patient reporting no pain or sensitivity. By day 34, the lesion had fully closed, and re-epithelialization was achieved. CONCLUSIONS Our patient had complete resolution of palatal necrosis after nervus deflation using TOOT with active oxygen gel (blue®m), and this therapy seemed to accelerate the healing process.