Grand Rounds Articles Grand Rounds Latest Articles en Life-threatening intestinal ischaemia and necrosis in a patient with cardiac arrest and atrial fibrillation A 68-year old man was successfully resuscitated after sudden cardiac arrest. Following this event, the patient developed intestinal ischaemia and necrosis requiring surgical treatment. Our case report investigates the cause of the intestinal ischaemia and warns physicians to be aware of this rare but life-threatening condition.<br /> by Nouar Dia Alyonan 13 Apr 2016 DOI:10.1102/1470-5206.2016.0001 Acquired haemophilia in an elderly woman Acquired haemophilia is a rare autoimmune condition with an annual incidence of one per million. It is more common in the elderly and is associated with the presence of anti-factor VIII IgG antibodies. Most cases are idiopathic but there are also known associations with malignancy, other autoimmune diseases and drug interactions. As aging itself is not a cause of changes in range of coagulation tests (prothrombin time, activated partial thrombin time or thrombin time), platelet count or fibrinogen levels, an abnormality in these should prompt the physician to search for a cause of the change. The case of an elderly lady who presented with severe soft tissue bleeding secondary to factor VIII inhibitor deficiency is presented in this report.<br /> by Vikram G. Aarella 14 May 2015 DOI:10.1102/1470-5206.2015.0002 Refractory relapsing polychondritis, responsive to IL-6 blockade Relapsing polychondritis is a rare immune-mediated condition, causing inflammation of cartilage and other structures, and associated with a high mortality. Its heterogenic nature and rarity raises a number of diagnostic and treatment challenges.<br /> by I.C. Thorne, A.S.M. Jawad, N. Sutcliffe 9 Mar 2015 DOI:10.1102/1470-5206.2015.0001 The discovery of a bullet lost in the wrist by means of roentgen rays: Robert Jones In 1896, Robert Jones submitted the first publication reporting a radiograph of a bullet seen inside the human body. A 12-year-old boy shot himself in the left hand ‘‘just above the left palmar arch’’. The bullet, a lead pellet, could not be found on enlarging the wound and it was ‘‘thought injudicious to prolong the search’’ given the ‘‘important structures in the vicinity’’. Professor Oliver Lodge used Roentgen rays to image the wrist and the bullet was clearly identified at the base of the 3rd metacarpal. It was thought to be sitting in the articular surface between the base of the 3rd metacarpal and the capitate, or ‘‘os magnum’’ as it was referred to. At the time it was quoted as being the first radiograph, or photograph, of a bullet embedded in a wrist. Before the Roentgen ray, this child would have either required extensive exploration or the foreign body would have been left in situ. The chosen imaging technique and outcome would not differ between what was published in the Lancet on 22 February 1896 and what happens currently in 2014, 118 years on. The absorbed radiation dose of the Roentgen ray in this case in 1896 was 12,500–25,000 times greater than it is today.<br /> by N. Carter and N.E. Hill 11 Nov 2014 DOI:10.1102/1470-5206.2014.L002 Ventilator-associated pneumonia after elective cardiac surgery caused by Pneumocystis jirovecii Ventilator-associated pneumonia is a severe complication among patients undergoing cardiac surgery. Although hospital-acquired bacterial pathogens, often multidrug resistant, are the most frequent cause, non-bacterial atypical and opportunistic agents traditionally associated with immunocompromise are increasingly recognized. We describe ventilator-associated pneumonia due to Pneumocystis jirovecii in the absence of traditional risk factors for Pneumocystis pneumonia in a patient after cardiac surgery.<br /> by E. Tobar, F. Silva, A. Zamorano, M. Cifuentes, R.F. Miller, S.L. Vargas 17 Sep 2014 DOI:10.1102/1470-5206.2014.0004 Colon adenocarcinoma metastasis to soft tissue of the wrist with heterotopic bone formation: a case study It is uncommon in clinical practice to discover cancer as either a metastasis within soft tissue or containing heterotopic bone formation. These rarities are documented primarily through case reports in the literature. This report describes a patient with colon cancer whose painful wrist lesion was proven to exhibit both of these unusual features. It is important to recognize soft tissue metastases, as these are managed differently than a carcinosarcoma, for instance. In addition, although heterotopic bone formation does not alter the prognosis or management of colon cancer, it can prove a valuable starting point for understanding carcinogenesis.<br /> by E. Killiam, R. Cicchino, T. Foster, J. Stead 3 Sep 2014 DOI:10.1102/1470-5206.2014.0005 Delayed management of a huge thyroid mass: how to avoid a disaster A rare case of a huge mass in the thyroid gland that developed in a 45-year-old man who presented with a diffuse neck mass is discussed. Imaging showed a large mass in the neck, with no extra thyroid extension. A preoperative diagnosis was made by fine-needle aspiration as suspicious for tuberculosis or malignancy. Open surgical excision biopsy yielded a definitive diagnosis of thyroid mucosa-associated lymphoid tissue (MALT) lymphoma.<br /> by S.S. Al Zaidia, S. Al Muhayawi, M.A. Al Reefi 4 Aug 2014 DOI:10.1102/1470-5206.2014.0002 Pathologic fracture of a giant cell tumour of the patella This report describes a pathologic fracture of the patella secondary to destruction by a giant cell tumour. Diagnosis was made after non-union of a patella fracture, with osteolysis and soft tissue invasion. Delayed union of any fracture should raise the possibility of an underlying pathologic process.<br /> by D. Neptune, J.L. Estens, B. Kenny, M.L. Broadhead 4 Aug 2014 DOI:10.1102/1470-5206.2014.0003 Respiratory difficulty after parathyroidectomy due to laryngospasm A 38-year-old woman was diagnosed as having hyperparathyroidism. Surgery to remove 3.5 parathyroid glands was scheduled along with intraoperative neuromonitoring of the recurrent laryngeal/superior laryngeal nerves. Even though the neuromonitoring during the surgery indicated intact recurrent laryngeal nerves, on removal of the endotracheal tube, the anesthesiologist found the patient could not be ventilated without unusual effort using the reservoir bag and tight pressure on the oxygen mask. Surgeons performing throat surgery should be aware that laryngospasm is another possible occurrence for midline paralysis of the vocalis after surgery involving the recurrent laryngeal nerves, and that iatrogenic damage to the recurrent/superior laryngeal nerves is not the only cause of respiratory difficulty after neck surgery.<br /> by R.C. Pearlman, B. Bahmanyar 23 Jul 2014 DOI:10.1102/1470-5206.2014.0006 Ormond disease: an old disease with a new name John Ormond is credited with the first description of idiopathic retroperitoneal fibrosis (RF) in the English literature. Seventeen years later, he speculated correctly that the disease was systemic and was in the same group of diseases as lupus, scleroderma and periarteritis. Presently, idiopathic RF is considered part of a recently defined group of diseases known as IgG4 related diseases. The disease is generally treated medically but surgery can be required if there is ureteric obstruction.<br /> by J. Fairweather and A.S.M. Jawad 2 Apr 2014 DOI:10.1102/1470-5206.2014.L001 Septic shock recognition by bedside chest ultrasonography in the emergency department The case of a young man who presented in the emergency department complaining of sudden onset of cough, fever and haemoptysis is described. Chest ultrasonography rapidly diagnosed an acute respiratory distress syndrome picture, which was confirmed on computed tomography. This allowed prompt management of the patient. Blood cultures yielded &lt;i&gt;Streptococcus pyogenes&lt;/i&gt; and pharyngeal exudates were positive for influenza B virus.<br /> by R. Giannuzzi, R. Maviglia, F. Cavallaro, V. Arena and A. Testa 29 Mar 2014 DOI:10.1102/1470-5206.2014.0001 A rare form of imported infectious heart block Background: Chagas disease is endemic in the southern cone of Latin America and is becoming more prevalent in the United States with more than 300,000 people infected. It is an important cause of heart block worldwide, but is thought to be rare in the United States, and therefore easily overlooked. Heart block from Chagas disease often occurs in the young, and is permanent; therefore, early diagnosis and treatment is crucial. Case report: A 37-year-old woman from Bolivia presented with decreased exercise capacity and generalized fatigue. Her electrocardiogram revealed right bundle branch block escape rhythm. Her enzyme-linked immunosorbent assay for Trypanosoma cruzi was negative, but given the high level of suspicion, an immunofluorescent antibody assay was performed, which was diagnostic. She was treated with benznidazole and permanent pacemaker placement. Conclusion: Chagas disease is becoming more prevalent in the United States and other regions of the developed world. Patients presenting from an endemic area with suggestive symptoms require investigation to detect this diagnosis because therapy restores patients to full functional capacity in the short term; in the long term, the prognosis is uncertain but cardiac surveillance for progressive ventricular dysfunction, thrombosis, and tachyarrhythmia is indicated. Treatment with anti-trypanosomal agents should be offered to patients with chronic Chagas disease and a permanent pacemaker should be considered in symptomatic patients with bradycardia.<br /> by Sarju Ganatra and David Martin 8 Jan 2014 DOI:10.1102/1470-5206.2013.0015 Atypical presentation (or a variant) of Klippel-Trenaunay-Weber syndrome: a case report and literature review We report the case of a 65-year-old man who we thought was an atypical presentation or a variant of the Klippel-Trenaunay-Weber syndrome. Although it is primarily a disorder of infancy and childhood, it has been reported to present in adulthood also[1,2]. Our case report highlights the need to consider the differential diagnosis of Klippel-Trenaunay-Weber syndrome in patients presenting with suggestive symptoms and signs, irrespective of their age.<br /> by Kanwaljit Singh and Chris Pycock 17 Dec 2013 DOI:10.1102/1470-5206.2013.0014 Anterior abdominal wall necrotizing fasciitis due to strangulated umbilical hernia: a diagnostic dilemma Necrotizing fasciitis of the abdominal wall is associated with high morbidity and mortality. Early recognition and aggressive debridement of necrotic tissue are essential to achieve good outcomes. We describe an unusual presentation of a woman who was diagnosed with infected wound on the abdomen and was initially treated with traditional therapies.<br /> by Michael Bartholomew Mwandri, Julius Chacha Mwita, Negussie Alula Bekele, Ibrahim Mohamed Ali and Michael Stephen Walsh 17 Dec 2013 DOI:10.1102/1470-5206.2013.0013 Multiple pathologic fractures in a 19-month-old boy with sickle cell disease Multiple pathologic fractures in a patient with sickle cell disease is rare; bone involvement is well documented in this disease, however multiple pathologic fractures as a complication are uncommon. We present a case involving a 19-month-old boy known to have sickle cell disease who developed multiple pathologic fractures as a complication of his disease. The patient was treated conservatively with excellent outcome.<br /> by Nawal Eltayeb Omer, Mohamed Azoz, Bader Eldin Idris, Limya Mustafa and Ahmed Abdelhai 22 Jul 2013 DOI:10.1102/1470-5206.2013.0012 Inflammatory oncotaxis in cholangiocarcinoma Inflammatory oncotaxis is the term used to describe the phenomenon whereby mechanically injured tissues are predisposed to the development of metastases. Normal tissue injury elicits an inflammatory response, and it has been found that the microenvironment created is similar to that of the tumour microenvironment. Subsequently tumours have often been described as “wounds that do not heal”. Here we present the first reported case of inflammatory oncotaxis in a patient with cholangiocarcinoma in whom the cancer preferentially metastasized to the site of a healing fracture; the underlying mechanisms are discussed.<br /> by Caroline M.A. Hutchison, Khalid Hameed, Abed Zaitoun and Srinivasan Madhusudan 22 Jul 2013 DOI:10.1102/1470-5206.2013.0011 Unusual presentation of a primary recurrent hydatid cyst We present a case of primary recurrent hydatid cyst of the tibialis posterior in a 55-year-old woman with complaints of leg pain. Hydatid cyst was diagnosed by ultrasonography and serological tests. The patient underwent surgical excision of the lesion with perioperative prophylaxis with albendazole.<br /> by Halil Koray Sezer, Muharrem Oztas, Ismail Hakki Ozerhan, Ramazan Yildiz and Mehmet Fatih Can 18 Jun 2013 DOI:10.1102/1470-5206.2013.0006 Acute-on-chronic type B aortic dissection presenting as cauda equina syndrome A 60-year-old woman transferred with suspected cauda equina syndrome lacked lower extremity pulses on arrival. She rapidly developed visceral malperfusion due to underlying type B aortic dissection, necessitating aortic fenestration with thrombectomy. Despite misdiagnosis and delayed treatment, she could ambulate 1 year postoperatively. Aortic dissection remains integral to the differential diagnosis of patients presenting with acute paraparesis.<br /> by Arin L. Madenci, Justin Zaghi, Michael D. Paul and Karen J. Ho 18 Jun 2013 DOI:10.1102/1470-5206.2013.0010 Spontaneous peripartum liver haemorrhage presenting as foetal distress We present the case of a 32-year-old woman who presented at 37 weeks’ gestation with foetal bradycardia. At caesarean delivery, an intra-abdominal haemorrhage was noted before the uterine incision was made. A subsequent exploratory laparotomy revealed the source of the bleeding to be an extensive ruptured haematoma involving both lobes of the liver. Radiologic investigations revealed the presence of multiple cavernous haemangiomata in the liver. The perioperative management of this patient is described, with a brief review of the literature.<br /> by B. Holst, E. McGuinness and G. Morris-Stiff 18 Jun 2013 DOI:10.1102/1470-5206.2013.0009 A chronic ulcerative wound in the neck and disseminated tuberculosis: a case report and review of the literature A 79-year-old woman was admitted to the emergency room with an ulcerated large wound in the lateral region of her neck. Computed tomography (CT) of the thorax revealed air bronchograms, nodular infiltration and areas of consolidation areas in both lungs. Multiple conglomerated lymph nodes, tending to coalesce with each other with areas of necrosis, were observed on the neck CT. Numerous acid-fast bacilli were seen on wound microscopy and in sputum. A case of disseminated tuberculosis is presented to draw attention to the dangers of delayed diagnosis despite improved tuberculosis treatment regimens.<br /> by Hadice Selimoglu Sen, Ozlem Abakay, Cengizhan Sezg&amp;inodot;, Abdurrahman Abakay, Omer Faruk Sabaz and Recep Is&amp;inodot;k 18 Jun 2013 DOI:10.1102/1470-5206.2013.0008 Missed small bowel obstruction that complicated an acute appendicitis: a misdiagnosis We present a case of an 11-year-old boy who had an abdominal pain for 4 days, which was found to be caused by an acute appendicitis that ruptured. The second day after an open appendectomy, he was found to have a small bowel obstruction that was not found during the procedure. The reasons for this misdiagnosis are discussed in this article to help other health care providers avoid this dangerous complication.<br /> by Mahmoud Abdullah AlReefi and Nasser Shukri 29 May 2013 DOI:10.1102/1470-5206.2013.0007 Feasibility of minimal access surgery in benign gastric tumour resections: report of 5 cases With the advent of modern techniques including the widespread use of gastric endoscopy, benign gastric lesions are diagnosed more frequently and can be characterized by means of biopsy. Of all gastric tumours, less than 5&amp;percnt; are benign and 90&amp;percnt; of these are polyps. The treatment options for benign gastric tumours vary from mucosal resection to limited gastric resection. Many different minimal access approaches to the limited resection of benign gastric tumours have now been described in the literature with reduced morbidity. This case report reviews the feasibility of laparoscopic approaches to surgical resection in 5 cases of benign gastric tumour, identified radiologically by computed tomography and histologically by gastroscopy and biopsy. Tumour size ranged from 2 cm to 5 cm in diameter. The mean operative time was 60 min, and mean blood loss was 50 mL. Bowel function returned on the second postoperative day. The mean length of hospital stay was 4 days. There has been no tumour recurrence over a mean follow-up of 24 months, with no complications and no mortality. The laparoscopic approach is ideal for the treatment of benign tumours of the stomach. Various options including a total laparoscopic approach or a combined laparoscopic and open approach are used depending on the site and type of tumour.<br /> by T. Narayanarao, T. Parvathi and A. Suvarchala 26 Apr 2013 DOI:10.1102/1470-5206.2013.0004 Ectopic pancreatic tissue on the lesser curvature of the stomach: case report and literature review Ectopic pancreatic tissue is most often an incidental finding of imaging, surgery, or autopsy. Image-guided diagnosis is difficult, and definitive diagnosis usually relies on histological analysis. A case of ectopic pancreatic tissue located near the lesser curvature of the stomach is presented followed by a brief discussion of the clinical management of heterotopic pancreas.<br /> by Mehdi M. Tajouri, Jan-Michael Van Gent and Bryan D. Eck 2 Apr 2013 DOI:10.1102/1470-5206.2013.0005 Embolia cutis medicamentosa after polidocanol injection of neovessels in Achilles tendinosis This report documents a case of embolia cutis medicamentosa after therapeutic injection of neovessels associated with Achilles tendinosis with polidocanol. This condition has not previously been reported as a complication of this procedure.<br /> by David Humphries 6 Mar 2013 DOI:10.1102/1470-5206.2013.0003 Leiomyosarcoma arising in the nasal cavity We report a rare case of leiomyosarcoma arising in the nasal cavity. A 45-year-old woman visited our hospital because of recurrent epistaxis in 1998. A biopsy was performed on a mass in the posterior area of the left nasal cavity, and a histological diagnosis of leiomyosarcoma was made. Although the nasal tumor was resected via left lateral rhinotomy, tumor recurrence was detected. In addition, multiple metastatic tumors were detected in both lungs. Therefore, CyberKnife therapy was performed for the recurrent tumor and radiofrequency ablation for a large tumor among the metastatic lung tumors. Although the patient died of multiple metastasis of the whole body in 2007, tumors in the lungs and the primary site, which were treated with radiofrequency ablation and CyberKnife therapy, did not increase. Leiomyosarcoma has a poor prognosis, and when recurrence or distant metastasis occurs, radical cure is even more difficult. In this patient, CyberKnife therapy and radiofrequency ablation were effective for treating local recurrent and metastatic lesions. Even in patients in whom a radical cure is difficult due to recurrence or distant metastasis, CyberKnife therapy and radiofrequency ablation can relieve symptoms and prolong survival.<br /> by Mutsuo Kudo and Harumi Suzaki 6 Mar 2013 DOI:10.1102/1470-5206.2013.0002 Laparoendoscopic single-site ovariectomy: an indication of choice for ovarian cryopreservation Nodular sclerosing Hodgkin disease stage IV according to the Ann Arbor classification was diagnosed in a 30-year-old nulliparous woman. Because management required the use of a chemotherapy regimen with a high risk of secondary infertility, ovarian cryopreservation was realized by single-site laparoscopic unilateral oophorectomy. The single-site approach can limit aesthetic consequences in young patients and complications related to trocar set-up should emergency chemotherapy be requested.<br /> by Maxence Dorez, Jérôme Delotte, Emmanuelle Thibault, Stefan Ciuca, Nicolas Mounier and André Bongain 6 Mar 2013 DOI:10.1102/1470-5206.2013.0001 Helminthic-induced pancreatitis: are we underdiagnosing? A patient was admitted and diagnosed as acute pancreatitis of obscure aetiology. Laboratory investigations and radiological studies failed to reveal the underlying cause. A worm was pulled out of the nasogastric tube by the patient. In a modern society and in developed hospital settings, is it possible that we are missing, or underdiagnosing what we once regarded as tropical diseases. Our case report highlights this obscure cause and reviews the literature.<br /> by Amina Bouhelal, Hiten RH Patel, Rehab Al Sayari, Hodon Abdi, Badriya Al Araimi and Bijendra Patel 23 Oct 2012 DOI:10.1102/1470-5206.2012.0012 A case of haemorrhagic angiomyolipoma after miscarriage A case of a 27 year-old patient who presented after medical management of a missed miscarriage with an acute abdomen is described. She was found to have a haemorrhagic angiomyolipoma, which was successfully treated radiologically. This case highlights the need to consider this differential in the presentation of acute abdomen in the context of a recent or concurrent pregnancy. It is the first case report to describe this phenomenon in the context of a miscarriage.<br /> by Ayomide Esan, Rezaur Rahman, Luke Sammut and Cheryl Main 23 Oct 2012 DOI:10.1102/1470-5206.2012.0011 An acute myopericarditis in a young adult: consider an acute Epstein-Barr viral infection We present a case of an uncommon viral myopericarditis in a 19-year-old man with chest pain. Electrocardiographic abnormalities and elevated cardiac enzymes were present. Myopericarditis of unknown origin was diagnosed following cardiac magnetic resonance imaging. During admission, the patient developed tonsillitis and serology tests confirmed an acute Epstein–Barr viral infection. Therefore, in acute myo(peri)carditis, we suggest early viral determination.<br /> by Maurice Remmelink, Paul Dekkers and Paul F.M.M. van Bergen 10 Aug 2012 DOI:10.1102/1470-5206.2012.0010 Actions and consequences: characterization of a deletion in the CFTR gene that encompasses a splice site We report an interesting complex CFTR gene mutation in a patient with cystic fibrosis. It is an insertion combined with a deletion that spans an exonic splice site, causes a frameshift and could affect splicing. This rare mutation poses a challenge to provide correct nomenclature and to interpret its clinical significance.<br /> by Carlos Jose Suarez, Terry Boyle, Tsoyu Chiang and Iris Schrijver 10 Aug 2012 DOI:10.1102/1470-5206.2012.0009