Background. Bowel perforation in a pregnant patient with COVID-19 infection is a rarely reported complication. With the uncovering of the different treatment modalities and complications of this disease, this case highlights diagnostic and therapeutic dilemmas and limitations in a special population. Clinical Presentation. A 35-year-old female, Gravida 2 Para 1 at 31 weeks age of gestation (AOG) who underwent cesarean section for nonreassuring fetal status in 2019, was admitted for severe COVID-19 infection presenting with dyspnea. During her hospitalization, she developed progressive dyspnea from worsening of COVID-19 infection. Patient was eventually intubated and was given a total of two doses of tocilizumab, adequate antibiotic treatment, remdesivir, and dexamethasone. An emergency repeat cesarean section was performed due to maternal deterioration and poor variability of the fetus. She delivered to a live preterm baby girl, with an Apgar score of 1 and 7 on the 1st and 5th minute of life respectively. During the postoperative days, patient remained intubated and sedated. Increasing residuals were noted per nasogastric tube (NGT). Serial scout film of the abdomen (SFA) and medical management were performed. Upon weaning from sedation, patient complained of right lower quadrant pain. A whole abdominal computed tomography (CT) scan with contrast was requested which revealed large bowel obstruction. Patient was referred to surgery service. Upon assessment, abdomen was noted to be rigid with guarding during palpation. A scout film of the abdomen was requested and revealed extensive amount of pneumoperitoneum with scanty to absent colonic gas suggestive of bowel perforation. Patient underwent emergency exploratory laparotomy. Upon opening the peritoneum, free air was evacuated. Approximately 1.4 liters of fecaloid peritoneal fluid was suctioned and adhesive band was noted at the pelvic area. A 2 cm full thickness perforation at the cecum with 17 cm serosal tear from the cecum to ascending colon was noted. Bowel loops proximal to the perforation were dilated. Nasogastric tube was inserted for bowel decompression. Right hemicolectomy was performed. Specimen was sent for histopathology. Acute inflammatory cells infiltrating the blood vessels and possible microthrombi and beginning thrombus formation were noted in the subserosa. Patient eventually expired on the 14th hospital day from sepsis. Conclusion. This case highlights a rarely reported complication of COVID-19 infection. Confluence of factors that predisposed the patient include pregnancy, COVID-19 infection, use of tocilizumab, and recent surgery. High index of suspicion is vital in the management and improvement of outcomes.

A. T. Guiritan

J. G. Cataluña

A Case Report of Bowel Perforation in a Gravid COVID-19 Patient

In the setting of the rapid development of currently available vaccines for coronavirus disease of 2019 (COVID-19), little is known about their less frequent potential side effects. Raising the awareness of clinicians and front-line healthcare workers about the less well-known potential side effects of vaccination is important. We describe the self-limited occurrence of gross hematuria in two elderly men on a combination of aspirin and another antiplatelet or anticoagulant following their second dose of the Moderna COVID-19 vaccination. While the bleeding seems to be self-limited, the long-term course currently remains elusive.

Maryam Sattari

Jourdan Mckinnis

Amir Kazory

Gross Hematuria following SARS-CoV-2 Vaccination

A 76-year-old woman presented with lower abdominal pain and nausea and was referred to the gastroenterology department in our institution. Previous contrast-enhanced computed tomography (CE-CT) for follow-up after breast cancer surgery had indicated a soft tissue mass below the right diaphragm, which was considered a benign change. CE-CT performed at the first visit to our department revealed further thickening of the soft tissue mass with extension to the liver surface. In addition, ascites and nodules were observed in the abdominal cavity. Histopathological examination of a biopsy specimen revealed peritoneal invasion of atypical epithelioid cells with trabecular and glandular patterns. The tumor cells were positive for AE1/AE2, calretinin, WT-1, D2-40, HEG1, EMA, BAP1, and MTAP and negative for carcinoembryonic antigen, MOC-31, Ber-Ep4, ER, PgR, TTF-1, claudin 4, and desmin. A diagnosis of epithelioid mesothelioma was made. The patient received chemotherapy with cisplatin (75 mg/m2) and pemetrexed (500 mg/m2). After six courses of combined chemotherapy, pemetrexed was administered as a single agent. At the time of writing this report, she was undergoing over the 30th course of chemotherapy without any significant side effects. Diffuse malignant peritoneal mesothelioma is a rare, fatal, and progressive disease. Our patient achieved long-term survival of more than 5 years with maintenance therapy using single-agent pemetrexed.

Yasuo Otsuka

Yoriaki Komeda

Masayuki Takeda

Takayuki Takahama

Masashi Kono

Mamoru Takenaka

Satoru Hagiwara

Naoshi Nishida

Hiroshi Kashida

Masatoshi Kudo

Long-Term Survival of More than 5 Years with Maintenance Therapy Using Single-Agent Pemetrexed in a Patient with Diffuse Malignant Peritoneal Mesothelioma

Malaria is an infection caused by protozoa of the genus Plasmodium, commonly found in tropical and subtropical regions worldwide. Plasmodium falciparum causes the most severe form of the disease and may progress to life-threatening manifestations. This case describes a 26-year-old man who suffered cerebral malaria with multiple organ dysfunction and successfully recovered despite poor initial prognosis. Negligent and late diagnosis of malaria leads to severe complications and a worse prognosis. This case emphasizes despite living in a low-endemic malaria area, physicians should remain meticulous and consider malaria as differential diagnosis even after initially presenting with nonspecific symptoms. Consequently, malarial screening should be performed to modify the risk of mortality. Furthermore, close monitoring and early administration of intravenous artesunate are also particularly critical.

Maria Teressa

Asep Purnama

Joshua Henrina

Agustinus Wiraatmadja

Angela M. B. Boro

Candida I. L. Sam

Tersila A. D. Dedang

Alius Cahyadi

Severe Malaria in an Adult Patient from Low-Endemic Area in Flores Island, East Nusa Tenggara

Postdural puncture headache is a frequently encountered complication following procedures such as lumbar puncture, neuraxial anesthesia, or intrathecal drug delivery device implantation. It classically presents as a painful orthostatic headache that is exacerbated when a patient is upright. For treatment, patients are often started on conservative options such as hydration, caffeine, bedrest, and NSAID analgesics; however, certain patients who fail these therapies may require intervention with an epidural blood patch. The epidural blood patch remains the gold standard for treating refractory postdural puncture headache. Contraindications to epidural blood patch include severe coagulopathy, patient refusal, or infection at the intended site of entry. There are no clear consensus recommendations regarding patients with a hematological malignancy and potential risk that autologous blood may seed malignant cells into the neuraxis. In this case report, we present a patient with acute myeloid leukemia who developed a postdural puncture headache after receiving subarachnoid administration of antineoplastics. The patient was refractory to conservative therapy, prompting multidisciplinary consultation and discussion with the patient about the risks and benefits of proceeding with an epidural blood patch. Ultimately, the patient elected to proceed with the offered epidural blood patch which led to complete resolution of his painful headaches and did not cause any spread of malignant cells into his neuraxis or cerebral spinal fluid.

Ross Barman

Jack McHugh

Thomas O’Mara

Thomas Pittelkow

Ryan S. D’Souza

Epidural Blood Patch in a Patient with a Hematological Malignancy

Introduction. Coronavirus infection is a risk factor for vascular thrombosis. This is of particular importance for patients undergoing myocardial revascularization since this infection can be a trigger for the formation of restenosis in the area of a previously implanted coronary stent. Understanding the risk factors for stent thrombosis and restenosis is of particular importance in individuals at risk for adverse outcomes. The rarity of such situations makes the present study unique. Objective. Studying the peculiarities of restenosis and thrombosis of the coronary arteries in patients after coronavirus infection. Methods. The study was performed in the Department of Cardiovascular Surgery of Emergency Hospital, Semey City, in 2021. We have examined the medical records of 10 consecutive patients with restenosis of coronary arteries after coronavirus infection and 10 matched-by-age patients with similar restenosis of coronary arteries who did not have coronavirus infection as a comparison group. To determine statistically significant differences between independent samples, we calculated the Mann–Whitney U test. Results. The average age of patients was 65.7 years. Only one case was classified as early restenosis (within 8 days of previous revascularization), two cases represented late restenosis, and seven cases were very late restenoses. In 70% of cases, restenosis was localized in the left anterior descending artery, in 30% of cases, it was in the right coronary artery, and in 40% of cases, it was in the left circumflex artery. In comparison with patients who did not have a coronavirus infection, there were statistically significant differences regarding IgG (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="19.289pt" style="vertical-align:-0.6370001pt" id="M1" height="9.2729pt" version="1.1" viewBox="-0.0498162 -8.6359 19.289 9.2729"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><path id="g117-91" d="M512 -3V55L134 254V256L512 456V514L75 281V230L512 -3Z"/></g></svg><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.182pt" style="vertical-align:-0.6370001pt" height="9.2729pt" version="1.1" viewBox="22.8711838 -8.6359 28.182 9.2729"><g transform="matrix(.013,0,0,-0.013,22.921,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg>) and fibrinogen (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="19.289pt" style="vertical-align:-0.2064009pt" id="M2" height="8.8423pt" version="1.1" viewBox="-0.0498162 -8.6359 19.289 8.8423"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.182pt" style="vertical-align:-0.2064009pt" height="8.8423pt" version="1.1" viewBox="22.8711838 -8.6359 28.182 8.8423"><g transform="matrix(.013,0,0,-0.013,22.921,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><path id="g113-58" d="M244 635C114 635 38 519 38 422C38 317 111 240 217 240C236 240 255 244 277 256L345 292C311 140 203 39 59 15L64 -15C89 -15 150 -5 204 17C339 72 440 202 440 386C440 521 368 635 244 635ZM228 602C326 602 352 479 352 390C352 370 351 347 348 324C327 308 293 296 258 296C174 296 124 369 124 458C124 517 152 602 228 602Z"/></g></svg>). Conclusion. Patients with myocardial revascularization in the past have a higher risk of stent restenosis against the background of coronavirus infection due to excessive neointimal hyperplasia, hypercoagulability, increased inflammatory response, and endothelial dysfunction.

Gulnara Batenova

Lyudmila Pivina

Evgeny Dedov

Altay Dyussupov

Zhanar Zhumanbayeva

Yerbol Smail

Tatyana Belikhina

Laura Pak

Diana Ygiyeva

Restenosis of Coronary Arteries in Patients with Coronavirus Infection: Case Series

Nitrous oxide is a commonly used inhaled anesthetic for medical procedures, as well as a drug of abuse throughout the world. Excessive nitrous oxide inhalation has been shown to cause a functional vitamin B12 deficiency and hyperhomocysteinemia, which can lead to peripheral neuropathy and hypercoagulability, respectively. While the development of neurologic toxicity from chronic nitrous oxide abuse (i.e., encephalopathy, myelopathy, and neuropathy) has been previously described, the thrombotic potential of chronic nitrous oxide abuse is less known. The authors report two cases of nitrous oxide abuse leading to both neurologic and thrombotic complications.

Erin Meier

Monica Malviya

Sukhdeep Kaur

Jacklynn Ibrahim

Andrew Corrigan

Andrew Moawad

Sathya Alekhya Bukkuri

Joshua Trebach

Mark K. Su

Manju Pillai

Neurologic and Thrombotic Complications in the Setting of Chronic Nitrous Oxide Abuse

Follicular lymphoma (FL) is one of the most commonly diagnosed types of indolent non-Hodgkin lymphoma (NHL). The median age of diagnosis for FL is 65 years old. Although the median life expectancy after diagnosis is approximately 10 years, the incurable disease has a high risk of transformation. This case report focuses on an 80-year-old patient diagnosed with low-grade follicular lymphoma which subsequently transformed leading to the patient’s eventual demise as the patient took on the palliative intent. This case report aims to highlight the importance of clinical markers or prognostic factors to identify patients, specifically the elderly population who are at risk of transformation to aggressive forms when their FL remains at stage I-II phases. Currently, elderly patients with FL tend to be quickly dismissed with curative intent with chemotherapy, given their age and comorbidities, despite forming the majority of the population with follicular lymphoma. Age more than 60 years old has been shown to be one of the most powerful yet poor prognostic features in follicular lymphoma international prognostic index (FLIPI)—the main scoring system used for FL. Hence, further studies are required to look into the tailoring treatment for elderly patients with follicular lymphoma after risk stratifying them with appropriate clinical and prognostic markers.

Jiao Jie Cherie Tan

Yuen Lei Sze

Clarice Choong Shi Hui

Managing Follicular Lymphoma in the Elderly Population

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Case Reports in Medicine publishes case reports and case series in all areas of clinical medicine.

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Case Reports in Medicine - Table of contents 2023

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Case Reports in Medicine publishes case reports and case series in all areas of clinical medicine.

Case Reports in Medicine