BMJ Case Reports最新文献

The BOOST-2 trial indicated that optimising brain oxygen (PbtO2) could be a viable therapeutic target for severe traumatic brain injury (sTBI). Previous studies have suggested the safety of airway pressure release ventilation (APRV) in sTBI patients, but its effect on PbtO2 has not been demonstrated. This study is aimed to show that APRV can improve PbtO2 in sTBI patients. In a retrospective case series, two sTBI patients with controlled intracranial pressures developed refractory hypoxemia and brain hypoxia, unresponsive to traditional therapies. Treated with APRV, both patients showed improved hypoxemia and increased PbtO2 levels above 20 mm Hg without adverse effects on intracranial pressure. They recovered from hypoxemia, transitioned to assist-controlled ventilation and were discharged to rehabilitation. These cases suggest that APRV can safely and effectively improve PbtO2 in sTBI patients when other treatments fail, warranting further exploration pending results from the ongoing BOOST-3 trial.

Various factors limit the acceptability of methadone as an opioid agonist treatment (OAT), in which case, buprenorphine becomes the preferred alternative. The classical approach is to gradually taper methadone to a low dose and buprenorphine is initiated after some opioid-free period, which generally takes weeks. A novel approach known as 'microdosing' or the 'Bernese method' might serve as a valuable alternative. We describe two cases where the patients were successfully transitioned from methadone to buprenorphine using this method.

Klebsiella variicola is part of the K. pneumoniae complex and has been recently identified to have pathogenic properties. Emerging reports show that it can cause bloodstream, respiratory and urinary tract infections. It has been shown to be an important causative agent in immunocompromised individuals. We report here three cases of K. variicola peritonitis encountered in our peritoneal dialysis patients.

We report the rare entity of ulcerative colitis-related severe enteritis (UCRSE) following colectomy in a child. This entity has been described primarily in adults and is characterised by diffuse enteritis with histology identical to ulcerative colitis (UC). The mainstay treatment is steroids and in recent years anti-tumour necrosis factor agents.A boy in early adolescence required urgent colectomy for medically refractory severe acute colitis. Colectomy specimen histology confirmed UC. Postoperatively, he developed fevers, severe abdominal pain and excessive stoma output (5 L/day). Endoscopy revealed severe extensive enteritis, histologically resembling UC. Infliximab (IFX) was commenced with significant improvement. He remains asymptomatic 28 months post-colectomy on maintenance IFX monotherapy. To our knowledge, this is the youngest patient with this complication.This case illustrates the need to consider UCRSE in a child with otherwise unexplained fever, severe abdominal pain and high stoma output post colectomy. IFX monotherapy is a successful treatment option.

A man in his 60s presented to the emergency department with central crushing chest pain on a background of a week's history of flu-like symptoms. An ECG demonstrated ischaemia with blood tests confirming myocardial injury; catheter angiography revealed an obstructed diagonal coronary artery. In addition, blood tests revealed elevated markers of inflammation, blood cultures grew Streptococcus gordonii and transthoracic echocardiography demonstrated a mitral valve lesion. A diagnosis of embolic infarction secondary to native mitral valve infective endocarditis was made. Imaging with [¹⁸F]Flurodeoxyglucose Positron Emission Tomography CT, cardiac MRI and brain MRI confirmed myocardial infarction, mitral valve infection and embolic phenomena within the brain, respectively. This case reinforces the need for strategic flexibility when faced with evolving clinical data, the role of multidisciplinary involvement in an endocarditis team and the benefits of multimodality imaging techniques to secure diagnostic certainty.

Tricuspid valve disease in carcinoid heart syndrome is usually diagnosed via screening echocardiography in patients with known carcinoid syndrome. Vasoactive intestinal peptide tumour (VIPoma) is a rare tumour with an incidence of 0.05%-2% that typically presents with symptoms related to the release of vasoactive intestinal peptide: flushing, diarrhoea and electrolyte abnormalities like hypokalaemia and hypochlorhydria. Historically, the cardiac valves are unaffected. We present a case where a finding of tricuspid regurgitation and stenosis on echocardiography prompted an expedited workup for malignancy ultimately leading to a diagnosis of VIPoma.

This case represents a young, previously healthy woman with intermittent palpitations, who was found to have a left ventricular outpouching. Imaging with echocardiography and magnetic resonance revealed a mildly dilated left ventricle with a slightly reduced ejection fraction. The outpouching was characterised as a left ventricular diverticulum (LVD) as it involved all three layers of the heart wall with synergistic contraction. This is an extremely rare, usually incidentally found entity. Management is based on case reports as guideline-based therapies lack with a wide range of treatment options, from watchful waiting to surgical repair, suggesting an unmet clear management strategy. Despite slightly reduced exercise capacity, symptoms and imaging findings remained stable over a period of 8 years with medical therapy and close follow-up. We underscore the importance of adopting a cautious strategy in the management of patients with LVD. The management decision, however, remains patient-tailored, considering the type of anomaly and patient characteristics.

Tuberculosis is a global disease and presents with an array of neurological manifestations. Presentation varies from meningitis, radiculo-myelitis, tuberculoma, brain abscess and other combinations. The association of Guillain-Barre' syndrome (GBS) with tuberculosis has been reported in a few reports. Neurological tuberculosis association with GBS is very rare. We here report an early adolescent patient with tubercular meningitis and tuberculoma who presented with acute areflexic quadriparesis and was subsequently diagnosed as an acute motor sensory axonal neuropathy variant of GBS. The diagnosis was confirmed with clinical examination, nerve conduction studies, positive anti-ganglioside antibody and clinical response to intravenous immunoglobulin. We present a case of an association between tubercular meningitis clinically presenting as encephalopathy and acute flaccid weakness due to GBS.