Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Anterior Approach in a Huge Lipomatous Tumor of the Thigh Wed, 01 Oct 2014 00:00:00 +0000 Confronted with a huge lipomatous anterior thigh tumor, the surgical approach had to be assessed. Those described in the literature did not seem appropriate for our case so some modifications were made. We present the case of a 77-year-old woman who presented with a huge anterior thigh compartment tumor with one-year evolution. Magnetic resonance imaging informed the presence of a lipomatous tumor with a possible vascular contact. Based on Thomson’s anterior approach, but modifying the skin incision, the medial distal femur was reached until the neurovascular bundle and, proximally, the lesser trochanter. The tumor was totally resected due to a good visualization using this approach. Jordi Faig-Martí Copyright © 2014 Jordi Faig-Martí. All rights reserved. Desmoid-Type Fibromatosis of the Mesentery: Report of a Sporadic Case with Emphasis on Differential Diagnostic Problems Tue, 30 Sep 2014 07:56:15 +0000 Desmoid-type fibromatosis is a rare mesenchymal neoplasm with local aggressiveness. The incidence of desmoid-type fibromatosis is 2–5/million/year with intra-abdominal fibromatosis, such as that which is reported in this clinical case, occurring only in 12–18% of cases. After having analyzed the pathogenetic hypotheses of desmoid-type fibromatosis, the authors point out that the diagnosis of this disease, especially in the intra-abdominal form, is often late, specifically when highly demolitive interventions are needed or when the limits of radical surgery have been exceeded. In the clinical case reported, the tumor was infiltrating both ileus and sigma. The authors consider the differential diagnosis of desmoid-type fibromatosis, especially with GISTs, with regard to both the radiological preoperative diagnostic and histological studies on the surgical specimen. Radical surgical excision is not always, for this disease, a sign of healing; in fact, even when the resection margins are negative, the incidence of recurrence is between 13 and 68%. The average time of recurrence is between 15 and 24 months; in this case report, the patient, who has not been subjected to complementary therapies, is tumor-free for over 30 months since surgery; his prognosis may be satisfactory if we consider the negativity of resection margins, which in any case remains the most important prognostic factor. Giovanni Li Destri, Maria Jessica Ferraro, Martina Calabrini, Monica Pennisi, and Gaetano Magro Copyright © 2014 Giovanni Li Destri et al. All rights reserved. Systemic Granulomatous Diseases Associated with Multiple Palpable Masses That May Involve the Breast: Case Presentation and an Approach to the Differential Diagnosis Tue, 30 Sep 2014 00:00:00 +0000 Palpable mass is a common complaint presented to the breast surgeon. It is very uncommon for patients to report breast mass associated with palpable masses in other superficial structures. When these masses are related to systemic granulomatous diseases, the diagnosis and initiation of specific therapy can be challenging. The purpose of this paper is to report a case initially assessed by the breast surgeon and ultimately diagnosed as granulomatous variant of T-cell lymphoma, and discuss the main systemic granulomatous diseases associated with palpable masses involving the breast. Rodrigo Menezes Jales, Patrick Nunes Pereira, Rafael Fantelli Stelini, and Luciano Moro Copyright © 2014 Rodrigo Menezes Jales et al. All rights reserved. MEN1 Syndrome and Hibernoma: An Uncommonly Recognised Association? Mon, 22 Sep 2014 00:00:00 +0000 MEN1 syndrome is known to classically result in parathyroid, pituitary, and pancreatic islet cell tumours. However, the potential association of MEN1 syndrome with hibernoma, a benign tumour with differentiation towards brown fat, is far less well known, despite their genetic profile both being linked to deletion of the MEN1 gene. Herein, we describe a case with its key radiological and pathological findings. Venus Hedayati, Khin Thway, J. Meirion Thomas, and Eleanor Moskovic Copyright © 2014 Venus Hedayati et al. All rights reserved. Minimally Invasive Resection of an Extradural Far Lateral Lumbar Schwannoma with Zygapophyseal Joint Sparing: Surgical Nuances and Literature Review Thu, 18 Sep 2014 10:51:37 +0000 Introduction. Spinal schwannomas are benign nerve sheath tumors. Completely extradural schwannomas of the lumbar spine are extremely rare lesions, accounting for only 0,7–4,2% of all spinal NSTs. Standard open approaches have been used to treat these tumors, requiring extensive muscle dissection, laminectomy, radical foraminotomy, and facetectomy. In this paper the authors present the case of a minimally invasive resection of a completely extradural schwannoma. Operative technique literature review is presented. Material & Methods. A 50-year-old woman presented with progressive complains of chronic right leg pain and paresthesia. The magnetic resonance imaging revealed a giant well-encapsulated dumbbell-shaped extradural lesion at the L3-L4 level. The patient underwent a minimally invasive gross total resection of the tumor using a tubular expandable retractor system. Results. The patient had complete resolution of radiculopathy in the immediate postoperative period and she was discharged home, neurologically intact, on the second postoperative day. Postoperative MRI demonstrated no evidence of residual tumor. At latest follow-up (18 months) the patient remains asymptomatic. Conclusion. Although challenging, this minimally invasive procedure is safe and effective, being an appropriate alternative, with many potential advantages, to the open approach. Vítor M. Gonçalves, Bruno Santiago, Vítor C. Ferreira, and Manuel Cunha e Sá Copyright © 2014 Vítor M. Gonçalves et al. All rights reserved. Hyperacute Rejection of a Living Unrelated Kidney Graft Wed, 17 Sep 2014 00:00:00 +0000 We present a case report of a 59-year-old man, who received a blood group identical living unrelated kidney graft. This was his second kidney transplantation. Pretransplant T-cell crossmatch resulted negative. B-cell crossmatch, which is not considered a strict contraindication for transplantation, resulted positive. During surgery no abnormalities occurred. Four hours after the transplantation diuresis suddenly decreased. In an immediately performed relaparotomy the transplanted kidney showed signs of hyperacute rejection and had to be removed. Pathological examination was consistent with hyperacute rejection. Depositions of IgM or IgG antibodies were not present in pathologic evaluation of the rejected kidney, suggesting that no irregular endothelial specific antibodies had been involved in the rejection. We recommend examining more closely recipients of second allografts, considering not only a positive T-cell crossmatch but also a positive B-cell crossmatch as exclusion criteria for transplantation. Dietlind Tittelbach-Helmrich, Dirk Bausch, Oliver Drognitz, Heike Goebel, Christian Schulz-Huotari, Albrecht Kramer-Zucker, Ulrich Theodor Hopt, and Przemyslaw Pisarski Copyright © 2014 Dietlind Tittelbach-Helmrich et al. All rights reserved. Trial of Zolpidem, Eszopiclone, and Other GABA Agonists in a Patient with Progressive Supranuclear Palsy Tue, 16 Sep 2014 05:36:23 +0000 Progressive supranuclear palsy (PSP) is a progressive, debilitating neurodegenerative disease of the Parkinson-plus family of syndromes. Unfortunately, there are no pharmacologic treatments for this condition, as most sufferers of the classic variant respond poorly to Parkinson medications such as levodopa. Zolpidem, a gamma aminobutyric acid (GABA) agonist specific to the -1 receptor subtype, has been reported to show improvements in symptoms of PSP patients, including motor dysfunction, dysarthria, and ocular disturbances. We observed a 73-year-old woman with a six-year history of PSP, who, upon administration of a single 12.5 mg dose of sustained-release zolpidem, exhibited marked enhancements in speech, facial expressions, and fine motor skills for five hours. These results were reproduced upon subsequent clinic visits. In an effort to find a sustainable medication that maximized these beneficial effects while minimizing side effects and addressing some of her comorbid neuropsychological conditions, a trial of five other GABA receptor agonists was performed with the patient’s consent, while she and her caregivers were blinded to the specific medications. She and her caretakers subsequently reported improvements, especially visual, while on eszopiclone, and, to a lesser degree, temazepam and flurazepam. Andrew Young Chang and Erica Weirich Copyright © 2014 Andrew Young Chang and Erica Weirich. All rights reserved. Grave’s Disease with Severe Hepatic Dysfunction: A Diagnostic and Therapeutic Challenge Mon, 15 Sep 2014 07:50:05 +0000 Hepatic dysfunction in a patient with thyrotoxicosis may result from hyperthyroidism per se, as a side effect of antithyroid drugs, and causes unrelated to hyperthyroidism which sometimes causes diagnostic and therapeutic difficulties. A young female patient was admitted to our hospital with symptoms of thyrotoxicosis, diffuse goiter and ophthalmopathy along with cholestatic pattern of jaundice, and proximal muscle weakness. She was treated with propylthiouracil with gradual recovery. She was continuing her antithyroid medication with regular follow-up. The patient was readmitted a few months later with worsening thyrotoxicosis, proximal muscle weakness, fever, and a hepatocellular pattern of jaundice with sepsis. Propylthiouracil was stopped and lithium along with steroid coverage was given to control her thyrotoxicosis which was later changed to methimazole. Broad spectrum antibiotic therapy was also started but without any response. During her hospital stay, the patient also developed a flaccid paraplegia resembling Guillain-Barre syndrome. IV steroid was started for the neuropathy but meanwhile the patient succumbed to her illness. So in centers where facility for radioiodine therapy is not readily available, some definite well-tested protocols should be formulated to address such common but complicated clinical situations. Ashok Krishna Bhuyan, Dipti Sarma, Uma Kaimal Saikia, and Bipul Kumar Choudhury Copyright © 2014 Ashok Krishna Bhuyan et al. All rights reserved. Spontaneous Massive Splenic Infarction in the Setting of Renal Transplant and Septic Shock: A Case Report and Review of the Literature Mon, 15 Sep 2014 06:01:35 +0000 Massive splenic infarction (MSI) is a rare phenomenon that results from compromised blood flow to more than half of the spleen. Causes of MSI include hematological disorders, coagulopathies, infection, and embolization, and, rarely, MSI is spontaneous. The mainstay of treatment is splenectomy. We report the case of a 50-year-old man with a history of renal transplant who presented with diffuse abdominal pain and rapidly developed septic shock. A computed tomographic study (CT scan) of the abdomen demonstrated MSI. The surgical team was consulted for splenectomy but conservative management was maintained and immune function preserved. The patient’s clinical condition was resolved over a three-week period. This report demonstrates successful nonoperative management of a spontaneous MSI most likely secondary to hypoperfusion and a hypercoagulable state from both septic shock and renal transplant. Christine L. Bokman, Maroun Sfeir, Veer Chahwala, and Enrique Ginzburg Copyright © 2014 Christine L. Bokman et al. All rights reserved. Breast Cancer Presenting as Paraneoplastic Erythroderma: An Extremely Rare Case Thu, 11 Sep 2014 08:45:16 +0000 The skin may exhibit the first clinical evidence of a systemic disease and may provide the first clues to a diagnosis in malignancies. Erythroderma is defined as generalized redness and scaling and it is a clinical manifestation of a variety of underlying diseases including, rarely, solid tumors. Breast cancer is associated with a variety of skin paraneoplastic manifestations like acanthosis nigricans, erythromelalgia, thrombotic thrombocytopenic purpura, acrokeratosis paraneoplastica, dermatomyositis, systemic sclerosis, and scleroderma. However, in the literature, the correlation of erythroderma with breast cancer is quite infrequent. Here, we describe a case of a 76-year-old woman who presented with a paraneoplastic manifestation of erythroderma due to breast cancer. Ioannis Protopsaltis, Aspasia Drossou, Ioannis Katsantonis, Nikolaos Roussos, Kassiani Manoludaki, Miltiadis Arvanitis, Athanasia Papazafiropoulou, and Stavros Antonopoulos Copyright © 2014 Ioannis Protopsaltis et al. All rights reserved. Intracranial Meningioma Diagnosed during Pregnancy Caused Maternal Death Wed, 10 Sep 2014 13:12:49 +0000 Brain tumors are rarely diagnosed during pregnancy. Accelerated growth of intracranial meningiomas during pregnancy sometimes requires urgent surgical intervention. We describe a 41-year-old pregnant woman with severe neurological decompensation requiring immediate neurosurgery. Cesarean section resulted in maternal death. Meningioma diagnosed during a viable pregnancy should be managed according to the severity of maternal neurological symptoms and gestational age of pregnancy. Early intervention for intracranial tumors during pregnancy may save maternal and fetal lives. Zehra Kurdoglu, Orkun Cetin, Ismail Gulsen, Deniz Dirik, and M. Deniz Bulut Copyright © 2014 Zehra Kurdoglu et al. All rights reserved. A Pancreatic Head Tumor Arising as a Duodenal GIST: A Case Report and Review of the Literature Wed, 10 Sep 2014 11:37:46 +0000 Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract that originate from the intestinal cells of Cajal (ICC) (Fletcher et al., 2002). Only a few cases have been described with extragastrointestinal stromal tumors (Kim et al., 2012; Soufi et al., 2013; Meng et al., 2011). They are often diagnosed as a pancreatic head tumor as they are very difficult to relate to the duodenum with CT, MRI, or ultrasound. We present a case of a sixty-four-year-old woman who presented with abdominal pain and cardialgia for a follow-up examination after breast cancer surgery. On laparotomy there was a 3 × 5 cm hypervascular mass arising from the pancreatic head with macroscopically no attachment to the duodenum. The patient underwent pancreatoduodenectomy (PD) modified after Traverso-Longmire, histopathology proved a duodenal GIST. This case proves that duodenal GISTs can grow invasively into the pancreas and appear as solid pancreas head tumor; therefore, these tumors should be included into differential diagnosis. Fabian Bormann, Wolfgang Wild, Hüseyin Aksoy, Pius Dörr, Sanja Schmeck, and Matthias Schwarzbach Copyright © 2014 Fabian Bormann et al. All rights reserved. Pleural Effusion: A Rare Side Effect of Nilotinib—A Case Report Tue, 09 Sep 2014 08:24:13 +0000 Pleural effusion, as a side effect of tyrosine kinases, may be seen as most commonly associated with dasatinib and very rarely seen with nilotinib. In this report we present a chronic phase of CML case that was treated with nilotinib due to imatinib (Gleevec) allergy and had pleural effusion with nilotinib at 5th year of treatment. If pleural effusion develops in patients taking nilotinib and if this effusion is exudative and lymphocyte predominant, after ruling out pulmonary and cardiac etiologies, it must be associated with nilotinib; according to stage of effusion drug should be discontinued and/or steroid should be started and/or surgery should be performed. Hava Üsküdar Teke, Olga Meltem Akay, Deniz Gören Şahin, Mustafa Karagülle, Eren Gündüz, and Neslihan Andıç Copyright © 2014 Hava Üsküdar Teke et al. All rights reserved. Fulminant Wilson’s Disease Managed with Plasmapheresis as a Bridge to Liver Transplant Tue, 09 Sep 2014 07:01:01 +0000 New-onset jaundice can be a manifestation of multiple pathologic processes including hemolysis, parenchymal liver disease, and cholestasis; the differential diagnosis is broad and requires a systematic approach. We report a case of a patient who presented with jaundice after starting minocycline for the treatment of acne vulgaris and rapidly developed fulminant liver failure found to be due to Wilson’s disease. She also manifested severe Coomb’s negative hemolytic anemia and renal failure secondary to hepatorenal syndrome. As a bridge to liver transplant, she was successfully treated with plasmapheresis to decrease serum copper in addition to hemodialysis for acidosis and hyperkalemia. She was able to receive a liver and made a full recovery. The case highlights the use of plasmapheresis as an adjunctive treatment modality in cases of fulminant liver failure due to Wilson’s disease. Talal Hilal and R. Scott Morehead Copyright © 2014 Talal Hilal and R. Scott Morehead. All rights reserved. Diagnosis and Monitoring of Choroidal Osteoma through Multimodal Imaging Mon, 08 Sep 2014 07:39:13 +0000 A 16-year-old Caucasian female with a 6-month history of decreased visual acuity and metamorphopsia in the left eye is reported. The fundus of the left eye revealed a well defined lesion in the macula region. Diagnosis of choroidal osteoma was established using spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and B-scan ultrasonography. Subretinal fluid (SRF) and retinal pigment epithelium (RPE) detachment were noted in the absence of obvious classic choroidal neovascularisation (CNV). The patient was followed up for over 13 months without any treatment in the interim and the lesion was noted to have enlarged but visual acuity and SRF had remained stable. We report an interesting case where subretinal fluid was noted in the absence of evident choroidal neovascularisation and provide an example of the imaging modalities application in the era of “optical biopsy.” Theodoros Empeslidis, Usman Imrani, Vasileios Konidaris, Fizza Mushtaq, Pandelis Fotiou, Periyasami Kumar, Somnath Banerjee, and Konstantinos T. Tsaousis Copyright © 2014 Theodoros Empeslidis et al. All rights reserved. Successful Reversal of Acute Kidney Failure by Ultrasound-Accelerated Thrombolysis of an Occluded Renal Artery Mon, 08 Sep 2014 00:00:00 +0000 Purpose. To describe the treatment of renal artery thrombosis with ultrasound-accelerated thrombolysis and discuss the management of prolonged renal ischemia. Case. A 76-year-old patient with a single functional kidney, mild chronic renal impairment, and a recent history of endovascular repair of a thoracoabdominal aneurysm with an aortic branch graft presented with acute flank pain, anuria, and renal failure. The side branch from the aortic stent graft to his single, right, functional kidney appeared to be completely thrombosed. Symptoms had started after cessation of oral anticoagulants because of a planned mastectomy for breast cancer. After identification of the occlusion, ultrasound-accelerated thrombolysis was started 19 hours after the onset of anuria. Angiography, 4 hours after beginning of therapy, already showed partial dissolution of the thrombus and angiographic control after 18 hours showed complete patency of the renal artery side branch. Despite a long period of ischemia, renal function was completely recovered. Conclusion. In patients with acute renal ischemia due to thrombosis of the renal artery, complete recovery of function can be achieved with ultrasound-accelerated thrombolysis, even after prolonged periods of ischemia. Renske Konings, Rutger J. Lely, Shaikh A. Nurmohamed, and Arjan W. J. Hoksbergen Copyright © 2014 Renske Konings et al. All rights reserved. An Unusual Presentation of Primary Lymphoma of the Ilium Mon, 08 Sep 2014 00:00:00 +0000 Primary bone lymphoma involving the pelvic bone is a rare entity. It does not have distinct clinical features or radiological features that are diagnostic. Biopsy is the gold standard investigation. We present a case of primary pelvic lymphoma with initial histopathological features of chronic osteomyelitis. Upon further clinical follow-up, repeat biopsy of the lesion revealed features of B-cell Non-Hodgkin’s lymphoma, thus emphasizing the need for a high index of suspicion and close clinical follow-up. This case is presented for the diagnostic dilemma and the unique feature of lymphomatous lesion mimicking chronic osteomyelitis in its early stages. Mohamad Gouse, Viswanath Jayasankar, and Manika Alexander Copyright © 2014 Mohamad Gouse et al. All rights reserved. Aseptic Splenic Abscess as Precursory Extraintestinal Manifestation of Inflammatory Bowel Disease Sun, 07 Sep 2014 09:21:19 +0000 Splenic abscesses are most often secondary to aerobic bacterial infections due to Streptococcus, Staphylococcus, and Enterococcus species of organisms. Sterile splenic abscesses rarely occur and diagnosis and treatment of those are challenging. We report a case of a previously healthy young female presenting with aseptic splenic abscesses as the initial manifestation of Crohn’s disease along with a review of the literature on aseptic splenic abscess as an extraintestinal manifestation of Crohn’s disease. Joel Brooks and Gisoo Ghaffari Copyright © 2014 Joel Brooks and Gisoo Ghaffari. All rights reserved. Retracted: Oral Haemangioma Wed, 03 Sep 2014 09:04:32 +0000 Case Reports in Medicine Copyright © 2014 Case Reports in Medicine. All rights reserved. Management of Hepatic Rupture Diagnosed after an Emergency Cesarean Section Sun, 31 Aug 2014 06:34:11 +0000 A careful management of hepatic capsular rupture, with massive hemoperitoneum which occurred 14 hours after an emergency cesarean section at 36 weeks of gestation, is meticulously reported. The grade of hepatic involvement varies from minor capsular laceration to extensive parenchymal rupture. Our management involved a combination of surgical interventions and aggressive supportive care. The patient was discharged after 53 days and 4 laparotomies and an unsuccessful attempt of superselective artery embolization. Ultrasound after 40 days from the last surgery showed uniform hepatic parenchyma free of focal lesions. Due to the rarity and the unpredictability nature of this devastating event we believe necessary to report our experience, reinforcing the importance of the postsurgery management. Gianluca Raffaello Damiani, Viviana Merola, Mario Barnaba, Stefano Landi, Gennaro Cormio, and Antonio Pellegrino Copyright © 2014 Gianluca Raffaello Damiani et al. All rights reserved. AREDS Formula, Warfarin, and Bleeding: A Case Report from the Michigan Anticoagulation Quality Improvement Initiative Thu, 28 Aug 2014 00:00:00 +0000 Importance. The anticoagulant warfarin has been shown to interact with other medications, vitamin K containing foods, and over-the-counter products. These interactions may inhibit or potentiate the effect of warfarin, resulting in serious clotting or bleeding events. Observations. We report the case of an 84-year-old woman with atrial fibrillation, prescribed warfarin in May 2010 for stroke prevention. Her international normalized ratio (INR) was stable until April 2013, when she was prescribed AREDS (Age Related Eye Disease Study) formula pills, an eye vitamin compound, to slow the progression of age-related macular degeneration. This change was not reported to the Anticoagulation Service. Eighteen days later, she presented to the ED with groin and back pain and an INR of 10.4. An abdominal CT revealed a retroperitoneal hemorrhage with extension in multiple muscles. Both warfarin and AREDS were discontinued and the patient was discharged to subacute rehabilitation. This case was reviewed by the Anticoagulation Service and actions were taken to prevent similar adverse events. Conclusions. This report provides an example of the potential danger of supplement use, in this case, AREDS formula, in patients prescribed warfarin, and the importance of communicating medication changes to the providers responsible for warfarin management. Eric Puroll, Steven T. Heidt, Brian Haymart, James B. Froehlich, Eva Kline-Rogers, and Geoffrey D. Barnes Copyright © 2014 Eric Puroll et al. All rights reserved. Stump Cholecystitis: Laparoscopic Completion Cholecystectomy with Basic Laparoscopic Equipment in a Resource Poor Setting Thu, 21 Aug 2014 13:17:53 +0000 Introduction. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. When this occurs, a completion cholecystectomy is indicated. Traditionally, these patients were subjected to open surgery because the laparoscopic approach was anticipated to be technically difficult. We present a case of completion cholecystectomy using basic laparoscopic equipment in a resource poor setting to demonstrate that the laparoscopic approach is feasible. Case Description. A 57-year-old woman presented with right upper quadrant pain and vomiting. She had an elective open cholecystectomy seven years before but reported remarkably similar symptoms. Abdominal ultrasound suggested calculous acute cholecystitis. MRCP confirmed the presence of a large gallbladder remnant with stones. Gastroduodenoscopy excluded other differentials. She had an uneventful laparoscopic completion cholecystectomy performed. Discussion. Although traditional dogma suggested that a completion cholecystectomy should be performed through the open approach, several small studies have demonstrated that laparoscopic completion cholecystectomy is feasible and safe. This report adds to the existing data in support of the laparoscopic approach. Shamir O. Cawich, Carlos Wilson, Lindberg K. Simpson, and Akil J. Baker Copyright © 2014 Shamir O. Cawich et al. All rights reserved. Pulmonary Pleomorphic Carcinoma Detected as a Result of Pneumothorax and the Subsequent Occurrence of Multiple Cystic Metastases Wed, 20 Aug 2014 07:40:41 +0000 A 39-year-old man was admitted for spontaneous pneumothorax. He underwent pulmonary resection to correct the lesion causing the air leakage, and a pathological diagnosis of pulmonary pleomorphic carcinoma was made because we thought that the pneumothorax developed due to the direct rupture of necrotic neoplastic tissue into the pleural cavity. After the operation, the patient received chemotherapy, during which multiple cystic metastases gradually developed in the lung that caused repeated occurrences of pneumothorax. Clinicians must be careful to recognize that pneumothorax can also be a complication of primary and various metastatic pulmonary malignancies. Hideaki Yamakawa, Masahiro Yoshida, Masami Yabe, Yuri Baba, Emiri Baba, Hiroaki Katagi, Takeo Ishikawa, Masamichi Takagi, Takeo Nakada, Tadashi Akiba, and Kazuyoshi Kuwano Copyright © 2014 Hideaki Yamakawa et al. All rights reserved. Chronic Hepatitis C Therapy in Liver Cirrhosis Complicated by Telaprevir-Induced DRESS Wed, 20 Aug 2014 06:39:37 +0000 Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare yet severe adverse drug-induced reaction with up to 10% mortality rate. Recent clinical trials reported an association between DRESS and telaprevir (TVR), an NS3/4A protease inhibitor of chronic hepatitis C (CHC) virus genotype 1. Its diagnosis is challenging given the variable pattern of cutaneous eruption and the myriad internal organ involvement. We present two patients who are middle-aged, obese, and white with CHC cirrhosis. They both developed a progressive diffuse, painful pruritic maculopapular rash at weeks 8 and 10 of CHC therapy with TVR, Peg-Interferon alfa-2a, and Ribavirin. They had no exposures to other medications that can cause this syndrome. Physical exam and labs and skin biopsy supported a “Definite” clinical diagnosis of DRESS, per RegiSCAR criteria. Thus Telaprevir-based triple therapy was discontinued and both patients experienced rapid resolution of the systemic symptoms with gradual improvement of eosinophilia and the skin eruption. These two cases illustrate the paramount importance of having a high index of suspicion for TVR-induced DRESS, critical for early diagnosis. Immediate discontinuation of TVR is essential in prevention of a potentially life-threatening complication. Risk factors for development of DRESS in patients receiving TVR remain to be elucidated. Omar Y. S. Mousa, Rossa Khalaf, Rhonda L. Shannon, Chukwuma I. Egwim, Scott A. Zela, and Victor Ankoma-Sey Copyright © 2014 Omar Y. S. Mousa et al. All rights reserved. Venipuncture-Induced Complex Regional Pain Syndrome: A Case Report and Review of the Literature Tue, 19 Aug 2014 10:35:13 +0000 Venipuncture, the most frequently performed invasive medical procedure, is usually benign. Generally it produces only transitory mild discomfort. Venipuncture-induced neuropathic pain is hard to recognize at an early stage. Medical literature reviews show that there is not adequate medical knowledge about this important subject. The inciting incident in complex regional pain syndrome (CRPS) can often seem far too trivial to result in a condition with such severe pathophysiologic effects. The practicing physician has little information available to enable early recognition of the condition, initiation of multidisciplinary treatment modalities, and proper referral to pain specialists. We encountered a unique case of venipuncture-induced complex regional pain syndrome (CRPS). The patient is a 52-year-old school teacher with no significant past medical history, who presented initially to the Center of Pain Medicine with left upper extremity pain. The pain started while phlebotomy was performed in the patient’s left antecubital area for routine blood check. The patient’s pain did not improve with multiple medications, physical therapy, or several nerve blocks. The patient demonstrated all the signs and symptoms of chronic neuropathic pain of CRPS in the upper extremity with minimal response to the continuous pain management. We decided to proceed with cervical spinal cord nerve stimulation along with continuing other modalities. The patient responded to this combination. During the follow-up, we noticed that the patient’s pain course was complicated by extension of the CRPS to her lower extremity. We will describe the course of treatment for the patient in this paper. In this paper we will discuss the electrical neuromodulation as an important modality in addition to the multidisciplinary pain management for a patient with venipuncture-induced chronic neuropathic pain. Foad Elahi and Chandan G. Reddy Copyright © 2014 Foad Elahi and Chandan G. Reddy. All rights reserved. Ogilvie’s Syndrome following Cardioversion for Atrial Fibrillation Tue, 19 Aug 2014 09:08:50 +0000 Acute colonic pseudoobstruction, also known as Ogilvie’s syndrome, is characterized by distension of the colon in the absence of a mechanical obstruction as evident by abdominal radiography. This syndrome is usually treated conservatively; however, medical or surgical therapies can be employed in refractory cases. Ogilvie’s syndrome has been reported following cardiac events, such as myocardial infarction, heart failure, and cardiac bypass surgeries. We report the first case of Ogilvie’s syndrome following synchronized electric cardioversion for atrial fibrillation. Moh’d Al-Halawani, Juanito Savaille, Mohammad Thawabi, Yazan Abdeen, Richard A. Miller, and Andre A. Fedida Copyright © 2014 Moh’d Al-Halawani et al. All rights reserved. Pseudomembranous Colitis: Not Always Caused by Clostridium difficile Mon, 18 Aug 2014 10:50:11 +0000 Although classically pseudomembranous colitis is caused by Clostridium difficile, it can result from several etiologies. Certain medications, chemical injury, collagenous colitis, inflammatory bowel disease, ischemia, and other infectious pathogens can reportedly cause mucosal injury and subsequent pseudomembrane formation. We present the case of a middle-aged woman with vascular disease who was incorrectly diagnosed with refractory C. difficile infection due to the presence of pseudomembranes. Further imaging, endoscopy, and careful histopathology review revealed chronic ischemia as the cause of her pseudomembranous colitis and diarrhea. This case highlights the need for gastroenterologists to consider non-C. difficile etiologies when diagnosing pseudomembranous colitis. Derek M. Tang, Nathalie H. Urrunaga, Hannah De Groot, Erik C. von Rosenvinge, Guofeng Xie, and Leyla J. Ghazi Copyright © 2014 Derek M. Tang et al. All rights reserved. Surgical Cryoablation of Drug Resistant Ventricular Tachycardia and Aneurysmectomy of Postinfarction Left Ventricular Aneurysm Thu, 14 Aug 2014 09:20:43 +0000 Heart failure is usually associated with left ventricle remodelling, wall thickening, and worsening of the systolic function. Ventricular tachycardia is a common and a negative prognostic factor in patients with endocardial scarring following myocardial infarction and aneurysm formation. The authors present a case of a 51-year-old man with ischemic heart disease, who suffered myocardial infarction four years ago. The patient was admitted to the hospital with sustained ventricular tachycardia despite maximal pharmacotherapy and also underwent unsuccessful percutaneous radiofrequency ablation in the right ventricle. Transthoracic echocardiography revealed left ventricle dysfunction with ejection fraction of 25%, aneurysm of the apex of the left ventricle with thrombus formation inside the aneurysm. Surgical therapy consisted of the cryoablation applied at the transitional zone of the scar and viable tissue and the resection of the aneurysm. The patient remained free of any ventricular tachycardia four months later. Marek Pojar, Jan Harrer, Nedal Omran, and Martin Vobornik Copyright © 2014 Marek Pojar et al. All rights reserved. Squamous Cell Carcinoma (Marjolin’s Ulcer) Arising in a Sacral Decubitus Ulcer Resulting in Humoral Hypercalcemia of Malignancy Wed, 13 Aug 2014 12:37:57 +0000 Long-standing burns, fissures, and ulcers that undergo malignant transformation into a variety of malignancies, including squamous cell carcinoma, is commonly referred to as a Marjolin’s ulcer. It is well recognized that squamous cell carcinomas of the lung and esophagus can cause humoral hypercalcemia of malignancy secondary to paraneoplastic secretion of parathyroid hormone-related peptide. However, it is extremely rare for a squamous cell carcinoma developing in a sacral decubitus ulcer to cause humoral hypercalcemia of malignancy. We describe the first case of a patient found to have elevated serum levels of parathyroid hormone related peptide related to his Marjolin’s ulcer. A 45-year-old African American man with T6 paraplegia and a sacral decubitus ulcer present for 20 years was admitted for hypercalcemia of unclear etiology. He was subsequently found to have elevated parathyroid hormone related peptide and an excisional biopsy from the ulcer showed invasive squamous cell carcinoma suggestive of humoral hypercalcemia of malignancy. The patient ultimately succumbed to sepsis while receiving chemotherapy for his metastatic squamous cell carcinoma. Humoral hypercalcemia of malignancy is a rare and likely underrecognized complication that can occur in a Marjolin’s ulcer. John T. O’Malley, Candace Schoppe, Sameera Husain, and Marc E. Grossman Copyright © 2014 John T. O’Malley et al. All rights reserved. The Bee Sting That Was Not: An Unusual Case of Hymenoptera Anaphylaxis Averted in a Patient Treated with Omalizumab for Asthma Tue, 12 Aug 2014 00:00:00 +0000 This paper presents a case of hymenoptera venom anaphylaxis averted by omalizumab, a monoclonal antibody to IgE antibody. This case suggests a novel and unintentional effect of this therapy. Currently omalizumab is only FDA approved for the treatment of moderate-persistent allergic asthma. However case reports, such as ours have illustrated omalizumab’s efficacy in the treatment of a myriad immunologic and allergic diseases. These outcomes have broadened the understanding of omalizumab’s complex mechanism of action. Evelyn M. Slaughter, Nathan Boyer, and Steven Bennett Copyright © 2014 Evelyn M. Slaughter et al. All rights reserved.