American Journal of Case Reports最新文献

BACKGROUND Cognitive errors are common in medical practice and can have serious consequences for patients related to misdiagnosis and delays in diagnosis and treatment. We report a case in which cognitive error substantially influenced a patient's diagnosis and treatment. CASE REPORT This report recounts the case of an adolescent girl with symptoms similar to those of her previous episodes of tetrahydrocannabinol-induced hyperemesis, despite a 21-kg weight loss over 6 months. She sought care at multiple facilities until finally being diagnosed with superior mesenteric artery syndrome. Treatment was conservative with intravenous hydration, nasogastric feeding, and gastric decompression until duodenal compression was relieved. The patient's condition had improved at 7-month follow-up, and she declined surgical consultation. CONCLUSIONS This case report seeks to raise awareness of the effects of cognitive errors in clinical practice. This tendency to prematurely attribute symptoms to a known diagnosis and thereby overlook alternative and potentially more accurate explanations can lead to delays in diagnoses and treatments. Awareness of cognitive error is especially important in the context of the increasing prevalence of legalization of tetrahydrocannabinol/marijuana in several states. Superior mesenteric artery syndrome, although rare, is linked to high morbidity and mortality when the diagnosis is delayed; thus, it is crucial to consider it in the differential diagnosis for a patient with weight loss and abdominal pain. By sharing this case, we hope clinicians and patients can become more aware of this rare consequence of tetrahydrocannabinol use to facilitate more comprehensive patient-centered investigations.

BACKGROUND Chylous ascites is defined as the development of lipid-rich ascitic fluid in the peritoneal cavity. The formation of chylous ascites revolves around non-portal-based and portal-based etiologies, and the diagnosis is made via paracentesis revealing an elevated triglyceride level and milky-white appearance. Chylous ascites is often reported as a postoperative complication in surgical procedures, but it has also been documented in cases of cirrhosis, malignancy, and tuberculosis. However, chylous ascites is rarely seen in chronic pancreatitis and non-cirrhotic portal hypertension. This report presents the case of a 65-year-old man with a history of necrotizing pancreatitis and portal hypertension amidst an incidental finding of chylous ascites upon elective umbilical hernia repair. CASE REPORT We present the case of a patient with chylous ascites discovered during hernia repair. A 65-year-old man with no alcohol or tobacco use and a history of recurrent episodes of acute necrotizing pancreatitis was admitted for umbilical hernia repair. However, upon entering the abdominal cavity, an enlarging mass of ascitic fluid was encountered and tracked into the hernia sac. The fluid was drained via paracentesis and cytology revealed chylous ascites. The patient was discharged in stable condition and was advised to consume a high-protein, low-fat diet. Postoperative computed topography (CT) demonstrated an unchanged necrotic mass in the head of the pancreas. CONCLUSIONS This report demonstrates that when dealing with unexpected findings, it is important to consider the existence of multiple pathologies as the driving cause. We describe a complex cause of chylous ascites, along with a review of the literature on the relationship between chylous ascites and chronic pancreatitis.

BACKGROUND Coronary artery aneurysms in patients with Kawasaki disease may develop acute myocardial infarction. It is challenging to achieve complete revascularization solely through percutaneous coronary intervention in these patients. Therefore, coronary artery bypass grafting is often necessary. CASE REPORT We present a case of a 68-year-old woman who developed multiple acute myocardial infarctions due to giant aneurysms formed in the right coronary artery (RCA) and the left circumflex artery (LCx). We diagnosed the cause of the aneurysms as Kawasaki disease based on the coronary angiogram, laboratory results, and family history. After the primary balloon angioplasty, we conducted coronary artery bypass grafting, which involved grafting 2 vessels to the LCx and 1 vessel to the RCA. The internal thoracic arteries, which are the standard graft vessels, were occluded, most likely due to Kawasaki disease vasculitis. Instead, we used saphenous vein grafts harvested using the "no-touch" technique, which preserves the perivascular adipose tissue, to improve the long-term patency. In addition, we ligated the LCx aneurysm to prevent occlusion of the grafts and rupture of the aneurysm. Four years after the uneventful discharge, the patient is in good health and coronary computed tomography angiography revealed good patency of all grafts. CONCLUSIONS This report highlights a successful combination of "no-touch" saphenous vein grafting and coronary aneurysm ligation in an adult patient with Kawasaki disease. These techniques may be especially useful for this vasculitic illness which is often associated with occlusion of internal thoracic arteries.

BACKGROUND Simultaneous occurrence of chronic lymphocytic leukemia (CLL) and plasma cell myeloma (PCM) is an uncommon hematological condition, with most patients presenting in late adult life. When these diagnoses occur concurrently, it often poses diagnostic challenges to the pathologist, with other important differential diagnoses including lymphoplasmacytic lymphoma, marginal-zone lymphoma, and chronic lymphocytic leukemia with plasmacytoid differentiation. Ancillary studies are indispensable in arriving at a reliable diagnosis in this clinical scenario. CASE REPORT We present 2 cases of simultaneous CLL and PCM that were diagnosed in our facility. The bone marrow in these patients showed increased plasma cells with a separate population of neoplastic lymphoid cells. Bone marrow examination and ancillary studies (immunohistochemistry, fluorescence in situ hybridization, and molecular studies) were performed in both cases to arrive at the diagnosis and rule out other important differential diagnoses. While the first patient was still being observed at the time of writing this report, and found to be clinically stable during his last clinic visit, the second patient succumbed to the disease as a result of gram-negative sepsis. CONCLUSIONS CLL and PCM can occasionally co-exist, posing diagnostic challenges to the pathologist. Ancillary diagnostic techniques are important in making a correct diagnosis. Making an accurate diagnosis is vital as this will guide appropriate treatment strategies. Whenever these 2 conditions occur simultaneously, patients often succumb as a result of progression of PCM.

BACKGROUND Taeniasis is a helminthic infection caused by the Taenia species, specifically T. solium, T. saginata, and T. asiatica. Generally, the parasites infect the small intestine; however, instances of atypical migration have also been reported. CASE REPORT A 47-year-old Thai woman presented to Nan Hospital with epigastric pain, nausea, and vomiting. Physical examination revealed tenderness in the right upper quadrant, and laboratory analysis revealed mild direct hyperbilirubinemia. Abdominal ultrasonography revealed multiple gallstones and acute cholecystitis. During an elective cholecystectomy, a 70-cm-long tapeworm was found in the gallbladder. Histological examination confirmed the presence of parasitic infection suggestive of Taenia spp., with acute inflammation and focal mucosal necrosis of the gallbladder. Microscopic examination revealed 20 to 22 uterine branches in each of the 5 gravid proglottids, with 42 to 55 uterine twigs and an average ratio of uterine twigs to branches of 2.41, confirming that the parasite in question was possible for T. saginata or T. asiatica. The patient's symptoms resolved after surgery. She was prescribed an oral antibiotic and antiparasitic drug after the operation and experienced no post-surgical complications. CONCLUSIONS Certain parasitic worms can migrate from the intestine to the biliary system. Although less common, T. solium, T. saginata, and T. asiatica can also be detected in the gallbladder and cause acute cholecystitis. This case stresses the potential for misdiagnosis in imaging studies and advises clinicians in endemic areas to consider Taenia spp. infections in the biliary system.

BACKGROUND Acquired synkinesis is a well-known phenomenon following oculomotor nerve injury. The abnormal movement appears within the distribution of 1 nerve, or other cranial nerves may be involved. The common misdirection of aberrant regeneration of oculomotor nerve involves the lid, extraocular muscles, or pupil. This report presents a case of aberrant connection between abducens and oculomotor nerve, which is quite rare. CASE REPORT A 21-year-old man with history of left-sided frontal, lateral orbital wall, and zygomatic fracture from head trauma in a motor vehicle accident presented for evaluation. He was comatose for 6 weeks in the intensive care unit. Six months later, he presented to the ophthalmology clinic for an eye examination. He had no history of eye problems prior to this accident. His best corrected visual acuity in the right eye was 20/20 and the left eye had no light perception. The right eye exam was normal, with normal ocular motility. The left eye exam showed small esotropia in primary position with markedly decreased adduction, elevation, and minimal depression, but on attempted abduction, the left eye would adduct instead. There was no globe retraction when left eye abduction was attempted. The abnormal movement seen resulted from third nerve function during sixth nerve stimulation, due to unusual ocular motility with abnormal connection between the sixth and third cranial nerves. CONCLUSIONS The most likely pathophysiologic mechanism here is peripheral neuronal misdirection hypothesis after trauma. Careful and detailed examination of a patient presenting with unusual ocular motility after trauma is very important. The abnormal connection between the sixth and third cranial nerves is quite rare but can occur.

BACKGROUND Obesity hypoventilation syndrome (OHS) is characterized by hypercapnia in obese patients, with acute hypercapnic respiratory failure often worsened by various conditions. Managing super-super obese patients presents complex challenges in critical care. Our case report details the successful treatment of acute respiratory failure in a patient with a body mass index (BMI) over 80 kg/m², highlighting the importance of comprehensive, multidisciplinary care in the Intensive Care Init (ICU). CASE REPORT A 39-year-old man with a BMI of 81.1 kg/m² presented to our emergency department with respiratory distress, altered consciousness, and an inability to move independently. Arterial blood gas analysis revealed severe hypercapnia and hypoxemia, indicating decompensated OHS. Laboratory tests and computed tomography scans suggested his condition was exacerbated by pneumonia and congestive heart failure. The patient was managed in the ICU with endotracheal intubation, mechanical ventilation, and esophageal pressure monitoring. In addition to antibiotics, diuretics were used to manage fluid balance. His care included multidisciplinary support with nutritional management and active physiotherapy. After 15 days, he was weaned from the ventilator and discharged from the ICU on day 20, continuing rehabilitation until he was discharged home on day 60. CONCLUSIONS This case report describes the successful treatment of acute hypercapnic respiratory failure from decompensated OHS in a super-super obese patient. Addressing the underlying conditions and tailoring clinical practices to the patient's specific needs, especially regarding ventilatory support, fluid balance, and nutrition, were crucial. A collaborative multidisciplinary approach was essential for improving outcomes.

BACKGROUND Adult-onset Still's disease (AOSD) is a rare multisystem inflammatory disorder with a highly variable clinical presentation. Pulmonary complications of AOSD most commonly include pleural effusion and transient pulmonary infiltrates. In extremely rare cases, pulmonary arterial hypertension (PAH) develops as a complication. We present the case of a 49-year-old woman with adult-onset Still's disease presenting with fever, dyspnea, and pleuritic chest pain who was diagnosed with PAH. CASE REPORT A 49-year-old woman with a history of adult-onset Still's disease presented to the Emergency Department due to 1 week of fever, dyspnea, and pleuritic chest pain. Imaging, cardiac, immunologic, and infectious workups were performed and detected elevated inflammatory markers. She then underwent right-heart catheterization, which revealed high pulmonary artery pressure (PAP) and mean PAP at 43/18 mmHg and 27 mmHg, respectively. The patient was stabilized and discharged for further management of heart failure with preserved ejection fraction, and group 1 pulmonary arterial hypertension secondary to Still's disease. CONCLUSIONS Pulmonary complications of adult-onset Still's disease, such as PAH, are rare but potentially life-threatening. The treatment of PAH in adult-onset Still's disease involves the use of pulmonary vasodilators, immunosuppressive therapy, and regular monitoring to assess the prognosis of PAH. Our case report highlights the importance of considering PAH in patients with adult-onset Still's disease who present with dyspnea, fatigue, and chest pain. Increased clinician awareness of this extremely rare complication of AOSD can assist with rapid identification and improved patient outcomes.

BACKGROUND Diffuse intrinsic pontine glioma represent approximately 10% to 20% of all pediatric central nervous system tumors. Classic brain stem symptoms are cranial nerve deficits, long tract signs, ataxia, alone or in combination. Focal radiotherapy has been the standard of care in patients with diffuse intrinsic pontine gliomas with minimum response. Here, we present an unusual case with excellent tumor regression with radiotherapy and good clinical outcome. CASE REPORT A 13-year-old girl presented with headache and imbalance during walking for the past 2-3 months, along with a deviation of the right eye in the last month. Brain magnetic resonance imaging (MRI) suggested a well-defined solid cystic altered-signal-intensity lesion involving the pons and medulla, causing its expansion up to the midbrain on the left side. The lesion was 4.6×3.7×3.6 cm. We applied the intensity-modulated radiotherapy technique (IMRT) using a 6-MV photon beam with the conventional dose fractionation of 54 Gy in 30 fractions (1.8 Gy/fraction). Three months later, MRI brain with spectroscopy and perfusion showed evidence of non-enhancing, altered-signal-intensity lesion in the pons and medulla, measuring 1.9×2.2×2.4 cm. CONCLUSIONS Early detection of symptoms of DIPG in a young patient along with effective radiological investigation with valid tumor board decision as definitive radiotherapy as a sole therapeutic treatment option and with robust radiotherapy planning resulted in an excellent response, with 80% reduction in gross tumor volume (GTV) as seen in pre-radiotherapy (RT) and post-RT MRI images.

BACKGROUND SARS-CoV-2 caused a worldwide pandemic, and mRNA vaccines against the SARS-CoV-2 spike protein were developed to avoid SARS-CoV-2 infection. Short-term adverse events, such as fever, malaise, body aches, and headaches, develop within a few days following COVID-19 vaccination. Those adverse events are common and widely known as transient reactions. Recently, an association with COVID-19 vaccine as an inducer of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has been noted. Furthermore, a relationship between COVID-19 vaccination and the development of autoimmune diseases has been reported and termed rheumatoid immune-mediated inflammatory disease. However, the mechanisms of the immune response following COVID-19 vaccination in relation to ANCA-associated vasculitis development remain unclear. CASE REPORT We report a case of a female patient who developed otitis media with ANCA-associated vasculitis following the third dose of COVID-19 mRNA vaccination. A 74-year-old woman presented with bilateral hearing loss and malaise for 1 month after COVID-19 vaccination. Serum myeloperoxidase-ANCA levels were confirmed to be elevated, and pure-tone audiometry revealed moderate bilateral mixed hearing loss. Treatment with steroids and rituximab led to recovery of hearing loss and a reduction in myeloperoxidase-ANCA titre. CONCLUSIONS The pathogenesis of adverse events following COVID-19 vaccination are still unclear. This report has indicated that ANCA-associated vasculitis can be related to COVID-19 mRNA vaccines. As our knowledge of autoimmune disease developing after COVID-19 vaccination is still in the accumulation phase, it is relevant to amass such case reports and use them for assistance in diagnosis in the future.