American Journal of Case Reports最新文献

BACKGROUND The anion gap is a critical parameter in the clinical assessment of acid-base disorders. While metabolic acidosis with an elevated anion gap is commonly encountered, cases involving a negative anion gap are rare and have been reported in the context of hypoalbuminemia, severe hyperkalemia, bromide intoxication, and laboratory error. Notably, metabolic alkalosis as a cause of negative anion gap has been rarely described in the literature. CASE REPORT A 73-year-old woman with a 4-year history of interstitial pulmonary fibrosis and a 1-year history of coronary artery disease had been taking oral spironolactone for the past year. Six months before admission, torasemide was added to her regimen in combination with spironolactone. Five days prior to admission, she developed progressive dyspnea and respiratory failure. Initial investigations revealed hypokalemia, hyponatremia, metabolic alkalosis (HCO₃⁻=61.6 mmol/L), and a negative anion gap (-9.00 mmol/L), which remained negative after albumin correction (-6.35 mmol/L). Further evaluation identified loop diuretic overuse as the primary cause of severe metabolic alkalosis and negative anion gap. The application of targeted next-generation sequencing (t-NGS) successfully identified the infectious pathogen responsible for the patient's clinical deterioration, thereby guiding appropriate antimicrobial therapy. CONCLUSIONS This case illustrates the diagnostic and educational value of recognizing a negative anion gap as a rare but physiologically predictable artifact of severe chloride-depletion alkalosis, underscoring the importance of mechanism-based interpretation in complex acid-base disorders.

BACKGROUND Immune checkpoint inhibitor (ICI) myocarditis imposes immunotherapy discontinuation due to concerns of poor outcomes. We present a case of ICI cardiomyopathy for which ICI re-challenge was safely performed. According to the World Health Organization (WHO), only 13 cases of takotsubo cardiomyopathy (TTS) have been associated with ICI use. We report a rare case of this. CASE REPORT A 64-year-old woman with history of stage IV squamous cell carcinoma of the right lung presented with symptoms of heart failure and worsening dyspnea. Her symptoms started 2 weeks after her first round of chemotherapy with carboplatin, paclitaxel, and pembrolizumab. Electrocardiography (EKG) revealed right bundle branch block with ST elevations, troponin peaked at 424 ng/L, and proBNP 865 pg/mL. A transthoracic echocardiogram (TTE) showed left ventricle ejection fraction (LVEF) of 35% to 39% along with akinesis of all the mid- to apical left ventricle (LV) wall segments. CONCLUSIONS Not all ICI-related heart failure is myocarditis. This case highlights the utility of CMR and endomyocardial biopsy to aid diagnosis of TTS. TTS and ICI myocarditis may appear similar on CMR, with prominent edema, although the regional distribution may help finalize the diagnosis. Endomyocardial biopsies can be helpful to identify pro-inflammatory macrophages as possible mediators in the association between oncology treatment and development of TTS. This interesting case highlights the utility of further advanced cardiac testing before making the diagnosing of ICI myocarditis and potentially withholding life-saving cancer therapy.

BACKGROUND The PreserFlo MicroShunt is a subconjunctival drainage device increasingly used to manage open-angle glaucoma. While its safety profile is considered favorable compared with that of trabeculectomy, rare postoperative complications, including corneal surface pathology, can still be encountered. To our knowledge, corneal dellen has not been previously reported following PreserFlo implantation. CASE REPORT A 15-year-old boy with pathological myopia and Stickler syndrome underwent PreserFlo MicroShunt implantation for refractory secondary open-angle glaucoma. Two weeks postoperatively, he developed a temporal area of corneal stromal thinning consistent with dellen, located adjacent to an elevated bleb in the horizontal plane. Conservative therapy, including a switch from prednisolone acetate to loteprednol etabonate, intensive preservative-free lubrication, autologous serum drops, and bandage contact lens placement, was initiated. Full corneal re-epithelialization and recovery were achieved within 1 week, without compromising bleb function or intraocular pressure control. CONCLUSIONS Corneal dellen is a potential, although previously undocumented, complication of PreserFlo MicroShunt surgery, particularly when bleb elevation is prominent in areas not protected by the eyelid. Prompt recognition and targeted conservative therapy may allow for complete recovery while preserving device function and visual outcomes. Surgeons should monitor the ocular surface for this complication and adjust postoperative management accordingly.

BACKGROUND Scars, particularly those that are hypertrophic and retracting, are a major difficulty in dermatological and plastic surgery. Laser therapy offers a versatile approach to managing hypertrophic lip scars, addressing aspects of scar tissue, such as vascularity and collagen. CASE REPORT This case report describes a 43-year-old woman treated for a hypertrophic, retracting lip scar using fractional CO₂ laser (10 W, 1500 µs dwell time, D-pulse, 500 µm spacing, stack 1, double pass). Two sessions, 56 days apart, led to marked aesthetic and psychosocial improvement without complications. Post-treatment care included 7 days of antibiotic ointment, followed by sun protection and nightly silicone gel. Images were captured before and after the second treatment. During the procedure, the patient reported a perceived pain level of 3 on a scale of 1 to 5, indicating a moderate and tolerable level of discomfort. The Modified Vancouver Scar Scale (mVSS) chart indicated an overall improvement in scar characteristics, especially in pliability, vascularity, and pigmentation, with minimal changes in height; pain and pruritus levels remained unchanged from before the therapy. After treatments, the patient expressed extreme satisfaction with the results achieved. She reported being "extremely content and satisfied" with the improvement in her scar after laser treatment. No significant adverse effects were observed. The estimated reduced daily activity time was approximately 1 week after each session, with normal activities resumed shortly thereafter. CONCLUSIONS This case highlights the potential of CO₂ laser treatment in managing a complex hypertrophic and retracting scar, leading to notable esthetic improvement and a positive impact on the patient's emotional well-being.

BACKGROUND Achondroplasia is an autosomal dominant skeletal dysplasia and the most common genetic cause of dwarfism, characterized by shortened pedicles, thickened laminae, and reduced interpedicular distances that lead to congenital narrowing of the spinal canal. These anatomical abnormalities frequently result in lumbar spinal stenosis (LSS) requiring surgical management. Surgical treatment typically involves decompression of neural elements, with or without fusion, to restore canal patency and prevent postoperative deformity. However, adjusting the surgical approach to the unique anatomical constraints of achondroplasia remains critical for optimizing clinical outcomes. CASE REPORT We present a rare case of a 55-year-old woman with achondroplasia who presented with a 5-year history of progressively worsening low back pain, bilateral foot drop, and neurogenic claudication after walking short distances. Magnetic resonance imaging (MRI) demonstrated critical lumbar spinal stenosis at L2-L3, L3-L4, and L4-L5. She underwent multilevel laminectomy under general anesthesia with intraoperative fluoroscopic guidance and high magnification. Postoperatively, she was mobilized within 3 hours and discharged the same day without complications. At 4-week follow-up, the muscle strength of the anterior tibialis and quadriceps had improved to 4/5 on the MRC scale, patellar reflexes were normalized, and lower-limb sensation showed marked recovery. CONCLUSIONS This case highlights the importance of intraoperative precision and an appropriate surgical approach in managing lumbar spinal stenosis associated with achondroplasia. Decision-making, detailed preoperative planning with assessment of imaginary findings, intraoperative use of microsurgical techniques, and postoperative care are important in minimizing complications and optimizing clinical outcomes.

BACKGROUND Although current guidelines classify prolonged cardiopulmonary resuscitation (CPR) as a relative contraindication to thrombolytic therapy, this treatment may serve as a viable reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI) who achieve return of spontaneous circulation (ROSC) when primary percutaneous coronary intervention (PCI) cannot be performed in a timely manner or is unavailable. This case series evaluated the safety and efficacy of thrombolytic therapy after ROSC in 12 patients with STEMI. CASE REPORT Twelve patients with STEMI (9 men and 3 women; mean age, 64.33 years) who had just returned to continuous spontaneous circulation via CPR received thrombolytic therapy at 3 hospitals (Hospital I, 1 patient; Hospital II, 9 patients; Hospital III, 2 patients) between April 2007 and February 2021. Electrocardiography showed anterior wall elevation in 66.7% and inferior wall elevation in 33.3% of patients; the ischemic site was independent of CPR duration (P=0.890). CPR duration was associated with a higher incidence of rib fractures (P=0.02) but not bleeding complications (P=0.160). Binary logistic regression analysis showed no correlation between CPR duration and grade of bleeding complications (odds ratio=1). Of the 8 long-term survivors, 1 had mild neurological sequelae. CONCLUSIONS Our findings support the safety and feasibility of post-ROSC thrombolysis as a therapeutic option for patients with STEMI after comprehensive clinical evaluation, particularly in resource-limited settings where primary PCI is unavailable. This approach achieves restoration of coronary perfusion and has a potential neuroprotective effect in survivors of cardiac arrest.

BACKGROUND Immune-checkpoint inhibitors (ICIs) targeting programmed cell death-1 (PD-1), its ligand PD-L1, and cytotoxic T lymphocyte antigen-4 (CTLA-4) have revolutionized the treatment landscape of non-small cell lung cancer (NSCLC). These agents restore antitumor immunity by reactivating suppressed T cells. Although PD-L1 expression is widely used as a predictive biomarker, responses to ICIs can occur even in tumors lacking PD-L1 expression, underscoring the complexity of the tumor immune microenvironment. Ongoing research on the tumor microenvironment aims to achieve a better understanding of cancer progression mechanisms and to improve the assessment of therapeutic efficacy. CASE REPORT We present an 80-year-old man with advanced NSCLC, without any remarkable past medical history, clinically staged as IVB (cT4N3M1c), and demonstrating a PD-L1 tumor proportion score (TPS) of less than 1%. Despite this, he exhibited an excellent response to combination therapy with anti-PD-1, anti-CTLA-4 monoclonal antibodies, and cytotoxic chemotherapy during hospitalization, with manageable adverse events. Notably, pathological analysis revealed marked infiltration of CD3-positive tumor-infiltrating lymphocytes (TILs), averaging 1100/mm². CD4- and CD8-positive TILs were present in equal numbers, suggesting a balanced population of helper and cytotoxic T cells. The patient received a total of 24 cycles of immunotherapy before disease progression was confirmed. CONCLUSIONS This case highlights a striking dissociation between TIL density and PD-L1 expression, suggesting that CD3-positive TILs may reflect underlying immune activity not captured by PD-L1 status alone. Our findings emphasize the need to further explore TIL profiling as a complementary biomarker, particularly in patients treated with anti-PD-1/anti-CTLA-4-containing regimens.

BACKGROUND Occult foreign body residue after penetrating buttock injury is rare. When it progresses to a suprasphincteric high anal fistula, diagnosis and treatment are challenging because early imaging findings may be subtle and symptoms are often non-specific. This report shows the importance of obtaining a detailed trauma history, careful review of serial imaging, and sphincter-sparing surgery in such cases. CASE REPORT A 34-year-old man sustained a penetrating buttock injury from woody brambles after falling from a height. Initial X-ray results were normal, and he underwent simple debridement and suturing. Over the next 18 months, he developed recurrent perianal abscesses that were repeatedly drained at 2 centers, with persistently elevated inflammatory markers and a non-healing wound, but the occult wooden foreign body was missed on early computed tomography (CT) and magnetic resonance imaging (MRI). On presentation to our center, he had perianal pain, purulent discharge, and liquid fecal incontinence. Pelvic MRI showed a left ischiorectal fossa abscess with a central low-signal focus suggestive of a retained foreign body, and a high anal fistula tract. Trans-sphincteric surgery was performed, 5 bramble fragments were removed, and the fistula tract was adequately drained while preserving the sphincter. The wound healed completely within 2 months and no recurrence or incontinence was observed at 6-month follow-up. CONCLUSIONS In patients with a history of penetrating buttock trauma and recurrent perianal infection or non-healing wounds, the possibility of an occult retained foreign body causing a high anal fistula should be considered. Multi-modal imaging, particularly MRI, and a sphincter-sparing trans-sphincteric approach are essential to achieve complete foreign body removal, control infection, and preserve anal function.

BACKGROUND Device embolization is a rare complication of percutaneous closure of paravalvular leaks after transcatheter, surgical aortic, or mitral valve replacement. Management typically involves surgical or endovascular intervention. However, the optimal management of asymptomatic patients with a delayed diagnosis of device embolization remains unclear, as evidence for watchful waiting and/or delayed intervention is limited. CASE REPORT We present a case of 73-year-old man who had undergone endovascular closure of a paravalvular leak following transcatheter aortic valve replacement. The patient experienced device failure and recurrence of aortic stenosis symptoms, and during the redo surgical aortic valve replacement, the occluded device was discovered to have embolized to the left external iliac artery. He initially declined immediate intervention and has remained asymptomatic 1 year after diagnosis. CONCLUSIONS This case highlights the need for individualized management strategies of device embolization. While endovascular or surgical intervention remains the standard approach, watchful waiting may be appropriate in selected asymptomatic patients with delayed diagnosis of peripheral device embolization.

BACKGROUND Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Their presentation varies from bleeding to perforation, but they rarely manifest as gastroduodenal intussusception or obstructive jaundice. We report a rare case of a gastric GIST that caused intussusception leading to gastric outlet obstruction with biliary obstruction and acute pancreatitis. CASE REPORT A 71-year-old woman presented with melena, vomiting, and generalized weakness. Evaluation revealed severe anemia and elevated liver and pancreatic enzymes. Imaging and endoscopy identified a large polypoid mass in the gastric antrum prolapsing into the duodenum. Magnetic resonance cholangiopancreatography showed a dilated common bile duct but no choledocholithiasis. She was advised to undergo surgery, during which a gastroduodenal intussusception compressing the ampulla was identified. The mass was excised via gastrotomy with wide margins. Postoperative recovery was uneventful. Histopathology confirmed a low-grade (G1) gastric GIST (pT3, CD117/Discovered On GIST-1 [DOG1]-positive, Ki-67 ~3%) with clear margins. CONCLUSIONS Gastroduodenal intussusception is a rare condition in adults. Fewer than 50 cases have been reported, and more than half were attributed to GISTs. Obstructive jaundice or pancreatitis due to external ampullary compression is uncommon. Imaging modalities such as computed tomography and magnetic resonance imaging are essential for diagnosis. Surgical excision remains the mainstay of management. This case highlights a rare, complex presentation of gastroduodenal intussusception with biliary obstruction due to a gastric GIST.