American Journal of Case Reports最新文献

The Figures were published in the incorrect order with incorrect captions. Below are the corrected versions. Reference: Karolina Spodzieja, Piotr Sobiech, Dorota Olczak-Kowalczyk. Innovative Combination of Tetracycline Rinse and CO₂ Laser Ablation for Treating White Sponge Nevus in Adolescents: A Case Study. Am J Case Rep 2024; 25:e944795. DOI: 10.12659/AJCR.944795.

BACKGROUND Methanol is a toxic alcohol that is often ingested accidentally or intentionally. Its metabolites can induce severe visual disturbances, metabolic acidosis, and neurological dysfunction, which can frequently become life-threatening. CASE REPORT A 44-year-old woman with a history of depression and alcohol use was hospitalized in the Intensive Care Unit after cardiopulmonary reanimation. According to relatives, an empty bottle of household chemicals was found next to the patient. The patient had symptoms of vomiting, headache, and vision loss. The patient had a hypertensive crisis, with blood pressure of 180/110 mmHg. Initially, on the computed tomography of the head, no conclusive acute changes were detected. However, a slight hypodensity in the basal nuclei was marked retrospectively. On day 4, magnetic resonance imaging of the head was performed, showing symmetrical acute ischemic changes in the basal nuclei with hemorrhage and spreading into the ventricles, and acute occlusive hydrocephalus. Bilateral acute symmetric ischemic changes of both optic nerves with cytotoxic edema were also detected on diffusion-weighted imaging. Dynamically, the condition did not improve, and all vital functions worsened. The patient's lethal outcome was confirmed. CONCLUSIONS Cerebral hemorrhage is a rare and serious complication of methanol poisoning. Early sign detection of methanol intoxication is crucial due to the rapid progression of severe, irreversible complications. Neuroimaging has a significant role in diagnosing and understanding the extent of damage in methanol poisoning cases.

BACKGROUND Congenital pericardial agenesis is a rare condition that is frequently associated with abnormal intrathoracic anatomy, especially malpositioning of the heart within the thoracic cavity. In the setting of coronary artery bypass, these anatomic derangements can present surgical challenges that can necessitate incorporating complementary, non-surgical solutions for complete revascularization. CASE REPORT A 48-year-old male patient presented with acute anginal symptoms, with workup revealing severe, multivessel coronary artery disease, as well as partial absence of the pericardium. Preoperative imaging revealed a severely displaced heart deep into the left chest. He was subsequently scheduled for coronary artery bypass grafting. However, altered anatomy from the absent pericardium required the procedure to be unexpectedly modified intraoperatively to address displaced coronary vessel targets that were surgically inaccessible. The patient's anterior vessels were grafted without complication, but the lateral and posterior vessels were unable to be grafted, due to excessive manipulation of the heart required for visualization. An intra-aortic balloon pump was utilized to maximize perfusion until a percutaneous coronary intervention could be completed by a cardiologist in these remaining vessels. CONCLUSIONS While congenital pericardial agenesis is a rare condition, the anatomic abnormalities encountered in this case are not uncommon within this patient population. These variances can interfere with standard coronary artery bypass grafting techniques. Understanding the unique challenges present in patients with this condition can aid in preoperative planning and coordination of a multispecialty approach for complicated revascularization.

BACKGROUND Brunneromas are among the rarest benign tumors of the upper gastrointestinal tract. They arise from the Brunner's glands and patients have a good prognosis if treated timely and radically. Because symptoms are rare, their diagnosis can be challenging, especially regarding the smaller ones. The symptoms reflect a vast spectrum, from asymptomatic to severe obstructive symptoms and bleeding. Given the elevated clinical suspicion, it is imperative to accurately diagnose these tumors. CASE REPORT We present a case of a 39-year-old male patient with a giant Brunneroma in the second segment of the duodenum. He was admitted to the hospital due to melena, epigastric pain, and persisting anemia during the last 2 months preceding his admission. A computed tomography (CT) scan revealed a tumor in the second pars of the duodenum. Following an endoscopic examination and biopsy of the tumor, the case was presented to the multidisciplinary team (MDT) at our hospital. In accordance with the recommendation of the MDT, the patient underwent laparotomy and duodenum-preserving radical tumor excision, without any adverse incidents. The final histopathological reports and preoperative biopsies established the diagnosis of Brunneroma. CONCLUSIONS Because of their rarity and benign character, Brunneromas are often unsuspected and may not have surveillance protocols and proper treatment. This case report presents our experience and perspective regarding the most advisable approach, the differential diagnosis, treatment, and management of these tumors.

BACKGROUND Coronary artery ectasia (CAE) represents not only an anatomical variant but also a clinical constellation of coronary artery disease associated with acute coronary syndrome (ACS). There is no consensus on the antithrombotic treatment for patients with CEA. CASE REPORT A 34-year-old man with severe diffuse dilatation of the left main artery and left circumflex (LCX) proximal segment confirmed by coronary angiography (CAG) developed 2 acute myocardial infarctions (AMIs), due to occlusion of a dilated LCX segment with thrombus shadows, within a 9-year interval. Emergency percutaneous coronary intervention with aspiration thrombectomy failed to restore adequate blood flow at the first presentation of AMI, and the patient was eventually discharged with warfarin. After 15 months, however, he discontinued the medication on his own. After a 9-year interval, the patient experienced the second AMI, and CAG revealed occlusion of the LCX opening with thrombus shadows and collateral circulation visible from the distal segment of the right coronary artery to the circumflex branch. Thereafter, the patient began to take rivaroxaban 20 mg once daily. No chest pain or ACS events occurred during 1 year of follow-up. CONCLUSIONS This case of 2 AMI events at the CAE segment caused by local thrombus formation suggests that lifetime systemic anticoagulation therapy for secondary prevention should be considered in such cases, and a novel oral anticoagulant may be a better choice for effectively preventing thrombosis.

BACKGROUND Tirzepatide is a long-acting glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist administered via subcutaneous injection for weight reduction and treating type 2 diabetes. CASE REPORT We report case series of hypoglycemic ketoacidosis after the use of tirzepatide to treat nondiabetic patients with obesity from Kuwait. The first case was a 29-year-old woman with a body mass index (BMI) of 32 kg/m² who developed abdominal pain and vomiting after increasing the dose to 5 mg subcutaneously in week 5 of treatment. The second case was a 34-year-old woman with a BMI of 31.3 kg/m² who presented with abdominal pain, vomiting, and diarrhea after increasing the dose to 5 mg subcutaneously. The third case was a 17-year-old girl with a BMI of 30.4 kg/m2 who presented with abdominal pain, vomiting, and diarrhea in week 5 of treatment. The fourth case was a 26-year-old woman with a BMI of 30.8 kg/m² who presented with abdominal pain, frequent loose motions, and vomiting. The median blood sugar level was <3.89 mmol/L and high anion gap metabolic acidosis with ketosis occurred. All the patients required inpatient treatment with intravenous fluid and the correction of hypoglycemia and ketosis. CONCLUSIONS Tirzepatide can induce hypoglycemic ketoacidosis in nondiabetic patients with obesity when used for weight reduction. Measuring urine and serum ketone levels in patients with gastrointestinal symptoms who are taking dual GLP-1 and GIP receptor agonists is crucial. Medical supervision is recommended when this medication is prescribed.

BACKGROUND Arterioportal fistulas (APFs) are abnormal connections between the arterial and portal venous systems, leading to portal hypertension (PH) and symptoms such as gastrointestinal bleeding, splenomegaly, and hepatic pain. Symptoms typically appear by the age of 2 years in about 75% of cases. CASE REPORT A 7-year-old boy with an asymptomatic APF developed life-threatening complications following a Clostridium difficile infection. He initially had chronic diarrhea, abdominal pain, weight loss, and anorexia for 3 weeks, despite normal liver enzymes. After antibiotic and antifungal treatment, his condition worsened, resulting in severe anemia and hemorrhagic shock due to variceal bleeding. Further evaluations revealed significant PH secondary to the APF. Intensive care involved blood transfusions, fluid resuscitation, and high-frequency ventilation. Emergency embolization successfully reduced PH and controlled bleeding. After stabilization, the patient was transferred for further care. A week later, a color Doppler ultrasound (CD-US) detected a thrombus in the left portal vein, which decreased by the 19-day follow-up. Spleen size reduction indicated decreased portal pressure. The presence and reduction of the thrombus and alleviation of PH symptoms indicate therapeutic success. Ten months after embolization, the patient remained asymptomatic, with normal liver function and no thrombus on follow-up imaging. CONCLUSIONS Early diagnosis and intervention are crucial in managing congenital APF in children. Severe variceal bleeding triggered by exacerbated PH due to a Clostridium difficile infection demonstrates the complications of APF. Endovascular treatment was highly effective, resulting in significant improvement. The recommended diagnostic approach includes initial computed tomography angiogram and CD-US, followed by digital subtraction angiography with possible intervention, and monitoring with CD-US.

BACKGROUND Open injury of multiple organs in the chest and abdomen, such as the colon, duodenum, kidney, liver and diaphragm, is relatively rare. The rescue of such a patient is difficult, and the results are often unsatisfactory. It is also a challenge for the hospital and doctors. CASE REPORT A 44-year-old man was injured by a heavy falling iron plate on a construction site. The right side of his abdomen was severely lacerated, with a 30-40-cm long wound and multiple exposed abdominal organs. He was send to our Emergency Department within 2 h, with gauze covering the wound. The relevant examinations were completed immediately, and emergency surgery was performed in a multidisciplinary manner. During surgery, we found that the hepatic flexure of colon, right kidney, and descending duodenum was ruptured, there was mild laceration to the liver, and the right diaphragm was ruptured, with hemopneumothorax. The right kidney, right half colon, gallbladder, duodenum, and part of the head of the pancreas were removed. Ileostomy was done, and gastric-intestine, biliary-intestine, and pancreas-intestine anastomosis were done. The liver and diaphragm were repaired. The patient was discharged after 23 days in hospital, without any serious complications. One year later, the ileostomy was closed in our hospital. CONCLUSIONS Multidisciplinary collaboration and adherence to evidence-based guidance are important for rescuing patients with severe chest and abdominal trauma.

BACKGROUND Recent studies have shown that peribiliary glands may be the potential cell origin of cholangiocarcinoma, and that precancerous lesions such as biliary intraepithelial neoplasms and intraductal papillary neoplasms of the bile duct may arise from these peribiliary glands. However, whether and how these precancerous lesions progress to cholangiocarcinoma is controversial. CASE REPORT Herein, an autopsy case of perihilar cholangiocarcinoma, exclusively periductal-infiltrating, is reported. Since repeated transpapillary biopsies and cytology showed no carcinoma cells, the patient was treated for sclerosing cholangitis until death. The findings at cholelithiasis treatment 1 year earlier had not aroused suspicion of the presence of precancerous lesions. The changes in the spread of bile duct stenoses on cholangiography and the unique findings at autopsy, namely (i) the distribution of cancer growing locally within the peribiliary gland compartment without invading the bile duct mucosa and (ii) the existence of in situ-like carcinoma cells replacing the epithelium of the peribiliary glands throughout the extrahepatic bile duct, suggested that cholangiocarcinoma arose from the peribiliary glands in the hilum without a detectable precancerous lesion and then spread to the lower end of the common bile duct via the peribiliary gland network. CONCLUSIONS This case report may help further our understanding of the natural history of cholangiocarcinoma and provide clues about cholangiocarcinogenesis and progression. In addition, histological and cytological diagnosis could be theoretically difficult by sampling tissue from the bile duct lumen in cholangiocarcinoma, as in this case.

BACKGROUND Malignant hyperthermia (MH) and anesthesia-induced rhabdomyolysis (AIR) are rare, yet life-threatening complications that need prompt therapeutic actions and logistic preparedness for treatment success. Both conditions are triggered by general anesthetics, particularly volatiles and depolarizing muscle relaxants. In comparison with MH, which is an inherited pharmacogenomic disease of calcium channel receptor subpopulation and arises only after trigger exposure, AIR has been described mostly in patients with muscular dystrophies. In perioperative settings, rhabdomyolysis is also observed during propofol infusion syndrome, neuroleptic malignant syndrome, and cocaine, heroin, and alcohol intoxication. Despite their diverse etiology, the main clinical manifestations of MH and AIR overlap: a hypermetabolic state, hyperpyrexia, hypercarbia, acute renal failure, and hyperkalemia progressing to cardiac arrest, making the therapeutic approach to the patient extremely difficult. CASE REPORT We present an unenviable and challenging clinical scenario of an obligatory general anesthesia with endotracheal intubation in a patient with difficult airways for breast conserving onco-surgery with simultaneous targeted intraoperative 20 Gy irradiation. The case was complicated even further by coincident suspicious clinical presentation of a mild and self-limited hypercarbia, together with a protracted rhabdomyolysis, without hyperpyrexia. Given the atypical and scarce clinical presentation leading to diagnosis uncertainty of MH or AIR, which was proved only after receiving the genetic results, dantrolene was not administered, and the patient underwent successful supportive treatment. CONCLUSIONS The study points to the diagnostic dilemma - crisis event MH or AIR - and raises issues about possible preoperative preventive measures and treatment options in patients with an uncertain diagnosis.