Journal of Clinical Case Reports

Angioedema is a known allergic reaction to many medications. Angiotensin Converting Enzyme Inhibitors (ACE-I) have been reported to cause such an adverse event, however, the mechanism of action is not clear enough. ACE-I induced angioedema is often misdiagnosed, although it could develop to a life-threatening situation. It is believed that it is caused by bradykinin induced activation of vascular bradykinin B2 receptors. Studies have reported an incidence of angioedema of 1 in 1000 during the first week of use, and 1 to 42,000 subsequently. Life threatening airway obstruction requiring intubation has been reported in up to 22% of angioedema cases caused by ACE inhibitors, with an overall mortality rate of 11%.

Introduction: Retroperitoneal Fibrosis (RPF) is a clinicopathological condition characterized by inflammatory fibrotic reaction around infrarenal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations. This case report shows how a Deep Vein Thrombosis (DVT) and subsequent Pulmonary Embolism (PE) can be a potential complication of this disease. A potential temporal association was seen with chronic beta blocker use and retroperitoneal fibrosis. Case presentation: A 62-year-old Caucasian male with history of hypertension on chronic beta-blocker therapy for 2 years (Metoprolol 50 mg twice daily) presented with sub-acute left sided non-radiating lower back pain of 5-day duration. Computerized Tomography (CT) scan with contrast of the abdomen and pelvis revealed large segment of inflammatory stranding involving the periaortic retroperitoneum extending from the level of the kidneys upto the pelvis and incasing the left Iliac veins. CT guided retroperitoneal core biopsy was done which was consistent with retroperitoneal fibrosis. Two months later, patient presented with complain of acute onset shortness of breath and increasing lower extremity edema, on the left side. Electrocardiogram was consistent with a finding of new onset Atrial fibrillation (A fib). Ultra Sono Gram (USG) Doppler study of lower extremities unveiled occlusive left sided DVT of the popliteal vein. A CT Angiography demonstrated segmental and sub-segmental pulmonary emboli of the right lower lobe with no evident pulmonary edema. He was treated with steroids, digoxin and warfarin. On follow up a repeat CT scan three months later of the abdomen and pelvis showed stable retroperitoneal mass with no further progression. Conclusion: Our patient presented with lower extremity edema and imaging revealed extension of RPF to involve common iliac vessels. With beta-blockers as a possible inciting event, RPF causing venous stasis, iliac vein compression and thus DVT/PE is the most plausible explanation This case reports add to the medical literature how DVT/PE can be cause by an underlying disease entity not related to the usual causes and if not worked up patients may be labeled as having unprovoked events. Any relationship between beta blockers and RFP is questionable and has not been proven in any randomized trials, but should be thought of by the physician if such clinical situation is encountered.

Introduction: We report a case of inflammatory myofibroblastic tumour with positive PET-CT involving the lung, hilar lymph node, liver and spleen in an asymptomatic young girl. Diagnosis was made four years after the initial presentation. Treatment: Conservative treatment. Outcome: Patient remained asymptomatic for 4 years. Conclusions: Multiple inflammatory myofibroblastic tumour may remain asymptomatic despite multiple organs involvement.

Neurofibromatosis type 1 (NF1) is an autosomal dominant multisystem disorder affecting approximately 1 in 3500 individuals. Patients with the disorder can develop carcinoid tumors, medullary thyroid carcinoma, pheochromocytoma and tumor of the hypothalamus. The association of NF1 with Primary Hyperparathyroidism (HPP) is very rare. We report a 56-year-old woman with NF1 who was referred to our service because of nephrolithiasis. Physical examination revealed the characteristic signs of NF1, and her laboratory calcium profile was compatible with HPP. The patient was referred for parathyroidectomy, but during the surgical work-up she underwent spontaneous remission of her HPP. This case is significant not only for the rarity of this presentation in NF1 patients, but also because of the spontaneous remission of HPP.

Programmable Intrathecal (IT) drug delivery systems are being increasingly used with radiation therapy for cancer treatment and palliation. Ionizing radiation is assumed to cause dysfunction of the programmable IT device. However, the dose limit and safety of the IT drug delivery device used concurrently with radiotherapy have not been extensively documented. Here we report a patient who underwent the implantation of an IT pump during radiotherapy. This device was subsequently directly exposed to radiation. Estimated cumulative doses to the pump were in the range of 1.28 to 9.98 Gy. The IT pump exposed to this high-dose radiation did not pose any risk to the patient or the environment. The device was queried during and after the completion of treatment and found to be functioning without fault. This is the first case description about the successful function of an IT drug delivery device directly exposed to ionizing radiation.

Three-dimensional conformal radiotherapy (3D-CRT) can improve local control of non-small cell lung cancer [1]. During the period of radiotherapy, tumor appears different degrees of shrinkage. It has been demonstrated that a clear dose-response relationship exists for radiotherapy, i.e. higher doses of radiation lead to increased local tumor control. According to tumor regression degree, adjusting the field shape and radiation strength, improve the tumor tissue irradiation dose, decrease peripheral normal tissue affected by radiation, improve local tumor control and prolong the survival time.

A 47 year old lady presented to the Orthopaedic out patient clinic following a referral from her General Practitioner. Since 2001 she had suffered from right-sided shoulder pain. In addition she reported a feeling of instability in the shoulder when doing manual activities, especially in over-head work. On questioning she reported occasional hand paraesthesia. This affected all of the fingers and thumb equally, rather than being confined to a particular nerve region or dermatome. There was no history of trauma.

Tuberculosis continues to be a leading cause of morbidity and mortality in the 21st century. The rise of multiresistant strains of Mycobacterium tuberculosis associated with an increase of disseminated tuberculosis due to the higher numbers of Human Immunodeficiency Virus (HIV) infected patients is threatening to compromise tuberculosis control worldwide. Here we report a rare case of disseminated tuberculosis, presenting with a wide spectrum of extra pulmonary involvement including prostate and leptomeningeal, and evolving to a fatal outcome due to lack of response to all tuberculostatic drugs used. This paper highlights the clinical complexity of this disease, and the diagnostic and therapeutic challenges that one faces when treating patients with tuberculosis.

Diagnosis of iatrogenic pneumothorax is often delayed, which should make physicians and critical care nurses vigilant. A 55 year old man referred to the emergency unit with chief complain dyspnea one week after CABG. In pulmonary CT angiography, huge pneumothorax was presented in left lung. Patient underwent emergent chest tube insertion and discharged two days later in a good condition.

Clinical studies have shown that premature infants may experience pain in spite of the immaturity of anatomical and functional pathways transmitting nociceptive stimuli [1]. Over the past decade, survival rates for pre-term neonates have increased markedly [2]. The increase in premature birth and survival is provided by O2 therapy and ventilatory management. Oxygen therapy is directly related to Retinopathy of Prematurity (ROP). Screening examination for ROP is a very brief painful procedure and requires long-term follow-up [3]. Although the management of neonatal pain from major single procedures (eg, postoperative pain) has improved significantly, pain management for multiple and repetitive diagnostic and therapeutic procedures (eg, heel lances, suctioning) have not kept pace [2]. Multiple invasive procedures in premature infants caused marked fluctuations in intracranial pressure, possibly leading to early intraventricular haemorrhage and periventricular leucomalacia. Premature infants tend to be more unstable systemically than full term infants of the similar postnatal age, and are more susceptible to apnea and bradycardia [3]. Tramadol was being used in paediatric surgery department even in newborn babies undergoing surgery under general anesthesia, we thought that it could be safe and effective for ROP examination also [4-7]. Here we would like to present 3 cases who had heavy sedation and respiratory depression with the use of tramadol 2 mg/kg (one drop/kg) in premature infants for pain relief and sedation during ROP examination.

A 30 year-old female who had undergone a DDD mode Pacemaker (PM) implantation 1 year ago at the another institute due to total atrioventricular block. One month before her present admission, she started to experience chills and shivering as the main complaints. For the last 2 weeks she also had fever and dyspnea (NYHA 2). She had a De Vega annuloplasty for ebstein anomaly during primary atrial septal defect repair 20 years ago at history. Her arterial blood pressure was 110/60 mmHg and pulse of 85 beats/minute with a regular rhythm, her body temperature was 36.5°C. On physical examination 3-4 /6 systolic murmur was heared over the tricuspid valve area. Other system examinations were normal.

Gout is a disorder of uric acid metabolism that causes deposition of Monosodium Urate (MSU) crystals in joint spaces, which, in turn, elicit an acute inflammatory reaction. We present a case in which diagnosis of gout was made by fine needle aspiration of tophus. FNAC of gouty tophus is an easy alternative to synovial biopsy. It is simpler, easier and less painful.

A 60 year-old female with a history of a heart transplant was treated with voriconazole for presumed pulmonary aspergillosis. After approximately three months, she began to experience progressively worsening musculoskeletal pain. Her presentation was notable for widespread tenderness, a lack of digital clubbing, and elevated alkaline phosphatase. Bone scintigraphy demonstrated increased activity at multiple locations correlating with the patient’s pain. Periostitis was identified in these locations on radiographs. A few months after discontinuing voriconazole, the patient’s pain had resolved, alkaline phosphatase had normalized, and abnormal activity on scintigraphy had markedly improved.

The giant hyperplasia of the prostate is extremely rare pathology of prostate gland. Here, we report the successful removal of a giant BPH (312 g) with multiple bladder stones in a 75 years old man with severe LUTS (30 IPSS) by supra-pubic prostatectomy.

The occurrence of ectopic decidua has been observed mostly in the ovaries, uterus and cervix. Ectopic gastrointestinal deciduosis is a physiological condition. Only several cases of ectopic decidua, causing complications have been presented in literature. To the best of our knowledge, sigmoid or any other bowel perforation, caused by deciduosis, has not been previously reported in literature. Case presentation: A 40-year old patient primigravida (32 weeks of gestation) was admitted with a severe abdominal pain and obstipation. An abdominal sonography was performed but no visual cause of the pain was diagnosed. Two days after admission the episode of severe pain reappeared. An abdominal sonography and x-ray showed “free air” under both domes of diaphragm. A laparotomy was performed. No perforation of hollow viscus was found. On the fifth postoperative day, the patient started to complain about acute abdominal pain. The decision was made to perform relaparotomy (a Caesarean section and reexploration of abdominal cavity during the same operation). During the relaparotomy a part of sigmoid colon was visually altered. A microperforation on tumour-like structures was found in the sigmoid colon. A Sigmoid resection was performed. Currently the patient has no residual complaints and is enjoying her motherhood. Conclusion: We assert that ectopic decidua can result in a perforation of the hollow viscus, which is a lifethreatening condition and should always be taken into account seriously. We believe that sigmoid microperforation could have found, we had taken a more aggressive approach and performed a Caesarean section during the first operation.