Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Supine Frequent Ventricular Extrasystoles in a Pregnant Woman without Structural Heart Disease Thu, 25 Aug 2016 16:52:23 +0000 Arrhythmias are the most common cardiac complication during gestational period and may occur in women with or without known structural heart disease. Premature extra beats and sustained tachyarrhythmias are the most common arrhythmias in pregnancy. Symptomatic episodes occur in 20–44% of pregnant women, usually as palpitations, dizziness, or syncope. We searched on Pubmed for ventricular premature complexes (VPC) in pregnant women and found no case reporting increased incidence of this arrhythmia while supine. The aim of this study is to report a case of a pregnant woman without previous structural heart disease that presented a great number of VPC when supine. The arrhythmogenesis increase during pregnancy is multifactorial. In the reported case, we believe that augmented venous return was the most important pathophysiologic process. When the patient changes to left lateral decubitus, there could be a sudden release of the inferior vena cava, causing an abrupt augmentation of venous return to the right heart chambers and increasing the risk of arrhythmias. Obstetricians and primary care physicians should be aware of palpitations and related patient complains while they are asleep or supine. Natália Stela Sandes Ferreira, Tatiana La Croix Barros, and Ronaldo Altenburg Gismondi Copyright © 2016 Natália Stela Sandes Ferreira et al. All rights reserved. Idiopathic Sclerosing Encapsulating Peritonitis: A Rare Cause of Subacute Intestinal Obstruction Thu, 25 Aug 2016 16:28:19 +0000 We present a case of a previously healthy 50-year-old gentleman who had recurrent vomiting and abdominal pain of two-month duration. The patient was subsequently diagnosed with abdominal cocoon on computed tomography. Idiopathic sclerosing encapsulating peritonitis, also known as abdominal cocoon, is a rare cause of small bowel obstruction. Visualization of variable encasement of the small bowel loops by a characteristic membranous sac, either preoperatively with cross-sectional imaging or intraoperatively, is the key to diagnosis. This is a highly treatable condition; surgical excision of the sac with adhesiolysis facilitates a full recovery in affected patients. Mei Chin Lim, Niketa Chandrakant Chotai, and Danilo Medina Giron Copyright © 2016 Mei Chin Lim et al. All rights reserved. Myocardial Infarction and Aortic Root Mycotic Aneurysm Complicating Aortic Valve Endocarditis: Utility of Cardiac CT Thu, 25 Aug 2016 13:43:20 +0000 Aortic mycotic aneurysms are a rare but life-threatening potential complication of infective endocarditis. Rapid deterioration of the vascular wall in highly focal areas makes these pseudoaneurysms particularly prone to rupture, resulting in uncontrolled aortic hemorrhage. While computed tomography angiography (CTA) is the imaging modality of choice for the evaluation of mycotic aneurysms, it is not routinely performed in patients with known or suspected infective endocarditis (IE). However, current valvular heart disease guidelines support the use of cardiac CTA in cases of IE and suspected perivalvular extension when there is inadequate or ambiguous visualization on echocardiography. Here, we describe a case of IE in which cardiac CTA was used for two purposes: to assess perivalvular complications and to define coronary anatomy in a patient with a suspected embolic myocardial infarction. Subsequent detection of an aortic root mycotic aneurysm not previously demonstrated on transthoracic or transesophageal echocardiography allowed for timely and uncomplicated surgical intervention, while avoiding invasive coronary angiography. Aimee E. Moores, Michael S. Cahill, and Todd C. Villines Copyright © 2016 Aimee E. Moores et al. All rights reserved. Effectiveness of a Short-Term Treatment of Oxygen-Ozone Therapy into Healing in a Posttraumatic Wound Mon, 22 Aug 2016 16:47:38 +0000 Introduction. A number of studies suggest that oxygen-ozone therapy may have a role in the treatment of chronic, nonhealing, or ischemic wounds for its disinfectant and antibacterial properties. Nonhealing wounds are a significant cause of morbidity. Here we present a case of subcutaneous oxygen-ozone therapy used to treat a nonhealing postoperative wound in a young man during a period of 5 weeks. Case Presentation. A 46-year-old man had a motorcycle accident and underwent amputation of the right tibia and fibula. At the discharge he came to our attention to start rehabilitation treatment. At that time the wound was ulcerated but it was afebrile with no signs of inflammation and negativity to blood tests. At 2 months from the trauma despite appropriate treatment and dressing, the wound was slowly improving and the patient complained of pain. For this reason in addition to standard dressing he underwent oxygen-ozone therapy. After 5 weeks of treatment the wound had healed. Conclusion. In patients with nonhealing wounds, oxygen-ozone therapy could be helpful in speeding the healing and reducing the pain thanks to its disinfectant property and by the increase of endogenous oxygen free radicals’ scavenging properties. Compared to standard dressing and other treatments reported in the literature it showed a shorter time of action. Degli Agosti Irene, Elena Ginelli, Bruno Mazzacane, Gabriella Peroni, Sandra Bianco, Fabio Guerriero, Giovanni Ricevuti, Simone Perna, and Mariangela Rondanelli Copyright © 2016 Degli Agosti Irene et al. All rights reserved. An Unexpected Interaction between Sofosbuvir/Ledipasvir and Atorvastatin and Colchicine Causing Rhabdomyolysis in a Patient with Impaired Renal Function Mon, 22 Aug 2016 16:45:51 +0000 Hepatitis C virus (HCV) infection affects roughly 170 million people worldwide. Sofosbuvir/Ledipasvir (Sof/Led) is a new once daily direct acting antiviral combination pill that was approved in October 2014 for use in patients with HCV genotype 1 infection. Coadministration of Sof/Led is studied only with rosuvastatin which shows significantly increased level of drug and is associated with increased risk of myopathy, including rhabdomyolysis. There is no mention of such HMG-CoA reductase inhibitor interaction as a class, as pravastatin did not have any clinically significant interaction with Sof/Led. Other myotoxic drugs, including colchicine are not studied. We present a case of a serious drug interaction between Sof/Led and atorvastatin, in the background of CKD and colchicine use. Shyam Patel, Jennifer Andres, and Kamran Qureshi Copyright © 2016 Shyam Patel et al. All rights reserved. Clinical Evolution of Central Pontine Myelinolysis in a Patient with Alcohol Withdrawal: A Blurred Clinical Horizon Tue, 16 Aug 2016 11:55:05 +0000 Central pontine myelinolysis (CPM), a potentially fatal and debilitating neurological condition, was first described in 1959 in a study on alcoholic and malnourished patients. It is a condition most frequently related to rapid correction of hyponatremia. Chronic alcoholism associated CPM tends to be benign with a favorable prognosis compared to CPM secondary to rapid correction of hyponatremia. We describe a normonatremic, alcoholic patient who presented with CPM after a rapid rise in his sodium levels. Our case illustrates the fact that CPM can manifest even in patients who are normonatremic at baseline. Rapid rises in sodium levels should be promptly reversed before clinical symptoms manifest in patient with risk factors for CPM irrespective of their baseline sodium levels. Furthermore, clinical evolution of CPM can be difficult to discern from the natural course of alcohol withdrawal delirium, requiring astuteness and maintenance of a high degree of clinical suspicion on the part of the physician. Abdul S. Mohammed, Prajwal Boddu, and Dina F. Yazdani Copyright © 2016 Abdul S. Mohammed et al. All rights reserved. Endobronchial Carcinoid Tumour with Extensive Ossification: An Unusual Case Presentation Tue, 16 Aug 2016 10:37:49 +0000 Carcinoid tumour is a well-known primary endobronchial lung neoplasm. Although calcifications may be seen in up to 30% of pulmonary carcinoid tumours, near complete ossification of these tumours is an unusual finding. Such lesions can prove diagnostically challenging at the time of intraoperative frozen section as the latter technique requires thin sectioning of the lesion for microscopic assessment. We present an unusual case of endobronchial carcinoid tumour with extensive ossification in a 45-year-old male. Preliminary intraoperative diagnosis was achieved through the alternative use of cytology scrape smears. The final diagnosis was confirmed after decalcification of the tumour. The prognostic implications of heavily ossified carcinoid tumours remain elusive. Long-term clinical follow-up of these patients is recommended. Allison Osmond, Emily Filter, Mariamma Joseph, Richard Inculet, Keith Kwan, and David McCormack Copyright © 2016 Allison Osmond et al. All rights reserved. Mounier-Kuhn Syndrome in an Elderly Female with Pulmonary Fibrosis Mon, 15 Aug 2016 08:09:46 +0000 Mounier-Kuhn syndrome (MKS), or tracheobronchomegaly, is a rare clinical and radiologic condition characterized by pronounced tracheobronchial dilation and recurrent lower respiratory tract infections. Tracheobronchomegaly presents when the defect extends to the central bronchi. MKS can be diagnosed in adult women when the transverse and sagittal diameters of the trachea, right mainstem bronchus, and left mainstem bronchus exceed 21, 23, 19.8, and 17.4 mm, respectively. Its diagnosis is based on chest radiograph and chest computed tomography (CT). Patients, usually middle-aged men, may be asymptomatic or present with clinical manifestations ranging from minimal symptoms with preserved lung function to severe respiratory failure. Pulmonary function tests (PFTs) typically reveal a restrictive pattern. This report presents an elderly woman with previously diagnosed pulmonary fibrosis with symptoms of increased sputum production and haemoptysis. High-resolution chest CT showed tracheal and main stem bronchi dilatation along with bronchial diverticulosis. PFTs indicated a restrictive pattern characteristic of the underlying pulmonary fibrosis. The patient is the oldest, referred to the female gender, at presentation of MKS hitherto reported. This case highlights the need to include MKS in the differential diagnosis of recurrent lower respiratory tract infections, even in older subjects. Panagiotis Boglou, Nikolaos Papanas, Anastasia Oikonomou, Stamatia Bakali, and Paschalis Steiropoulos Copyright © 2016 Panagiotis Boglou et al. All rights reserved. Ulipristal Acetate in Myomectomy Optimization in an Infertile Patient with Giant Myomas Wed, 10 Aug 2016 09:07:29 +0000 The use of ulipristal acetate (UPA) has been recently introduced in the treatment of uterine leiomyomas. This drug has proven useful to control menometrorrhagia and to reduce myoma size. In the case presented here, we show the benefits of UPA treatment in facilitating surgical removal of giant myomas in an infertile patient. In addition to myoma reduction and a better control of preoperative bleeding, the treatment with UPA reduced the duration and complexity of the surgery, as well as the area of uterine wall involved and the resulting scar. No side effects were observed and the patient became pregnant 6 months after the surgery and had a normal pregnancy and delivery. This case report shows the beneficial effects of UPA in the preoperative treatment of myomas which affect uterus function. Elena de la Fuente, María Dolores Borrás, Miriam Rubio, and Nuria Abril Copyright © 2016 Elena de la Fuente et al. All rights reserved. Tracheobronchial Amyloidosis Mimicking Tracheal Tumor Tue, 09 Aug 2016 07:49:23 +0000 Tracheobronchial amyloidosis is a rare presentation and accounts for about 1% of benign tumors in this area. The diagnosis of disease is delayed due to nonspecific pulmonary symptoms. Therapeutic approaches are required to control progressive pulmonary symptoms for most of the patients. Herein, we report a case of a 68-year-old man admitted with progressive dyspnea to our institution for further evaluation and management. He was initially diagnosed with and underwent management for bronchial asthma for two years but had persistent symptoms despite optimal medical therapy. Pulmonary computed tomography scan revealed severe endotracheal stenosis. Bronchoscopy was performed and showed endotracheal mass obstructing 70% of the distal trachea and mimicking a neoplastic lesion. The mass was successfully resected by mechanical resection, argon plasma coagulation (APC), and Nd-YAG laser during rigid bronchoscopy. Biopsy materials showed deposits of amorphous material by hematoxylin and eosin staining and these deposits were selectively stained with Congo Red. Although this is a rare clinical condition, this case indicated that carrying out a bronchoscopy in any patient complaining of atypical bronchial symptoms or with uncontrolled asthma is very important. Elif Tanrıverdi, Mehmet Akif Özgül, Oğuz Uzun, Şule Gül, Mustafa Çörtük, Zehra Yaşar, Murat Acat, Naciye Arda, and Erdoğan Çetinkaya Copyright © 2016 Elif Tanrıverdi et al. All rights reserved. Hyperemesis Gravidarum in Undiagnosed Gitelman’s Syndrome Sun, 07 Aug 2016 12:46:54 +0000 Introduction. Gitelman’s syndrome (GS) is an autosomal recessive inherited defect in the thiazide-sensitive sodium-chloride cotransporter (NCCT) in the renal distal convoluted tubule. Physiologic changes of pregnancy promote renal potassium wasting, but serum potassium levels are kept in the physiologic range by increased levels of progesterone, which resist kaliuresis. In the presence of GS, this compensatory mechanism is easily overwhelmed, resulting in profound hypokalemia. We present a case of an 18-year-old primigravida with undiagnosed GS who presented with hyperemesis gravidarum in her 7th week of pregnancy. This report adds to the limited experience with GS in pregnancy as reported in literature and provides additional information on medical management that leads to successful maternal and fetal outcomes. Maria Czarina Acelajado, R. Michael Culpepper, and Wilburn D. Bolton III Copyright © 2016 Maria Czarina Acelajado et al. All rights reserved. IL-6-Producing, Noncatecholamines Secreting Pheochromocytoma Presenting as Fever of Unknown Origin Sun, 07 Aug 2016 07:28:10 +0000 Fever of unknown origin (FUO) can be an unusual first clinical manifestation of pheochromocytoma. Pheochromocytomas are tumors that may produce a variety of substances in addition to catecholamines. To date, several cases of IL-6-producing pheochromocytomas have been reported. This report describes a 45-year-old woman with pheochromocytoma who was admitted with FUO, normal blood pressure levels, microcytic and hypochromic anemia, thrombocytosis, hyperfibrinogenemia, hypoalbuminemia, and normal levels of urine and plasma metanephrines. After adrenalectomy, fever and all inflammatory findings disappeared. Marco Ciacciarelli, Davide Bellini, Andrea Laghi, Alessandro Polidoro, Antonio Pacelli, Anna Giulia Bottaccioli, Giuseppina Palmaccio, Federica Stefanelli, Piera Clemenzi, Luisa Carini, Luigi Iuliano, and Cesare Alessandri Copyright © 2016 Marco Ciacciarelli et al. All rights reserved. Amelioration of Sickle Cell Pain after Parathyroidectomy in Two Patients with Concurrent Hyperparathyroidism: An Interesting Finding Thu, 04 Aug 2016 09:16:24 +0000 Patients with sickle cell disease have high morbidity and healthcare utilization due to repeated painful crises. Some coexisting conditions which cause pain similar to sickle cell disease may go undiagnosed in these patients. We report two adults with concurrent hyperparathyroidism who experienced significant improvement in sickle cell pain following parathyroidectomy thereby pointing to hyperparathyroidism as the principal causative factor for their pain. Meticulous evaluation for parathyroid disorders can be rewarding in sickle cell disease. John Muthu and Mir Ali Copyright © 2016 John Muthu and Mir Ali. All rights reserved. Needle Fracture during Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspicious Thoracic Lymph Nodes Sun, 31 Jul 2016 08:52:29 +0000 Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is used to make a cytopathologic diagnosis of suspicious lesions located around the gastrointestinal tract. It is a safe technique with few complications. The most common complications of EUS-FNA are related to pancreatic lesions (pancreatitis, bleeding, and abdominal pain). Rare complications have been noted such as stent malfunction, air embolism, infection, neural and vascular injuries, and tumor cell seeding. There are very few studies examining equipment malfunctions. We report a case of needle fracture during the EUS-FNA of suspicious thoracic lymph nodes in a 79-year-old man investigated for unexplained weight loss. Bartosz Adamowicz, Thibaut Manière, Vincent Déry, and Étienne Désilets Copyright © 2016 Bartosz Adamowicz et al. All rights reserved. Simultaneous Two-Vessel Subacute Stent Thrombosis Caused by Clopidogrel Resistance from CYP2C19 Polymorphism Sun, 31 Jul 2016 08:50:49 +0000 Clopidogrel resistance from CYP2C19 polymorphism has been associated with stent thrombosis in patients undergoing percutaneous coronary intervention with drug-eluting stents. We present a case of a 76-year-old male who received drug-eluting stents to the right coronary artery and left anterior descending artery for non-ST elevation myocardial infarction and was discharged on dual antiplatelet therapy with aspirin and clopidogrel. He subsequently presented with chest pain from anterior, anteroseptal, and inferior ST segment elevation myocardial infarction. An emergent coronary angiogram revealed acute stent thrombosis with 100% occlusion of RCA and LAD that was successfully treated with thrombus aspiration and angioplasty. Although he was compliant with his dual antiplatelet therapy, he developed stent thrombosis, which was confirmed as clopidogrel resistance from homozygous CYP2C19 polymorphism. Ashwad Afzal, Bimal Patel, Neel Patel, Sudhakar Sattur, and Vinod Patel Copyright © 2016 Ashwad Afzal et al. All rights reserved. Systemic Sarcoidosis Unmasked by Cushing’s Disease Surgical Treatment Mon, 25 Jul 2016 09:41:34 +0000 Diseases responsive to glucocorticoids, like sarcoidosis, are rarely masked by Cushing’s syndrome. An ACTH secreting pituitary adenoma is a possible cause of Cushing’s syndrome and its resection can make a subclinical sarcoidosis clear. Only few cases of sarcoidosis following the treatment of hypercortisolism are reported in literature. We report a case of sarcoidosis after the resection of an ACTH secreting pituitary adenoma. Daniele Bongetta, Cesare Zoia, Francesco Lombardi, Elisabetta Lovati, Pietro Lucotti, and Paolo Gaetani Copyright © 2016 Daniele Bongetta et al. All rights reserved. Multiple Small Coronary Artery Fistulas Emptying into the Left Ventricle: A Rare but Challenging Problem Mon, 25 Jul 2016 08:35:24 +0000 A coronary artery fistula (CAF) is an abnormal communication between a coronary artery and a cardiac chamber or a great vessel. CAFs are rare based on coronary arteriography and when found they most often empty into the right ventricle and atrium and less often into the high pressure, low compliance left ventricle (LV). A patient who presented with atypical chest pain and was found to have multiple small CAFs originating from the ramus intermedius coronary artery and emptying into the LV is presented. This case highlights the challenges in providing an appropriate therapy for multiple small CAFs emptying into the LV. Omar Kahaly and Konstantinos Dean Boudoulas Copyright © 2016 Omar Kahaly and Konstantinos Dean Boudoulas. All rights reserved. Ulcerative Colitis Activity Presenting as Fever of Unknown Origin, in a Patient with Longstanding Disease under Continuous Treatment with Mesalazine Mon, 18 Jul 2016 12:42:15 +0000 Background. The presence of ulcerative colitis (UC) with no bowel symptoms, as fever of unknown origin (FUO), is uncommon. Objective. To describe the case of an 80-year-old woman who presented with fever, with a history of UC under treatment with mesalazine. Case Presentation. She was admitted due to fever lasting for 12 days with no associated symptoms. Seven years earlier, she was diagnosed with UC. After an extended workup for FUO that failed to reach the diagnosis, she underwent a gallium-67 scintigraphy. This revealed a persistent diffuse concentration of gallium-67 in the ascending colon at 24-hour imaging that remained stable at 48- and 72-hour imaging without any topographic change after the use of laxatives. Considering the results and in the absence of another diagnosis, the patient was treated with 30 mg prednisone daily and mesalazine, as treatment of active UC. Subsequently, the patient’s condition improved markedly and the fever retreated. One month later, she was reevaluated with a gallium-67 scintigraphy with total absence of gallium-67 concentration in the ascending colon. Conclusion. UC activity must be included in the differential diagnosis of FUO in patients with longstanding disease, since fever may present alone, with no other manifestations. Panagiota Voukelatou, Elissavet Sfendouraki, Theodoros Karianos, Sofia Saranti, Dimitrios Tsitsimelis, Ioannis Vrettos, and Andreas Kalliakmanis Copyright © 2016 Panagiota Voukelatou et al. All rights reserved. Diversification of Antitumour Immunity in a Patient with Metastatic Melanoma Treated with Ipilimumab and an IDO-Silenced Dendritic Cell Vaccine Mon, 18 Jul 2016 08:19:14 +0000 Indoleamine 2,3-dioxygenase (IDO) expression in dendritic cells (DCs) inhibits T-cell activation and promotes T-cell differentiation into regulatory T-cells. Moreover, IDO expression promotes resistance to immunotherapies targeting immune checkpoints such as the cytotoxic T lymphocyte antigen-4 (CTLA-4). Here, a patient with metastatic melanoma pretreated with ipilimumab, an anti-CTLA-4 blocking antibody, was vaccinated with IDO-silenced DCs cotransfected with mRNA for survivin or hTERT tumour antigens. During vaccination, T-cell responses to survivin and hTERT tumour antigens were generated, and a certain degree of clinical benefit was achieved, with a significant reduction in lung, liver, and skin metastases, along with a better performance status. T-cell responses against MART-1 and NY-ESO-1 tumour antigens were also detected in the peripheral blood. The patient also mounted an antibody response to several melanoma proteins, indicating diversification of the antitumour immunity in this patient. The identification of such serum antibody-reacting proteins could facilitate the discovery of tumour neoantigens. Mouldy Sioud, Marta Nyakas, Stein Sæbøe-Larssen, Anne Mobergslien, Steinar Aamdal, and Gunnar Kvalheim Copyright © 2016 Mouldy Sioud et al. All rights reserved. Pulmonary Talcosis in an Immunocompromised Patient Thu, 30 Jun 2016 15:41:16 +0000 The first case of pulmonary talcosis or talc pneumoconiosis related to inhalation of talc during its extraction and processing in mines was described by Thorel in 1896. Pulmonary talcosis is most commonly seen secondary to occupational exposure or intravenous (IV) drug abuse and, occasionally, in excessive use of cosmetic talc. Based on literature review, there has been an increase in reported incidents of pulmonary talcosis due to various forms of exposure to the mineral. We report an 82-year-old man who is diagnosed with Philadelphia chromosome positive pre-B cell acute lymphoblastic leukemia (ALL) treated with palliative imatinib who presented with chronic hemoptysis and dyspnea shortly after his diagnosis. His symptoms were initially thought to be due to an infectious etiology due to his malignancy, immunocompromised state, and radiographic findings until high-resolution computerized tomographic (HRCT) findings showed a diffuse pulmonary fibrosis picture that prompted further questioning and a more thorough history inquiry on his exposure to causative agents of interstitial lung disease. Very often, patients do not recognize their exposure, especially in those whose exposure is unrelated to their occupation. Our case emphasizes the need for thorough and careful history taking of occupational and nonoccupational exposure to known causative agents of interstitial lung disease. Thanh-Phuong Nguyen, Sowmya Nanjappa, Manjunath Muddaraju, and John N. Greene Copyright © 2016 Thanh-Phuong Nguyen et al. All rights reserved. Sanguineous Pericardial Effusion and Cardiac Tamponade in the Setting of Graves’ Disease: Report of a Case and Review of Previously Reported Cases Wed, 29 Jun 2016 15:12:59 +0000 Introduction. Pericardial effusion in the setting of hyperthyroidism is rare. We present a patient with Graves’ disease who developed a sanguineous pericardial effusion and cardiac tamponade. Case Description. A 76-year-old man presenting with fatigue was diagnosed with Graves’ disease and treated with methimazole. Two months later, he was hospitalized for uncontrolled atrial fibrillation. Electrocardiography showed diffuse low voltage and atrial fibrillation with rapid ventricular rate. Chest radiograph revealed an enlarged cardiac silhouette and left-sided pleural effusion. Thyroid stimulating hormone was undetectable, and free thyroxine was elevated. Diltiazem and heparin were started, and methimazole was increased. Transthoracic echocardiography revealed a large pericardial effusion with cardiac tamponade physiology. Pericardiocentesis obtained 1,050 mL of sanguineous fluid. The patient progressed to thyroid storm, treated with propylthiouracil, potassium iodine, hydrocortisone, and cholestyramine. Cultures and cytology of the pericardial fluid were negative. Thyroid hormone markers progressively normalized, and he improved clinically and was discharged. Discussion. We found 10 previously reported cases of pericardial effusions in the setting of hyperthyroidism. Heparin use may have contributed to the sanguineous nature of our patient’s pericardial effusion, but other reported cases occurred without anticoagulation. Sanguineous and nonsanguineous pericardial effusions and cardiac tamponade may be due to hyperthyroidism. Peter V. Bui, Sonia N. Zaveri, and J. Rush Pierce Jr. Copyright © 2016 Peter V. Bui et al. All rights reserved. Anesthetic Management in a Gravida with Type IV Osteogenesis Imperfecta Tue, 28 Jun 2016 10:32:05 +0000 Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissues caused by abnormalities in collagen formation. OI may present many challenges to the anesthesiologist. A literature review reveals a wide range of implications, from basic positioning to management of the difficult airway. We present the anesthetic management of a 25-year-old gravid woman with OI, fetal demise, and possible uterine rupture, admitted for an exploratory laparotomy. Elizabeth Vue, Juan Davila, and Tracey Straker Copyright © 2016 Elizabeth Vue et al. All rights reserved. Overlapping of Serotonin Syndrome with Neuroleptic Malignant Syndrome due to Linezolid-Fluoxetine and Olanzapine-Metoclopramide Interactions: A Case Report of Two Serious Adverse Drug Effects Caused by Medication Reconciliation Failure on Hospital Admission Tue, 28 Jun 2016 08:23:48 +0000 Antipsychotic and antidepressant are often used in combination for the treatment of neuropsychiatric disorders. The concomitant use of antipsychotic and/or antidepressant with drugs that may interact can lead to rare, life-threatening conditions such as serotonin syndrome and neuroleptic malignant syndrome. We describe a patient who has a history of taking two offending drugs that interact with drugs given during the course of hospital treatment which leads to the development of serotonin syndrome overlapped with neuroleptic malignant syndrome. The physician should be aware that both NMS and SS can appear as overlapping syndrome especially when patients use a combination of both antidepressants and antipsychotics. Faizan Mazhar, Shahzad Akram, Nafis Haider, and Rafeeque Ahmed Copyright © 2016 Faizan Mazhar et al. All rights reserved. Rapidly Progressing Refractory Hodgkin Lymphoma: A Case Report and a Possible Explanation Sun, 26 Jun 2016 10:02:31 +0000 Introduction. Hodgkin lymphoma is a highly curable lymphoid malignancy; however treatment of a significant number of patients remains challenging. Case Report. The authors present an unusually rapidly progressing case of refractory advanced stage classical nodular sclerosis subtype Hodgkin lymphoma with unfavorable prognosis. A 66-year-old male patient was refractory for first-line doxorubicin, bleomycin, vinblastin, dacarbazine (ABVD) treatment with persistent disease; therefore physicians changed treatment for dexamethasone, cytarabine, and cisplatin (DHAP) and later ifosfamide, gemcitabine, and vinorelbine (IGEV) regimen. Unfortunately the patient developed acute kidney and respiratory failure and died after 6 months of treatment. Current and retrospective histological examination of the patient’s lymph node biopsy, skin lesion, and autopsy revealed the same aberrantly expressing CD4 positive nodular sclerosis subtype Hodgkin lymphoma. Conclusion. Aberrant expression of T-cell antigens on the Hodgkin and Reed/Sternberg cells could be associated with inferior outcome. T-cell associated antigens should be investigated more often in patients not responding sufficiently to treatment and hence treatment should be intensified or targeted therapy (brentuximab vedotin) should be considered. Ádám Jóna, Gábor Irsai, Sándor Barna, Gábor Méhes, Árpád Illés, and László Váróczy Copyright © 2016 Ádám Jóna et al. All rights reserved. Simultaneous Chronic Invasive Fungal Infection and Tracheal Fungus Ball Mimicking Cancer in an Immunocompetent Patient Thu, 23 Jun 2016 12:02:50 +0000 Fungal infections of the lung are uncommon and mainly affect people with immune deficiency. There are crucial problems in the diagnosis and treatment of this condition. Invasive pulmonary aspergillosis and candidiasis are the most common opportunistic fungal infections. Aspergillus species (spp.) are saprophytes molds that exist in nature as spores and rarely cause disease in immunocompetent individuals. In patients with immune deficiency or chronic lung disease, such as cavitary lung disease or bronchiectasis, Aspergillus may cause a variety of aspergillosis infections. Here we present a case of a 57-year-old patient without immunodeficiency or chronic lung disease who was diagnosed with endotracheal fungus ball and chronic fungal infection, possibly due to Aspergillus. Bronchoscopic examination showed a paralyzed right vocal cord and vegetating mass that was yellow in color, at the posterior wall of tracheal lumen. After 3 months, both the parenchymal and tracheal lesions were completely resolved. Erdoğan Çetinkaya, Mustafa Çörtük, Şule Gül, Ali Mert, Hilal Boyacı, Ertan Çam, and H. Erhan Dincer Copyright © 2016 Erdoğan Çetinkaya et al. All rights reserved. ST Segment Elevation with Normal Coronaries Wed, 15 Jun 2016 09:42:56 +0000 Noncardiac causes should be kept in the differential while evaluating ST elevation on EKG. Rarely abdominal pathologies like acute pancreatitis can present with ST elevation in the inferior leads. Once acute coronary syndrome is ruled out by emergent cardiac catheterization alternative diagnosis should be sorted. Abdominal pathologies, like acute pancreatitis and acute cholecystitis, can present with ST elevation in the inferior leads. Treating the underlying condition would result in resolution of these EKG changes. Pooja Sethi, Ghulam Murtaza, Ashwini Sharma, and Timir Paul Copyright © 2016 Pooja Sethi et al. All rights reserved. Simultaneous Clear Cell Sarcomas of the Duodenum and Jejunum Tue, 07 Jun 2016 08:04:55 +0000 Clear cell sarcoma (CCS) is an uncommon tumor that usually presents as an extremity mass but can rarely manifest as a gastrointestinal tumor with a diverse spectrum of symptoms, most commonly related to a mass effect or ulceration. Herein we report a case in which two separate tumors, one in the duodenum and the other in the jejunum, present concurrently. The subject presented with symptomatic anemia and underwent imaging and endoscopic studies that culminated in the discovery of the two lesions. He subsequently underwent operative treatment with resection of both tumors and made an unremarkable recovery. The resection specimen consisted of two separate clear cell sarcomas with negative margins. Under microscopic evaluation, they demonstrated nested growths of epithelioid cells with scattered spindled cells infiltrating the enteric wall. The neoplastic cells were positive for S100 with scattered expression of Melan A. Florescence in situ hybridization revealed a translocation at the EWRS1 locus. He was disease-free for 30 months following the procedure; then he developed a rapidly progressing metastatic disease with subsequent death 4 months later. Maitham A. Moslim, Gavin A. Falk, Michael Cruise, and Gareth Morris-Stiff Copyright © 2016 Maitham A. Moslim et al. All rights reserved. Cardiac Arrest and Gastrointestinal Bleeding: A Case of Medical Heuristics Mon, 06 Jun 2016 08:18:57 +0000 Insufficient clinical data from patients is a major cause of errors in medical diagnostics. In an attempt to make a diagnosis, initial clinical information provided to the physician may be overly relied on as the only information required in making diagnosis leading to anchoring. Failure to rely on differential diagnoses in spite of new signs and symptoms or rethinking of initial hypothesis may lead to fixation on a certain diagnosis, which may lead to significant morbidity and mortality. In the event that there is an anchoring heuristic, like in our patient, it is important to consider differential diagnoses; however, it is not wrong to rely on some form of anchor. We report a case of a 62-year-old male with a history of multiple medical conditions and a history of acetaminophen overdose who presented to the hospital with large amounts of coffee ground emesis. He was subsequently transferred to the liver transplant center on discovery that he was in fulminant hepatic failure and died two days later in spite of aggressive medical treatment. Tokunbo Ajayi and Jerome Okudo Copyright © 2016 Tokunbo Ajayi and Jerome Okudo. All rights reserved. Intracavitary Irradiation as a Safe Alternative for Cystic Craniopharyngiomas: Case Report and Review of the Literature Sun, 05 Jun 2016 06:26:11 +0000 Craniopharyngioma treatment remains a challenge for clinicians and patients. There are many treatment alternatives; however one of them (intracavitary irradiation) seeks to control this type of benign brain tumor using minimally invasive techniques, with the specific aim of avoiding causing significant damage to important structures surrounding the sellar/suprasellar region. We present the case of a 3-year-old patient with a predominantly cystic craniopharyngioma who underwent intracavitary irradiation by stereotactic placement. Using this approach, the patient showed a successful response with remission of headaches and hydrocephalus. A reduction in the size of the cyst was achieved, without deterioration of visual fields, with no hormonal supplementation being needed, and with no evidence of focal neurological signs. Alejandro Enriquez-Marulanda, Melibea Sierra-Ruiz, Luz Maritza Pabón, and Javier Lobato-Polo Copyright © 2016 Alejandro Enriquez-Marulanda et al. All rights reserved. Medical Management for the Treatment of Nontuberculous Mycobacteria Infection of the Parotid Gland: Avoiding Surgery May Be Possible Wed, 01 Jun 2016 12:29:40 +0000 Infection with nontuberculous mycobacteria (NTM) is uncommon in the head and neck; therefore there is no clear consensus on treating these infections. Our objective was to report our experience with a unique case of NTM infection of the parotid in an immunocompetent patient, in order to determine appropriate management through our experience with this pathology. A 57-year-old man, known for numerous comorbid diseases, presented to our institution complaining of right parotid swelling and pain. A computed tomography (CT) of the neck showed a multiloculated collection in the inferior portion of the right parotid gland, compatible with abscess formation. This abscess was drained by interventional radiology (IR) but required repeat drainage twice due to lack of initial improvement. He was treated with several antibiotics as culture results initially indicated Gram-positive bacilli and then Mycobacterium species, with final identification by a reference laboratory as Mycobacterium abscessus. Imipenem was initiated with amikacin and clarithromycin. His infection clinically and radiologically resolved after 5 months of antibiotherapy. In our case, the patient improved following intravenous antibiotic therapy. Our experience demonstrates that appropriate antibiotherapy can lead to resolution of Mycobacterium abscessus infection in the parotid without the risks associated with surgical intervention. Emily Kay-Rivest, Sarah Bouhabel, Matthew Thomas Oughton, and Michael Peter Hier Copyright © 2016 Emily Kay-Rivest et al. All rights reserved.