Clin. Pract., Volume 2, Issue 3 (October 2012) – 24 articles

The authors report a case of Waugh’s syndrome in an adult. Waugh’s syndrome is rare in adults as most of the cases present in paediatric age group. We have discussed treatment options and it is suggested that the possibility of Waugh’s syndrome should always be kept in mind when a case of intussusception is being treated by either operative or non-operative method. Full article

Spontaneous rupture of kidney is a rare clinical entity. A 35-year-old female presented in emergency with left flank pain and features suggestive of haemorrhagic shock. Investigations showed rupture of kidney with perinephric haematoma. Emergency left nephrectomy was done. Patient was discharged in satisfactory condition. Nephrolithiasis with secondary bacterial infection rarely presents as spontaneous kidney rupture. In presence of haemorrhagic shock management is emergency surgery. Full article

We present the case of a 7-year old boy with traumatic brain injury who received propofol during 38 h. Thirty-six hours after cessation of propofol infusion asystole occurred. After immediate mechanical and medical resuscitation, unreactive dilated pupils were observed. The following computed tomography scan revealed a generalized brain edema with transtentorial herniation. Prolonged bradyarrhythmia, rhabdomyolysis, and peracute renal failure were observed. Despite immediate craniectomy, barbiturate treatment, hemofiltration, and recovery of appropriate cardiac function, the patient died four days after discontinuation of propofol. In this case, metabolic acidosis, cardiac failure, rhabdomyolysis, and renal failure are in accordance with the symptoms of propofol infusion syndrome (PRIS), while seizure, brain edema, and transtentorial herniation could be caused by traumatic brain injury. However, it may be assumed that the entire clinical picture was caused by PRIS. This view could be explained by a common loss of function of ryanodine receptors in patients presenting with PRIS. Full article

Studies performed in developed countries have shown that infections by third generation cephalosporin resistant Escherichia coli (G3CREC) are associated with increased mortality, but data from developing countries are scarce. In this observational study, we collected clinical and microbiological information of 194 patients admitted to a district hospital in India who had community-acquired isolation of Escherichia coli. The proportion of patients with G3CREC was 79.4%. In a multivariable logistic regression analysis, factors associated with 21-day mortality were isolation from a normally sterile site, HIV infection and isolation of G3CREC. Strains of Escherichia coli isolated from normally sterile sites had lower levels of resistance to quinolones and beta-lactam antibiotics. The proportion of meropenem and ciprofloxacin resistance was 11.1% and 80.9% respectively. The high proportion of G3CREC in the community and the association of G3CREC with 21-day mortality indicate that G3CREC is a major public health problem in developing countries. Full article

We report a case of a premature infant presenting with recurrent pulmonary hemorrhage in which we performed a therapeutic lavage with diluted surfactant after an acute episode of bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10x2 mL) allowed rapid improvement in oxygenation and reduction of required mean airway pressures during high frequency oscillatory ventilation. This observation may suggest that surfactant lavage could be beneficial in massive pulmonary hemorrhage in infants. A randomized controlled trial might be needed to clarify the potential benefit of this therapeutic intervention on outcome of infants suffering from this life-threatening complication. Full article

After aneurysmal subarachnoid hemorrhage, most center practices treatment modality selection based on size and geometry in computed tomographic angiography. However, the validity as compared to digital subtraction angiography (DSA) is not well studied. Twenty patients with ruptured internal carotid artery aneurysm were identified in a two-year period. Mean difference in measurements from 3D computed tomographic angiography (3D-CTA) and 3D-DSA were less than 1 mm and 3D-DSA measurement did not alter the decision to proceed for endovascular embolization. With modern multislice computed tomography technology, good quality 3D-CTA alone would be sufficient to make size and geometry assessment for treatment selection for patients with ruptured internal carotid artery aneurysm. Full article

Choriocarcinoma is a beta human chorionic gonadotrophin secreting neoplasm pertinent to uterus and pregnancy mostly. It occurs primarily in gonads but rarely in extragonadal sites. Primary hepatic choriocarcinoma is an extremely rare tumor. Most of the reported cases are seen in infants representing metastasis from an occult placental choriocarcinoma. Till date, only 7 cases of primary hepatic choriocarcinoma in adults have been reported in literature. We present a case of a 40-yearold male presenting as haemoperitoneum due to ruptured hepatic tumor. He underwent emergency left lateral segmentectomy. He died on 10th postoperative day. The surgical specimen and autopsy findings confirmed it to be primary hepatic choriocarcinoma. This is the first case report from Indian Subcontinent. A brief case report and review of literature is presented. Full article

Maisonneuve fractures result from a disruption of the medial ankle structures and a proximal fibular fracture. Patient complaints can be misleading and there is a significant rate of delayed diagnosed injuries. We present a case of bilateral Maisonneuve fractures after a fall due to a syncopal collapse. A precise clinical examination led to this rare diagnosis. The injuries were treated with syndesmotic screw fixation, removal of hardware followed after 6 weeks. The patient was asymptomatic at threemonths follow up. Patients with bilateral injuries undergoing standard surgical treatment can gain full recovery, but high suspicion in clinical examination is needed to detect this uncommon bilateral injury. Full article

Syringocystadenocarcinoma papilliferum is a rare form of adenocarcinoma of the skin. It is the malignant counterpart of syringocystadenoma papilliferum (SCAP). It usually develops on the scalp in a long-standing lesion identified clinically as SCAP. Twelve cases of syringocystadenocarcinoma papilliferum have been reported in literature, with limited information regarding its clinical and histological characteristics. Sarcomatous change in a case of SCAP has not been reported in literature till date to the best of our knowledge. We present the first case of syringocystadenocarcino-sarcoma papilliferum in a middle-aged female with a satellite lesion over the scalp. Full article

Injury of anterior teeth is a relatively common event that mainly affects children and adolescents. Dentists are confronted with managing dental trauma and restoring fractured teeth on a regular basis. Hence the techniques that speed and simplify the treatment, restore esthetics and improve long term success rate are considered of potential value. If an intact tooth fragment is present after trauma, immediate attachment of the incisal edge is a conservative yet, simple and aesthetic alternative. Fracture reattachment possesses challenging conservative and economically viable procedure within a single visit. The authors wuld report a case of fractured maxillary central incisor using fragment reattachment. Full article

Dual and triple infections with hepatitis virus C (HCV), B (HBV) and D (HDV) frequently lead to severe liver damage. Hereby we describe a 38-year-old Caucasian male coinfected with HCV (genotype 3a), HBV [positive hepatitis B surface antigen (HbsAg) and antibody to hepatitis B core antigen; negative hepatitis B e antigen (HbeAg) and antibody to hepatitis B e antigen (anti-HBe)] and HDV. Laboratory diagnostics revealed increased liver enzymes and histological examination of the liver showed signs of fibrosis with moderate inflammation. On therapy with pegIFN-a2b and ribavirin HCV-RNA was undetectable at week 8. After week 24 the antiviral therapy was stopped because of a HBs-seroconversion, the loss of HbeAg and the detection of anti-HBe. Furthermore the HCV-RNA was negative. Six months after successful treatment of the triple-infection, HCV- and HDV-RNA and HbsAg remained negative and the liver enzymes had been completely normalized. In conclusion, pegylated-interferon plus ribavirin may be an effective therapy for HCV, HBV and HDV-coinfected patients. Full article

Atrial septal defect (ASD) is usually asymptomatic in infancy, unless pulmonary hypertension or severe co-morbidity is present. We report a case of a 4-week-old infant with moderate- sized ASD, small patent ductus arteriosus (PDA), and a borderline sized left ventricle that developed heart failure. Despite the relatively small diameter of the ASD, this defect influenced the mechanism of heart failure significantly. After surgical closure of both PDA and ASD, the signs of pulmonary hypertension resolved and the patient developed a normal sized left ventricle. This report illustrates that the presence of a small ASD in combination with a marginal left ventricle may result in inadequate left ventricular filling, pulmonary hypertension and heart failure. Full article

A large anterior chest wall defect following tumor resection was reconstructed with a Gore- Tex^® membrane and a combined musculocutaneous rectus femoris and tensor fasciae latae free flap. Subsequent paradoxical respiration impeded weaning from the ventilator. Appliance of Vacuum Assisted Closure^® (VAC^®) resulted in immediate chest wall stability and a decrease in the patient’s need for respiratory support. Shortly thereafter, the VAC^® was discontinued and the patient was discharged from the intensive care unit (ICU). This case report is the first to describe the successful use of VAC^® as an adjuvant to a one-stage procedure for large thoracic wall reconstruction, allowing sufficient temporary external fixation to eliminate paradoxical respiration and plausibly shorten the stay in the ICU. No adverse effects on flap healing or haemodynamics were recorded. It is likely that external VAC^® can improve thoracic stability and pulmonary function in a patient with flail chest and decrease the need for mechanical ventilation. Full article

T-cell large granular lymphocyte (T-LGL) leukemia represents a clonal proliferation of cytotoxic T-cells which etiology has not been entirely elucidated. However, CD4+, CD4–,CD8–, CD4+, CD8+ cases have been described. The disease is usually characterized by cytopenias and a modest lymphocytosis. The majority of patients with T-LGL leukemia remains asymptomatic for a long period and will require treatment later during the course of their disease. Hereby we describe a case of T-LGL leukemia diagnosed by flow cytometry, which presented indolent course and required no treatment so far. Full article

Extracranial meningioma with extension into a middle ear is very uncommon. A 74-year-old female was admitted to our hospital with right ear bleeding when removing earwax. In this case, magnetic resonance imaging, computed tomography, her past history and operative findings would consider as infiltrative growth from the right sphenoid ridge meningioma to the right middle ear via the right petrous pyramid and bilateral optic nerve. She underwent only partial extirpation with decompression for optic nerve, rather than total extirpation including middle ear and temporal bone, due to wide invasion of the middle cranial fossa and caversinus sinus. Full article

The present study evaluates the incidence of early and late seizures after head injury in patients under 18 years old. Factors correlating with a high risk of developing posttraumatic seizures were identified. Such risk factors were the severity of the head trauma and a Glasgow Coma Scale of 3-8. In contrast to many studies, we observed that the incidence of posttraumatic seizures was significantly higher in patients older than 12 years old (12-16 and 12-18). Most of the late seizures were paroxysmal electroencephalography (EEG) discharges diagnosed on a snapshot-EEG during the follow-up examination of the patients without clinical symptoms. We suppose that EEG-examination in head injured children is important to identify patients with epileptic potentials without clinical symptoms. Epileptic patterns of the EEG could worsen the diagnosis and clinical outcome of the children in accordance to studies performed in the adult population. Full article

A 58-year-old Caucasian male presented to the urology clinic reporting an approximate one-year history of a persistent irritating, slowly progressive, glans penis redness. Biopsy revealed penile squamous cell carcinoma in situ. He underwent a partial glansectomy with circumcision and skin grafting. At three months follow-up there is no evidence of local disease recurrence. In western countries, primary malignant penile cancer is uncommon, with an incidence of less than 1 per 100,000 males. Squamous cell cancer accounts for more than 95% of cases of penile cancer. Squamous cell carcinoma in situ on the penile mucosa or transitional surfaces is also known as Erythroplasia of Queyrat. In the region, one third of penile squamous cell carcinoma in situ cases progress to invasive squamous cell carcinoma. Full article

Subcutaneous swelling as first clinical presentation of small cell lung carcinoma is uncommon and rarely reported in literature. This case highlights a rare presentation in which subcutaneous swelling was the first clinical manifestation of a small cell carcinoma of lung which also had metastasis to rib bone, muscle and pleural involvement as pleural effusion. We describe the case of a 64-year-old male patient who presented with dyspnea, pleuritic pain, loss of weight and nodule on his anterior chest, back and left arm suspicious of lipoma. Biopsies revealed small cell carcinoma of lung. This case demonstrates the meticulous work up of subcutaneous swelling in the clinical scenario of breathlessness, chest pain and loss of weight. Full article

The authors report a case of mucinous carcinoma of the male breast firstly diagnosed as a mucinous carcinoma of the skin. The immunohistochemical results of this tumor were as follows: cytokeratin7 (-), gross cystic disease fluid protein 15 (-), p63 (-), estrogen receptor (+), and progesterone receptor (+) for the primary nodule; cytokeratin7 (-), thyroid transcription factor-1 (-), gross cystic disease fluid protein 15 (-), p63 (-), cytokeratin8 (+), cytokeratin18 (+), and cytokeratin20 (+) for the recurrent nodule. The tumor cells had cytokeratin7 (-)/ cytokeratin20 (+) phenotype and it was very unusual for mucinous carcinoma of the breast. Full article

Intervertebral fusion through an anterior approach with polymethylacrylate is a wellestablished neurosurgical technique in the treatment of cervical spine degeneration. However, questions still remain concerning the post-surgical outcome. Factors influencing surgical outcome that could help to predict which patients need further post-surgical treatment and what to expect after surgery are the subject of numerous studies. In the present study, we retrospectively collected data from patients who had undergone intervertebral fusion and defined which pre-operative factors could influence the surgical outcome. Between 1993 and 1997, 379 patients were surgically treated with the ventral fusion technique in our hospital. In 2006, we sent a questionnaire to the patients and 164 responses were received. We identified pre-operative presence of severe pain, hypesthesia, palsy and gait disturbance as negative predictive factors, whereas age, body mass index, pre-operative physical strain and the cervical segment involved did not seem to influence prognosis. In conclusion, identifying preoperative factors which influence prognosis after intervetebral fusion will help predict postoperative outcome. Full article

Simple bone cysts (SBC) are pseudocysts occurring less commonly in the maxillofacial region. The uncertain and unclear etiopathogenesis led to numerous synonyms to refer this particular cyst. These cysts are devoid of an epithelial lining and are usually empty or contain blood or straw-colored fluid. In jaws initially it mimics a periapical cyst and later can lead to cortical bone expansion warranting for radical approach, which is seldom required. SBC is predominantly diagnosed in first two decades of life. Here we report a case of solitary bone cyst mimicking a periapical cyst of a mandibular molar in a 37-year-old patient. Full article

Fibrosarcoma of the oral and maxillofacial region is a rare entity with poor prognosis. Most common sites are the extremities, with only one percent of fibrosarcoma arising in the head and neck area. Oral fibrosarcoma are locally infiltrative and destructive, spreads by haematogenous dissemination. The positive immunostaining for vimentin, together with negativity for muscular immunomarkers help to diagnosis the fibrosarcoma. Surgical management of fibrosarcoma in maxillofacial region is far from satisfactory, because of lack of inadequate clearance. This paper describes an unusual case of soft tissue fibrosarcoma of premaxillary region in an adult aged 71 years. Full article

Myeloid sarcoma is a rare extramedullary tumour consisting of immature myeloid cells. It can arise at any anatomical location and often develops in the bowel. This report describes a case of severe acute disseminated intravascular coagulation (DIC) with multi-organ failure occurring in a 57-year-old man with chronic myelomonocytic leukaemia during bowel resection for newly diagnosed adenocarcinoma of the sigmoid colon. Histopa thology however revealed a differentiating myeloid sarcoma encompassing a well-differentiated adenocarcinoma. This is the first documented case of acute DIC to be triggered following surgical manipulation of myeloid sarcoma. Full article

The aim of this study was to present the data of a large cohort of patients with spontaneous supratentorial intracerebral hemorrhage (ICH), who were treated in our department and give a current overview considering special clinical characteristics, performed therapy and different predictive factors for morbidity and mortality. We reviewed the data of all patients with spontaneous ICH, who were treated in our department in a time span of 11 years through an analysis of our prospective database. Patients with spontaneous supratentorial ICH were included in the study. Patients with hemorrhage associated to vascular malformation or to cerebral ischemic stroke were excluded. The clinical performance at time of admission and discharge were scored using the Glasgow coma scale (GCS) and the Glasgow outcome scale (GOS) respectively. The patients’ cohort was divided into surgically and conservatively treated groups. Statistical analysis [Analysis of Variance (ANOVA) and ?²-test] was done for various parameters to analyze their impact on morbidity and mortality. In total, we analyzed the data of 817 patients (364 female and 453 male). Two hundred and sixty-nine patients (32%) were treated conservatively and 556 patients (68%) underwent surgical procedures, i.e. cerebrospinal fluid drainage in 110 (19.8%), craniotomy in 338 (60.7%) and application of both methods in 108 patients (19.4%). Total mortality rate was estimated with 23.5%. GCS<8, age over 70 years, intraventricular and basal ganglia hemorrhage, coumadin medication, combination of co-morbidities, hypertensive hemorrhage and postoperative re-bleeding were statistically significant risk factors for worse outcome (GOS 1 and 2) in the operated group. Similar to the observations of the operated group, GCS<8, age over 70 years and coumadin medication were statistically significant for worse outcome in the conservative group. In contrast, lobar plus basal ganglia ICH and multi-lobar hemorrhages were the most significant factors for worse outcome in the conservative group. The results of our study show that ICH remains a multifarious disease and challenges neurosurgeons repeatedly. Selection of the treatment modality and prediction for neurofunctional outcome underlies various parameters. Treatment recommendations of ICH remain an unsolved issue. The consideration of the GCS grade at admission is the most important predictive factor. Old age is not an absolute contraindication for surgery, but cumulative multi-morbidity, especially cerebrovascular and cardiovascular diseases and oral anticoagulant therapy should be regarded critically in view of surgical treatment. Full article