BMJ Case Reports最新文献

Background: Angular pregnancy is a rare event and is a commonly missed diagnosis in the antepartum period. Data regarding the optimal mode of delivery and management of the placenta are limited.

Case description: A patient in her 30s, gravida 3, para 1 presented at 37 weeks with severe range blood pressure and was admitted for induction of labour due to preeclampsia. Her labour course and delivery of the neonate were uncomplicated. Despite attempts at manual extraction and suction dilation and curettage, the placenta was unable to be removed. Ultrasound revealed the placenta in the right cornua, suspicious for angular pregnancy. She was taken to the operating room for exploratory laparotomy and hysterotomy for extraction of the placenta. She had an uncomplicated postpartum course and was discharged home on postpartum day 4.

Conclusion: In patients with suspected angular pregnancy, exploratory laparotomy and hysterotomy may be required for placental removal.

Rectal cancer metastasising to the penis is an exceptionally rare clinical entity, with less than 80 reported cases. Metastasis to the penis is typically identified in conjunction with widespread metastatic disease and as such is usually associated with a very poor prognosis. We report a case of a man who presented with a metastatic deposit in his penis 15 years after the initial diagnosis of rectal cancer. The patient was initially managed with radical penectomy and perineal urethrostomy formation. This was followed by FOLFIRI chemotherapy regimen when further nodules were identified in his lungs on postoperative imaging. At 20months' follow-up, the patient remains alive and disease-free.

A previously healthy female infant was brought to the paediatrics outpatient department by her mother reporting increased irritability and swelling behind her left shoulder, accompanied by restricted movement in her left arm. The irritability had been present for the past 5 months, with swelling also noticed at that time, gradually increasing in size. On examination, a large, firm, immobile mass was detected on the left scapular region. The mass was tender to touch, without any hardening or induration of the overlying skin. The child was afebrile, and her vital signs were stable. Subsequent imaging revealed hyperostosis in the left scapula, along with swelling of the surrounding soft tissue. After ruling out conditions such as chronic osteomyelitis, Ewing's sarcoma, rhabdomyosarcoma, trauma or child abuse, chronic recurrent multifocal osteomyelitis and hypervitaminosis A, the findings pointed to Caffey disease. Although infantile cortical hyperostosis, or Caffey disease, is rare, it should be considered in the differential diagnosis of a bony swelling in a young child.

A woman in her 20s presented with nephrotic syndrome and hyperemesis in early pregnancy. Pertinent initial investigations revealed a severe acute kidney injury, a serum albumin of 19 g/L, a random protein creatinine ratio of 800 g/mol and microscopic haematuria. All immunological and infection serology testing including anti-glomerular basement membrane (anti-GBM; ELISA) were negative. Kidney biopsy demonstrated diffuse crescentic glomerulonephritis with cellular crescents involving >90% of glomeruli, with immunofluorescence demonstrating intense linear reactivity for IgG consistent with atypical anti-GBM glomerular nephritis. Early pregnancy termination and treatment with immunosuppression were chosen after shared decision-making between the patient and physician. The patient had a poor response to treatment and remained dialysis dependent 12 months later.

Scrotal calcinosis is an infrequent benign pathological condition characterised by the presence of multiple calcified nodules on the skin of the scrotum. Despite the formulation of several theories, the precise pathogenesis of this condition remains a subject of controversy within the scientific community. The predominant concern associated with scrotal calcinosis is of an aesthetic nature, and histological examination serves as the definitive method for confirmation of the diagnosis. The manifestation of scrotal nodules and cysts is an uncommon occurrence, and in cases where these manifestations are asymptomatic, the diagnostic timeframe may extend over several years, potentially spanning decades. Surgical excision of the calcified lesions is the established treatment modality, serving both diagnostic and therapeutic objectives.

This case report describes a woman in her late 50s with mesenteric volvulus, an uncommon and potentially fatal condition. She developed excessive abdominal distension, nausea and vomiting for a duration of 2 days. The preliminary ultrasound indicated a large, thick-walled, tight fluid region in her upper abdomen, indicating a probable gastric outlet obstruction. A subsequent contrast-enhanced CT scan of the abdomen confirmed the diagnosis, showing significant distension of the stomach with a thick septum displacing adjacent organs. The mesenteric volvulus was surgically treated as an emergency to restore blood flow to the afflicted mesentery. This condition poses a serious concern due to decreased blood flow and ischaemia, and this example emphasises the necessity of a CT scan for early and precise diagnosis and offers a comprehensive insight into the nature of the volvulus, resulting in prompt surgical treatment and improved patient outcome.

We present the case of a patient with cystic fibrosis on long-term oral linezolid treatment for Mycobacteria abscessus lung infection who developed severe linezolid-induced lactic acidosis (LILA) resulting in deranged clotting and pancytopenia. The lactic acidosis was resistant to treatment with intravenous fluid but resolved within 20 hours of initiating continuous veno-venous haemofiltration. An unintended consequence of haemofiltration was that vascular access interfered with effective chest physiotherapy, resulting in worsened lung consolidation requiring prolonged intravenous antibiotic therapy for coexisting Pseudomonas aeruginosa infection. Given the potential mortality and morbidity of LILA, monitoring lactate levels may be clinically important but the optimum timing of monitoring is currently unclear.

Acquired factor V (FV) inhibitors are extremely rare and present with a broad spectrum ranging from asymptomatic laboratory anomalies to life-threatening critical bleeds. The overall rarity along with the heterogeneity of clinical presentations poses a challenge in diagnosis. There is currently no standard of care immunosuppressive therapy (IST) in these settings. Most patients in the literature receive multiple agents, including but not limited to combinations of IST and/or recombinant products.Here, we present a case of a man in his 50s who initially presented with oozing at peripheral IV and tracheostomy sites with intermittent epistaxis. He was later found to have an FV activity level of less than 1% and an FV inhibitor titre of 184 Bethesda units/mL. The patient was initially stabilised with fresh frozen plasma, platelets and tranexamic acid and treated with intravenous immunoglobulin and glucocorticoids. However, this resulted in only mild improvement in his coagulation studies. He was then treated with weekly doses of rituximab for 4 weeks with ongoing glucocorticoids without complications. This adds to the growing literature on rituximab as a possible treatment option for acquired FV inhibitors.

A woman in her early 60s presented to the emergency room with worsening pain 10 days after an injury to her right abdomen. CT revealed a large subcutaneous haematoma and contained small bowel perforation. She was tachycardic and anaemic and her international normalized ratio (INR) was 2.6 on warfarin for atrial fibrillation. General surgery was consulted and percutaneous drainage of the perforation was recommended, requiring an INR of 1.5 or less. Intravenous (IV) phytonadione was administered to accelerate the lowering of INR; however, the patient developed a severe infusion-related reaction. She recovered once IV phytonadione was stopped and oral diphenhydramine was administered. However, there was still a need for warfarin reversal therapy. A 1.25 mg dose of oral phytonadione was trialled 2.5 hours later and well tolerated. An additional rechallenge of 5 mg by mouth was given without reaction (<8 hours after the initial reaction). Her INR was 1.5 the next morning.

Protein C deficiency is a hereditary disorder that increases the risk of thrombotic events but has unclear effects on rotational thromboelastometry (ROTEM) analysis. A man in his 60s with a history of protein C deficiency and multiple thrombotic events underwent inferior vena cava (IVC) filter removal, iliocaval thrombectomy and infrarenal IVC placement for IVC-related complete iliocaval and common femoral vein thromboses. A ROTEM analysis showed normal coagulation in NATEM and EXTEM and only a slight shortening in A10 and A20 in INTEM, which was unexpected given his diagnosis of protein C deficiency. Normal results indicate that there is complexity and variability of coagulation to maintain a balanced state even in individuals with underlying coagulation disorders.