Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Collapsing Focal Segmental Glomerulosclerosis in a Patient with Acute Malaria Sun, 05 Jul 2015 14:04:44 +0000 Introduction. Collapsing focal segmental glomerulosclerosis (FSGS) is most commonly seen in association with HIV infection. Rare data is available about the association between collapsing FSGS and malaria. Case Description. A 72-year-old African male patient presented to the hospital for generalized body aches, fatigue, fever, and night sweats for three days. He had history of recent travel to Ghana. Patient looked in acute distress and was shivering. Laboratory tests showed elevated serum creatinine (Cr) of 2.09 mg/dL (baseline was 1.5 mg/dL in 2012). Hospital course was significant for rapid elevation of Cr to 9.5 mg/dL and proteinuria of 7.9 grams. Autoimmune studies resulted negative. Blood smear resulted positive for Plasmodium falciparum and patient was treated with Artemether/Lumefantrine. Patient’s fever and pain improved, but kidney function continued to deteriorate and he became oliguric. On day seven, he was started on Hemodialysis. Tests for different causes of glomerular pathology were also negative. He underwent left kidney biopsy which resulted in findings consistent with severe collapsing glomerulopathy. Discussion. This case illustrates a biopsy proven collapsing FSGS likely secondary to malarial infection requiring renal replacement therapy. Literature review revealed only few case reports that suggested the possible association of malaria with secondary form of FSGS. Najamus Sehar, Emad Gobran, and Suzanne Elsayegh Copyright © 2015 Najamus Sehar et al. All rights reserved. Exercise-Induced Pulmonary Edema in a Triathlon Thu, 02 Jul 2015 09:55:40 +0000 Introduction. Family physicians have more opportunities to attend athletic competitions as medical staff at first-aid centers because of the increasing popularity of endurance sports. Case. A 38-year-old man who participated in a triathlon race experienced difficulty in breathing after swimming and was moved to a first-aid center. His initial oxygen saturation was 82% and a thoracic computed tomography scan showed bilateral ground glass opacity in the peripheral lungs. His diagnosis was noncardiogenic pulmonary edema associated with exercise or swimming: exercise-induced pulmonary edema (EIPE) or swimming-induced pulmonary edema (SIPE). Treatment with furosemide and corticosteroid relieved his symptoms of pulmonary edema. Discussion. Noncardiogenic pulmonary edema associated with endurance sports is not common, but knowledge about EIPE/SIPE or neurogenic pulmonary edema associated with hyponatremia, which is called Ayus-Arieff syndrome, is crucial. Knowledge and caution for possible risk factors, such as exposure to cold water or overhydration, are essential for both medical staff and endurance athletes. Conclusion. To determine the presence of pulmonary edema associated with strenuous exercise, oxygen saturation should be used as a screening tool at a first-aid center. To avoid risks for EIPE/SIPE, knowledge about these diseases is essential for medical staff and for athletes who perform extreme exercise. Hirotomo Yamanashi, Jun Koyamatsu, Masaharu Nobuyoshi, Kunihiko Murase, and Takahiro Maeda Copyright © 2015 Hirotomo Yamanashi et al. All rights reserved. Lupus-Associated Pulmonary Arterial Hypertension: Variable Course and Importance of Prompt Recognition Thu, 02 Jul 2015 09:13:42 +0000 We describe a critically ill young woman with systemic lupus erythematosus (SLE) presenting with circulatory shock, multiorgan dysfunction, and elevated right-sided heart pressures. She was found to have recurrent acute severe pulmonary arterial hypertension (PAH) in the setting of an SLE flare. Our report highlights the variable course that SLE-associated PAH can take in the same patient and the implications of this for instituting the most effective treatment approach with each episode. This report also highlights the potential for SLE-associated PAH to present with life-threatening symptoms requiring critical care level interventions. We also describe evidence-based therapies, which can result in significant improvement in symptoms, function, and long-term outcomes. Kofi A. Mensah, Rajwardhan Yadav, Terence K. Trow, Cristina M. Brunet, and Wassim H. Fares Copyright © 2015 Kofi A. Mensah et al. All rights reserved. Intravascular Hemolysis and Septicemia due to Clostridium perfringens Emphysematous Cholecystitis and Hepatic Abscesses Wed, 01 Jul 2015 09:10:17 +0000 Context. Clostridium perfringens septicemia is often associated with translocation from the gastrointestinal or gastrourinary tract and occurs in patients who have malignancy or are immunocompromised. Clostridium perfringens septicemia is usually fatal without early identification, source control, and antibiotics. Case. We present a case of a 65-year-old female with Clostridium perfringens septicemia secondary to emphysematous cholecystitis, with progression to hepatic abscesses. Conclusion. Septicemia secondary to Clostridium perfringens is generally fatal if not detected early. Source control with surgery or percutaneous drainage and early antibiotic therapy is imperative. Hyperbaric oxygen therapy may reduce mortality. Clinicians caring for patients with sepsis and intravascular hemolysis must have Clostridium perfringens septicemia on their differential diagnosis with a low threshold for starting antibiotics and pursuing source of infection. Justin Cochrane, Lacie Bland, and Mary Noble Copyright © 2015 Justin Cochrane et al. All rights reserved. Acute Renal Failure Induced by Chinese Herbal Medication in Nigeria Thu, 25 Jun 2015 09:03:37 +0000 Traditional herbal medicine is a global phenomenon especially in the resource poor economy where only the very rich can access orthodox care. These herbal products are associated with complications such as acute renal failure and liver damage with a high incidence of mortalities and morbidities. Acute renal failure from the use of herbal remedies is said to account for about 30–35% of all cases of acute renal failure in Africa. Most of the herbal medications are not usually identified, but some common preparation often used in Nigeria includes “holy water” green water leaves, bark of Mangifera indica (mango), shoot of Anacardium occidentale (cashew), Carica papaya (paw-paw) leaves, lime water, Solanum erianthum (Potato tree), and Azadirachta indica (Neem) trees. We report a rare case of a young man who developed acute renal failure two days after ingestion of Chinese herb for “body cleansing” and general wellbeing. He had 4 sessions of haemodialysis and recovered kidney function fully after 18 days of admission. Effiong Ekong Akpan and Udeme E. Ekrikpo Copyright © 2015 Effiong Ekong Akpan and Udeme E. Ekrikpo. All rights reserved. Bernese Periacetabular Osteotomy in a Hip Extra-Articular Resection Followed by Reconstruction Using an Extracorporeal Irradiated Acetabulum Autograft with Megaprosthesis, for Proximal Femur Osteosarcoma in a Pediatric Patient Thu, 25 Jun 2015 08:13:42 +0000 Osteosarcoma is the most common primary malignant tumour of bone. The oncologic surgery of a proximal femur osteosarcoma affecting the hip joint can be very challenging. We present an 8-year-old boy with a 5-month history of right hip pain. Radiographs and magnetic resonance imaging (MRI) showed a lytic lesion of the proximal femur extending 13 cm to the diaphysis. Histological evaluation was consistent with high-grade osteoblastic osteosarcoma. After completing chemotherapy we performed an extra-articular resection of the hip. Reconstruction was accomplished by reimplanting the acetabulum after irradiation and modular proximal femur megaprosthesis. Endoprosthetic reconstruction following proximal femur resection is a good treatment alternative achieving good postoperative function. Extra-articular resection of the hip using a periacetabular osteotomy technique enabled us to achieve wide margins and leave an intact posterior column to optimize acetabular reconstruction stability. Extracorporeal irradiation and reimplantation is a valuable treatment option in a situation such as this where allograft geometric fit is a priority. We conclude that an extra-articular resection of the hip, followed by reconstruction with an extracorporeally irradiated acetabulum and a proximal femur modular megaprosthesis, is a useful combined treatment option for malignant lesions involving the hip joint, especially in paediatric patients. Victor Barro, Roberto Velez, Daniel Pacha, Jordi Giralt, Isabel Roca, and Marius Aguirre Copyright © 2015 Victor Barro et al. All rights reserved. Hypercalcemia, Anemia, and Acute Kidney Injury: A Rare Presentation of Sarcoidosis Tue, 23 Jun 2015 11:53:23 +0000 We discuss a case of a 61-year-old woman who presented with substernal chest pain. She was found to have elevated calcium levels, anemia, and acute kidney injury. The hypercalcemia persisted despite therapy with fluids and bisphosphonates. She was found to have nonparathyroid hormone (PTH) mediated hypercalcemia. The chest X-ray did not reveal any pathology. Our Initial impression was likely underlying hematologic malignancy such as lymphoma or multiple myeloma. A bone marrow biopsy was performed that revealed nonnecrotizing granulomatous inflammation. Further workup revealed elevated vitamin 1,25 dihydroxy level, beta-two microglobulin level, and ACE levels. Noncontrast computed tomography (CT) scan of chest showed bilateral apical bronchiectasis, but did not show any lymphadenopathy or evidence of malignancy. Subsequently, a fiber optic bronchoscopy with transbronchial biopsy showed nonnecrotizing granulomatous inflammation consistent with sarcoidosis. After initiating glucocorticoid therapy, the patient’s hypercalcemia improved and her kidney function returned to baseline. Neeraj Sharma, Hassan Tariq, Kalpana Uday, Yevgeniy Skaradinskiy, Masooma Niazi, and Sridhar Chilimuri Copyright © 2015 Neeraj Sharma et al. All rights reserved. Myocardial Infarction in a Premenopausal Woman on Leuprolide Therapy Tue, 23 Jun 2015 06:28:04 +0000 Premenopausal women with chest pain syndrome may have nonatherosclerotic coronary arteries with abnormal coronary flow. Estrogens have cardioprotective effect improving coronary vasodilatation. This case report discusses the consequences of leuprolide use by decreasing estrogen levels which led to acute myocardial infarction. Irving E. Perez, Mark A. Menegus, and Cynthia C. Taub Copyright © 2015 Irving E. Perez et al. All rights reserved. Complete Surgical Resection of a Leiomyosarcoma Arising from the Inferior Vena Cava Thu, 18 Jun 2015 07:26:43 +0000 A 76-year-old Japanese man was referred to our hospital with chief complaint of right hypochondoralgia. Abdominal ultrasound showed a retroperitoneal tumor in the suprarenal region of the right kidney. Computed tomography revealed an enhanced lobular tumor with irregular, circumscribed, and indistinct border. Ultrasound-guided biopsy was performed. The tumor consisted of spindle-shaped cells with a giant nucleus and multinuclear cells. The diagnosis was leiomyosarcoma by immunohistochemical staining. The patient underwent surgery accessed by a right eighth intercostal thoracoabdominal incision. The tumor was completely resected, accompanied by removal of the posterosuperior segment of the right hepatic lobe, right adrenal gland, and a portion of the inferior vena cava (IVC). The histopathologic diagnosis was leiomyosarcoma arising from the IVC. We present a rare case of a successfully managed leiomyosarcoma of the IVC. This case suggests the importance of curative surgical resection of the tumor due to low efficacy of adjuvant chemotherapy for leiomyosarcoma. Hirofumi Sonoda, Keisuke Minamimura, Yuhei Endo, Shoichi Irie, Toru Hirata, Takashi Kobayashi, Ken-ichi Mafune, and Masaya Mori Copyright © 2015 Hirofumi Sonoda et al. All rights reserved. Propionibacterium acnes: A Treatable Cause of Constrictive Pericarditis Wed, 17 Jun 2015 13:19:19 +0000 In this case report we share a case of infective Pericarditis caused by Propionibacterium acnes (P. acnes) in an immune-competent, nonsurgical patient. This case and review will illustrate the importance of considering P. acnes as a cause of idiopathic pericardial effusion and effusive constrictive disease. The patient was a 61-year-old male with history of osteoarthritis of the knee. He received an intra-articular steroid injection in July 2013. Two months later, he presented with atrial fibrillation and heart failure. He was found to have pericardial and bilateral pleural effusions which grew P. acnes. This organism was initially considered to be contaminant; however, as P. acnes was isolated from both pleural and pericardial fluids, he was started on oral amoxicillin. He was noted to have recurrence of effusions within 2 weeks with evidence of constrictive physiology by echocardiography. Treatment was subsequently changed to intravenous Penicillin G with marked symptomatic improvement, resolution of pericardial/pleural effusions, and no echocardiographic evidence of constrictive pericarditis at 10 weeks follow-up. Pursuit and treatment of P. acnes could lead to prevention of constrictive pericarditis. We believe that further studies are needed to assess prevalence of P. acnes and response to intravenous Penicillin G in patients presenting with effusive constrictive disease. Daniel Cruz, Haitham Ahmed, Yousuf Gandapur, and M. Roselle Abraham Copyright © 2015 Daniel Cruz et al. All rights reserved. Neuroleptic Malignant Syndrome: A Case Aimed at Raising Clinical Awareness Thu, 11 Jun 2015 14:31:36 +0000 A 60-year-old man with a history of bipolar disorder on risperidone, bupropion, and escitalopram was admitted for community acquired streptococcal pneumonia. Four days later, he developed persistent hyperthermia, dysautonomia, rigidity, hyporeflexia, and marked elevation of serum creatine phosphokinase. He was diagnosed with neuroleptic malignant syndrome (NMS) and improved with dantrolene, bromocriptine, and supportive therapy. This case emphasizes the importance of considering a broad differential diagnosis for fever in the ICU, carefully reviewing the medication list for all patients, and considering NMS in patients with fever and rigidity. Jad Al Danaf, John Madara, and Caitlin Dietsche Copyright © 2015 Jad Al Danaf et al. All rights reserved. Autoresuscitation: A Case and Discussion of the Lazarus Phenomenon Mon, 08 Jun 2015 09:24:25 +0000 Lazarus phenomenon or autoresuscitation is a very rare condition defined as delayed unassisted return of spontaneous circulation after cessation of cardiopulmonary resuscitation. Based on a case with a 67-year-old male who came back to life after discontinuation of cardiopulmonary resuscitation, we discuss the background and possible countermeasures related to the Lazarus phenomenon. Kjartan Eskjaer Hannig, Rasmus Wulff Hauritz, and Erik Lerkevang Grove Copyright © 2015 Kjartan Eskjaer Hannig et al. All rights reserved. Obstructive Jaundice as Initial Presentation of Multiple Myeloma: Case Presentation and Literature Review Sun, 07 Jun 2015 16:11:45 +0000 Multiple myeloma is a malignant plasma-cell disorder that primarily involves the bone marrow, but extramedullary involvement is becoming increasingly common (Bladé et al., 2012) both at initial presentation and follow-up. Most common initial presentations for multiple myeloma include generalized fatigue, renal insufficiency, bone pain, and recurrent bacterial infections. We present a case of a healthy 55-year-old man that presented to the emergency department with a three-week history of anorexia and jaundice without any past medical history. Patient’s initial labs were significant for hyperbilirubinemia and elevated liver function enzymes (AST, ALT, ALP, and GGT). Additional laboratory workup was significant for mild hypercalcemia and increased protein gap. MRI and ERCP suggested primary sclerosing cholangitis but were not diagnostic. Liver biopsy illustrated plasma-cell infiltration and bone marrow biopsy diagnosed multiple myeloma with extramedullary disease. Patient was started on dexamethasone, bortezomib, and cyclophosphamide, but, despite this aggressive regimen, the patient continued to decline. We take this opportunity to present this atypical presentation of a common hematological malignancy and review the associated literature. Yasir Khan, Iyad Mansour, Eric Ong, and Manish Shrestha Copyright © 2015 Yasir Khan et al. All rights reserved. Stress Induced Cardiomyopathy with Midventricular Ballooning: A Rare Variant Thu, 04 Jun 2015 11:22:31 +0000 Stress cardiomyopathy (SCM) also referred to as the “broken heart syndrome” is a condition in which intense emotional or physical stress can cause fulminant and reversible cardiac muscle weakness. SCM most commonly involves the apical segment of left ventricle but newer and rare variants have recently been seen reported. We here report a case of rare midventricular variant of stress related cardiomyopathy. A 72-year-old female with past medical history, only significant for SVT, presented with an episode of severe substernal chest pain while hiking with her husband. She felt a significant heaviness in her chest and was short of breath. During her hospitalization she was found to have positive cardiac enzymes. EKG showed 1 mm downsloping ST segment changes. Ventriculogram during left heart catheterization revealed dyskinetic midventricle. Patient was diagnosed with midventricular SCM. The patient was placed on ACE inhibitor and beta-blocker and discharged in a well-compensated state. We suggest identifying these patients by standard lab testing, electrocardiography, echocardiography, and left heart coronary angiography and ventriculography. Management of this unique entity is similar to the other variants with close observation and treatment of accompanying heart failure, valvular dysfunction, and any arrhythmias that may develop. Muhammad Umer Siddiqui, Michael C. Desiderio, Nicholas Ricculli, and Arthur Rusovici Copyright © 2015 Muhammad Umer Siddiqui et al. All rights reserved. Acute Renal Failure due to Leukaemic Infiltration in Chronic Lymphocytic Leukaemia Thu, 04 Jun 2015 08:17:09 +0000 Chronic lymphocytic leukemia (CLL) is a malignancy characterized by clonal proliferation and accumulation of B lymphocytes. Although leukaemic infiltration of the kidney is well recognized in CLL, acute renal failure (ARF) due to leukaemic infiltration is extremely rare. Here we present a case of ARF as the initial manifestation of CLL. The diagnosis was made by a kidney biopsy. Treatment with cyclophosphamide and prednisolone resulted in a completely improved renal function. Yusuf Kayar, Iskender Ekinci, Ilker Bay, Nuket Bayram Kayar, Jamshid Hamdard, and Rumeyza Kazancıoğlu Copyright © 2015 Yusuf Kayar et al. All rights reserved. Progressive Familial Intrahepatic Cholestasis: A Rare Cause of Cirrhosis in Young Adult Patients Tue, 02 Jun 2015 07:15:39 +0000 Hepatic cirrhosis is an important cause of morbidity and mortality. An unusual case of cirrhosis and portal hypertension in an 18-year-old patient secondary to Progressive Intrahepatic Cholestasis is discussed. The clinical and biochemical findings are discussed and a clinical approach to determining the underlying etiology of cirrhosis is outlined. Significant complications of portal hypertension include ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, varices, and hepatic encephalopathy. A clinical approach to these complications of cirrhosis is presented. Progressive Familial Intrahepatic Cholestasis (PFIC) is a rare congenital metabolic abnormality. There are 3 subtypes and Type 3 PFIC commonly presents in late adolescence and early adulthood. Clinical and laboratory findings as well as management for the condition are described. Gavin R. Sun and Michele Burns Copyright © 2015 Gavin R. Sun and Michele Burns. All rights reserved. Parkinsonism and Sjögren’s Syndrome: A Fortuitous Association or a Shared Immunopathogenesis? Sun, 31 May 2015 16:46:15 +0000 Background. The Sjögren Syndrome (SS) can include various manifestations of central nervous system impairment. Extrapyramidal signs are known to be very rare and unusually discovered on early onset in this pathology. Observation. A 46-year-old woman with a history of progressive Parkinsonism for 6 years and a normal brain magnetic resonance imaging was partially improved with levodopa therapy. The later discovery of a sicca syndrome led to performing of further investigations, which revealed the presence of anti-SSA antibodies and a sialoadenitis of grade 4 according to Chisholm’s classification on labial salivary gland biopsy. The diagnosis of primary SS was established and the adjunction of corticotherapy has remarkably improved Parkinson’s signs without use of other immunosuppressive agents. Conclusion. Based on these findings, we discuss the hypothesis of either a causal link between SS and Parkinsonism or a fortuitous association of two distinct pathologies with or without a shared immunopathogenesis. Mariem Kchaou, Nadia Ben Ali, Intissar Hmida, Saloua Fray, Hela Jamoussi, Mohamed Jalleli, Slim Echebbi, Afef Achouri, and Samir Belal Copyright © 2015 Mariem Kchaou et al. All rights reserved. Treatment of Oroantral Communication Using the Lateral Palatal Sliding Flap Technique Sun, 31 May 2015 13:23:57 +0000 Herein, we present a case of oroantral communication that was to be treated with clinical examination, tomography, and prototyping. A patient presented with oroantral communication with purulent exudation for 4 months, since the displacement of the dental implant and O-ring component to the maxillary sinus. Tomographic examination and prototyping revealed a 5 mm bone gap. The patient underwent local washes and antibiotic therapy. After local palpation, a bone defect detected by prototyping was suspected to be greater than that observed. For the surgery, a communication tunnel was made, and the bone defect was found to be 12 mm in diameter. A pedicle flap was raised on the palate, followed by sliding and suturing. No complications were observed during the postoperative period, and the suture was removed after a week. Four months later, communication did not resume, and the patient did not complain of pain, foul smelling, or purulent discharge and was satisfied with the outcome. The findings of this case suggest that the lateral sliding flap can be used as an efficient technique for closing oroantral communications. An accurate clinical examination is a critical tool that can be used instead of tomography and prototyping, which can be misleading. Fernando Salimon Ribeiro, Cassio Torres de Toledo, Michele Romero Aleixo, Maria Cristina Durigan, Willian Corrêa da Silva, Samanta Kelen Bueno, and Ana Emília Farias Pontes Copyright © 2015 Fernando Salimon Ribeiro et al. All rights reserved. Hereditary Hemorrhagic Telangiectasia with Hepatic Vascular Malformations Thu, 21 May 2015 12:05:14 +0000 Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disease. Early diagnosis is important to avoid complications from vascular lesions, but diagnosis is difficult in asymptomatic patients. A 69-year-old Japanese male patient was referred to our hospital for evaluation of hepatic vascular malformations. He had mild anemia with iron deficiency, and dynamic contrast-enhanced computed tomography revealed significant arteriovenous and arterioportal shunts throughout the liver. Telangiectasia from the pharynx to the duodenum was confirmed by gastrointestinal endoscopy. The patient history revealed episodes of epistaxis as well as a family history of epistaxis. He was diagnosed with HHT, although no other family member had been diagnosed with definite HHT. A diagnosis of HHT must be considered in patients with hepatic vascular malformations. Yujiro Nishioka, Nobuhisa Akamatsu, Yasuhiko Sugawara, Junichi Kaneko, Junichi Arita, Yoshihiro Sakamoto, Kiyoshi Hasegawa, and Norihiro Kokudo Copyright © 2015 Yujiro Nishioka et al. All rights reserved. Primary Breast Burkitt’s Lymphoma in an HIV-Infected Woman Thu, 21 May 2015 11:47:25 +0000 A 30-year-old HIV positive woman presented with a multifocal mass tumour associated with axillary and lateral-cervical lymphadenopathy in the right breast. Laboratory examination of the biopsy confirmed a case of mammary Burkitt’s lymphoma with a nodular infiltration of the breast. Antiretroviral treatment and chemotherapy were effective to control the tumour. Although Burkitt’s lymphoma rarely involves the breasts, it should be considered during routine breast examination of African woman. Bangaly Traoré, Marie-Eve Fondrevelle, Mamoudou Condé, Catherine Chassagne-Clément, Tidiane Kourouma, Ahmed Monzomba Keita, Moussa Koulibaly, and Bakary Sidiki Sylla Copyright © 2015 Bangaly Traoré et al. All rights reserved. Deep Venous Thrombosis with Pulmonary Embolism Related to IVIg Treatment: A Case Report and Literature Review Tue, 19 May 2015 13:09:03 +0000 IVIg therapy has potentially been related to arterial and venous therapy. We performed an Ovid review focusing on IVIg and thrombotic events. While a few case reports were reviewed case series and case control studies were particularly reviewed in relation to thrombotic events. Outcomes demonstrate a correlation between underlying cardiovascular risk factors with predominately arterial events which typically occurred within 4–24 hours of infusion. While venous events occurred less commonly they were associated with traditional risk factors and occurred later, typically, 1–7 days following infusion of IVIg. Potential causation of thrombotic events was discussed. Michael T. Flannery and Deborah Humphrey Copyright © 2015 Michael T. Flannery and Deborah Humphrey. All rights reserved. Treatment of Refractory Postural Tachycardia Syndrome with Subcutaneous Octreotide Delivered Using an Insulin Pump Tue, 19 May 2015 11:02:19 +0000 Postural Tachycardia Syndrome (PoTS) represents a disorder of the autonomic nervous system that results in symptoms of orthostatic intolerance. Despite having a severe impact on the patient’s quality of life, the current treatment options for PoTS are based on limited evidence. Subsequently, this results in clinicians having to utilise a variety of treatment regimens in the hope of successfully providing symptomatic relief. However, the options available for PoTS are not without significant side effects that can worsen an already debilitating condition. Our cases provide a further novel treatment option for clinicians to consider in PoTS refractory to established treatments. Muhammad Khan, Jing Ouyang, Karen Perkins, John Somauroo, and Franklin Joseph Copyright © 2015 Muhammad Khan et al. All rights reserved. A Case Report of Acute Esotropia in a Young Woman following Heroin Withdrawal Sun, 17 May 2015 12:08:29 +0000 Introduction. Esotropia is a form of strabismus that can give the affected individual a “cross-eyed” appearance. Acute onset of esotropia is an uncommon form; in the vast majority of cases, no underlying neurological etiology is found. Case Presentation. A 22-year-old female with a long history of opiate abuse presented with acute onset of diplopia. She noted her eyes were crossing and started seeing double. She stopped using heroin 11 days prior to presentation. There was large inward deviation of her left eye. Convergence was difficult and accompanied by horizontal nystagmus. Diplopia resolved by covering each eye. Further investigations including imaging studies were normal. Discussion. Acute onset esotropia is rare and must be investigated right away to exclude central nervous system pathologies, where no opiates use is reported. Diplopia in the form of acute esotropia may manifest in up to 30% of individuals undergoing heroin withdrawal. Evaluating acute esotropia requires detailed information of medical history with an emphasis on drug use. Conclusion. Acute onset esotropia with double vision can be caused by abrupt withdrawal of opiates. This case should serve to raise awareness among health care professionals, to avoid costly and unnecessary diagnostic evaluations and interventions. Bethel Shiferaw, Ebisa Bekele, Sara Syed, Lu Fan, Nirav Patel, Samia Qazi, and Nicolas Biro Copyright © 2015 Bethel Shiferaw et al. All rights reserved. Merkel Cell Carcinoma of the Axilla and Adrenal Gland: A Case Report with Imaging and Pathologic Findings Sun, 17 May 2015 11:41:00 +0000 Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine carcinoma of the skin. MCC is characterized by a high incidence of locoregional recurrence, and distant metastasis, and often requires short-term follow-up after treatment. In this present paper, we describe a rare case of MCC, which presented as a palpable axillary mass and an incidental adrenal mass, and report on the ultrasonography, computed tomography, and 18F-fluorodeoxyglucose-positron emission tomography findings. The patient underwent surgery and adjuvant radiation therapy. Seven months after the initial diagnosis, distant metastasis was detected during a follow-up examination. Soo Heui Baek, Hyun Kyung Jung, WooGyeong Kim, Suk Jung Kim, Hye Jin Baek, Seung Ho Kim, Yedaun Lee, and Young Mi Park Copyright © 2015 Soo Heui Baek et al. All rights reserved. An Incarcerated Colon Inguinal Hernia That Perforated into the Scrotum and Exhibited an Air-Fluid Level Wed, 13 May 2015 09:11:06 +0000 There are few reports of a transverse colon inguinal hernia; furthermore, an inguinal hernia perforating the scrotum is rare. Here we report the case of a 79-year-old man who died after developing an incarcerated colon inguinal hernia that perforated the scrotum and exhibited an air-fluid level. The patient was referred to our hospital in November 2011 with a complaint of inability to move. Physical examination revealed an abnormally enlarged left scrotum and cold extremities. He reported a history of gastric cancer that was surgically treated more than 30 years ago. His white blood cell count and C-reactive protein level were elevated. Abdominal and inguinal computed tomography revealed that his transverse colon was incarcerated in the left inguinal canal. Free air and air-fluid level were observed around the transverse colon, suggestive of a perforation. The patient and his family refused any surgical intervention; therefore, he was treated with sultamicillin tosilate hydrate and cefotiam hydrochloride. However, he succumbed to panperitonitis 19 days after admission. The findings from this case indicate that the transverse colon can perforate into an inguinal hernia sac. Seisuke Ota, Toshio Noguchi, Tomoya Takao, Takumi Sakamoto, Yuichiro Kanie, Ken-ichi Omae, Shunji Fujie, Yoshiaki Kanaya, Akinori Kasahara, and Tadashi Matsumra Copyright © 2015 Seisuke Ota et al. All rights reserved. Intoxication due to Papaver rhoeas (Corn Poppy): Five Case Reports Wed, 13 May 2015 06:56:57 +0000 Introduction. In this paper, we aimed to present five Papaver rhoeas intoxication cases, which is very rare in the literature. Case 1. A 35-year-old female patient was admitted to our emergency room with the complaints of nausea, restlessness, and dyspnea developing 3 hours after eating Papaver rhoeas. On physical examination, her general condition was moderate; she was conscious and the vital findings were normal. The pupils were myotic. She was transferred to the toxicology intensive care unit as she experienced a generalized tonic clonic seizure lasting for three minutes. Case 2. A 41-year-old female patient was brought to our emergency room by 112 ambulance as she had contractions in her arms and legs, unconsciousness, and foam coming from her mouth two hours after Papaver rhoeas ingestion. On physical examination, she was confused, the pupils were myotic, and she was tachycardic. Arterial blood gases analysis revealed lactic acidosis. Case 3. A 38-year-old female patient was admitted to our emergency room with complaints of nausea and vomiting two hours after ingestion of Papaver rhoeas. Her physical examination and tests were normal. Case 4. A 34-year-old male patient was admitted to our emergency room with complaints of numbness and loss of power in his arms and legs one hour after Papaver rhoeas ingestion. He was hospitalized at the toxicology intensive care unit for follow-up and treatment. Dyspnea and bradycardia developed on the follow-up. The oxygen saturation without oxygen support was 90%. ECG revealed sinus bradycardia. The cardiac enzymes did not increase. Case 5. A 42-year-old female patient was brought to our emergency room by 112 ambulance with contractions in her arms and legs and unconsciousness two hours after Papaver rhoeas ingestion. On her physical examination, she was confused and the pupils were myotic. Arterial blood gases analysis revealed lactic acidosis. Conclusion. All patients were followed up for a few days and then discharged from the hospital with recovery. Unconscious consumption of Papaver rhoeas leads to a clinical condition resembling morphine intoxication, CNS depression, and epileptic seizures. Yahya Kemal Günaydın, Zerrin Defne Dündar, Bora Çekmen, Nazire Belgin Akıllı, Ramazan Köylü, and Başar Cander Copyright © 2015 Yahya Kemal Günaydın et al. All rights reserved. Rare Case of Aspergillus ochraceus Osteomyelitis of Calcaneus Bone in a Patient with Diabetic Foot Ulcers Tue, 12 May 2015 11:18:31 +0000 Diabetes is the most common metabolic disease in humans. One of the major complications of the disease is foot ulcer that is prone to infection. The most common causes of infection which have been reported in these patients are bacteria and fungi such as Candida, Aspergillus, and Rhizopus species. We report one such rare case with calcaneal osteomyelitis caused by Aspergillus ochraceus in a patient with diabetic foot osteomyelitis. The case was a 68-year-old male with a history of type II diabetes for 2 years. The patient had two ulcers on the right heel bones for the past 6 months with no significant improvement. One of the most important predisposing factors to infectious diseases, especially opportunistic fungal infection, is diabetes mellitus. Aspergillus species can involve bony tissue through vascular system, direct infection, and trauma. Proper and early diagnosis and treatment of diabetic foot infection can reduce or prevent complications, such as osteomyelitis and amputation. The annual examination of feet for skin and nail lesion, sensation, anatomical changes, and vascular circulation can be useful for prevention and control of infection. Farhang Babamahmoodi, Tahereh Shokohi, Fatemeh Ahangarkani, Mojtaba Nabili, Elham Afzalian Ashkezari, and Sosan Alinezhad Copyright © 2015 Farhang Babamahmoodi et al. All rights reserved. A Rare Reason for Pelvic Pain in Pregnancy: Infectious Sacroiliitis Tue, 12 May 2015 09:23:26 +0000 Introduction. Although the incidence of pregnancy-associated sacroiliitis is low, it is associated with significant morbidity and mortality. Timely diagnosis of the disease is confusing due to its nonspecific clinical features. Case. A 28-year-old woman at 34 weeks of gestation with severe pain in her right buttock radiating down the backside of the right thigh was admitted to our hospital. White blood cell (WBC) count and C-reactive protein (CRP) were elevated. The pelvic magnetic resonance imaging (MRI) scan revealed right sacroiliitis. Conclusion. Infectious sacroiliitis should be considered as a differential diagnosis even in low-risk women who present with debilitating pelvic pain in pregnancy and medical treatment should not be delayed. Yasemin Cekmez, Ahmet Göçmen, Oğuz Arslan, Fatih Şanlıkan, and Simge Bağcı Türkmen Copyright © 2015 Yasemin Cekmez et al. All rights reserved. Recurrent Syncope Associated with Lung Cancer Tue, 12 May 2015 07:13:33 +0000 Syncope is an important problem in clinical practice with many possible causes that might be misdiagnosed. We present an unusual case of syncope, which has a normal chest X-ray. Exercise EKG and coronary angioplasty results confirmed the existence of serious coronary heart disease. The patient was treated with coronary stent transplantation. However, scope occurred again and the elevated tumor makers cytokeratin-19-fragment and neuron-specific enolase revealed the bronchogenic carcinoma, which was confirmed by enhanced CT examination. The treatment of carcinoma by chemotherapy was indeed sufficient for prompt elimination of the syncope symptoms. Dingguo Zhang, Liansheng Wang, and Zhijian Yang Copyright © 2015 Dingguo Zhang et al. All rights reserved. Autologous Fat Grafting in the Treatment of Painful Postsurgical Scar of the Oral Mucosa Tue, 12 May 2015 06:36:47 +0000 Background. Persistent pain as a consequence of surgical treatment has been reported for several common surgical procedures and represents a clinical problem of great magnitude. Material and Methods. We describe the case of a 47-year-old female who presented a retractile scar that adhered to deep planes at the upper right of the vestibule due to surgical removal of maxillary exostosis, which determined important pain symptoms extending till the right shoulder during both chewing and rest. We subsequently treated her with autologous fat grafting according to Coleman’s technique. Results. Clinical assessments were performed at 5 and 14 days, 1, 3, and 6 months, and 1 year after surgical procedure. We observed a progressive release of scar retraction together with an important improvement of pain symptoms. Conclusion. The case described widens the possible application of autologous fat grafting on a new anatomical site as buccal vestibule and in one specific clinical setting confirming its promising biological effects. Andrea Lisa, Valeria Summo, Valeria Bandi, Luca Maione, Matteo Murolo, Francesco Klinger, and Marco Klinger Copyright © 2015 Andrea Lisa et al. All rights reserved.