Journal of Clinical Case Reports

In this issue of Clinical Case Reports, Nadig [1] describe a case of myasthenia gravis (MG) unmasked after treatment with beta-blockers for hypertrophic cardiomyopathy. MG presents at an age when comorbid conditions are common and require treatment with multiple medications. In addition, heart disease may be a manifestation of MG. In one study, 16% of 108 patients with MG showed signs of heart disease, mainly arrhythmia.

Invasive aspergillosis (IA) is one of the most common fungal infections in immunocompromised patients. Is an air-borne disease and the majority of patients develop pneumonia or sinusitis. However central nervous system (CNS) aspergillosis may also occur. Infections by Aspergillus fumigatus are most prevalent although in recent years, non-fumigatus Aspergillus species such as A. flavus has become common as causal agents this mycosis. The major risk factors associated include neutropenia, hematological malignancy,andtransplantation of hematopoietic stem cells and solid organs. Therefore, here we report a fatal case of pulmonary aspergillosis and CNS due Aspergillus flavus in neutropenic patient with acute lymphoblastic leukemia. The diagnosis of pulmonary infection was based in the isolation of A. flavus in tracheal secretions associated with the pulmonary infiltration detected in the Chest X-ray. Because of the thrombocytopenia the CNS aspergillosis was diagnosed only by brain magnetic resonance imaging. This case underscores the Importance of IA as a serious disease and late diagnosis leading to a poor prognosis with fatal course due to worsening clinical.

The Levonorgestrel Intrauterine System (LNG-IUS) has become increasingly popular due to its success in treating heavy menstrual bleeding and as a contraceptive. It still however carries a significant risk of an ectopic pregnancy at any time in its five year half-life. This case highlights an atypical presentation and as failure to diagnose can lead to significant morbidity and mortality.

Heterotopic pregnancy (HP) is a rare form of multiple pregnancy where a combined intrauterine gestation develops simultaneously with an extrauterine pregnancy. The majority of extrauterine implantations are tubal. Other uncommon sites can include ovaries, cervix and the abdomen.

Perioperative ischemia remainsa significant problem and carries a very high morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG) in patients with ST-elevation myocardial infarction (STEMI). Different therapeutic options are available for the clinician to manage this complication. These include direct reoperation, percutaneous coronary intervention (PCI) and conservative medical management. Immediate PCI has been reported to be a viable alternative to emergent redo CABG in these patients. Here in, we report an additional case of emergent PCI immediately after failed primary CABG in patient with cardiogenicshock.

Strongyloides Stercoralis is a nematode and infection from it is common in Sub-Saharan and South East Asia continent. It is mostly asymptomatic but if it presents, then is usually seen with vague gastrointestinal complaints. Small bowel obstruction is a poorly recognized and possibly underreported complication. We hereby present a case of partial small bowel obstruction from S. Stercoralis. A 35 year old man from Africa presented with one year history of post prandial nausea, abdominal bloating and bilious vomiting along with significant weight loss. His abdomen X ray and CT scan were consistent with partial proximal bowel obstruction. He presented to different hospitals and was treated for his symptoms, but a definite diagnosis could not be made. We performed upper endoscopy and biopsy which was consistent with S. Stercoralis infection. He was treated aggressively with Ivermectin and Albendazole until his stool cultures became negative for infectious larvae. He was followed up after 3 and 6 months with complete resolution of symptoms. We conclude that, since S. Stercoralis is an uncommon etiology for proximal bowel obstruction, high index of suspicion should be exercised in patients presenting as above and recent travel to areas endemic for S. Stercoralis.

The Intrauterine Devices (IUDs) to include the copper T380A IUD and levonorgestrel intrauterine system are effective reversible contraceptives options for women. A well-known but infrequent complication of the IUD is uterine perforation. Most uterine perforations occur at the time of IUD insertion but can also occur spontaneously after placement. IUDs located within the abdomen have potential to cause significant morbidity for patients to include perforation into surrounding structures such as the omentum, mesentery, small intestine, colon, and ovaries. Surgical management should be pursued upon confirmation of uterine perforation prevent sequel. Most misplaced IUDs can be managed by laparoscopic retrieval; however, laparotomy may be required when there is extensive adhesive disease. We present a case of a 28-year-old female who required laparotomy to remove a copper T380A IUD embedded into the small intestine and ovary after perforating through the uterus. The intent of this case report is to illustrate the importance of proper technique when placing IUDs and the steps in retrieving an IUD which is suspected to have perforated the uterus.

Aim: Myoepithelioma of salivary glands are extremely rare, comprising approximately only 1-1.5% of all salivary gland tumors.

Background: Minor Salivary gland tumors are infrequent, representing 10-15% of all salivary neoplasms. Their frequent location is parotid gland & myoepithelioma from palatal salivary glands is considered as a rare entity. Yet again, the Plasmacytoid Myoepithelioma from palatal salivary glands is sporadic, till date it has been reported merely 15 cases.

Case description: Here we report a 51 years old female patient with a slow growing palatal swelling. Cytological features of FNAC were suggestive of Myoepithelioma. The patient underwent wide surgical excision of lesion and after a month patient was followed up wherein oronasal communication was existing, subsequently patient was provided with themaxillaryobturator.

Conclusion: Clinically, its presentation may resemble pleomorphic adenoma, which hampers the correct diagnosis. Clinical relevance: This case report reinforces the need to alert dentists to include Myoepithelioma in the differential diagnosis of palatal swellings in elderly patients.

Mycobacterium szulgai was first defined in 1972 as a non-pathogenic mycobacterium. It is a rarely seen nontuberculous mycobacterium (NTM or mycobacteria other than tuberculosis (MOTT)) and evidence of disease usually accompanies its isolation from clinical specimen.

Association of Hypertrophic cardiomyopathy (HCM) with immune linked disorders like myasthenia gravis is extremely rare. Various pharmacologic agents can potentially precipitate or unmask underlying signs and symptoms of myasthenia gravis. Oral beta blockers are an important mainstay in the pharmacological management of patients with HCM. We report a case of obstructive HCM who when treated with beta blockers developed increasingly severe weakness and fatigue. Detailed clinical examination led to a clinical diagnosis of underlying myasthenia gravis which was secondary to a thymoma. The patient had developed acute unmasking of the latent myasthenia gravis following institution of therapy with beta-blockers. The patient underwent successful resection of the thymic mass and made an uneventful recovery. Symptoms like fatigue, shortness of breath and weakness are common among patients with HCM and are also frequent in patients with myasthenia gravis, sometimes making a clinical diagnosis difficult. It is important for physicians to be aware of such unusual associations to be able to appropriately manage such cases in clinical practice.

Isotretinoin (13-cis retinoic acid) is the most potent known inhibitor of sebum production and is by far one of the most effective antiacne medications for the treatment of severe and scarring acne, but it has been shown to be teratogenic when used duringpregnancy.

A 72-years-old male visited our institution because of severe abdominal distention. Abdominal computed tomography revealed liver cirrhosis with massive retention of ascites. Ascites was treated using diuretic drugs and albumin preparation. Gastroendoscopy revealed esophageal varices, which was successfully treated with endoscopic variceal ligation. A follow-up gastroendoscopy performed 4 months later revealed the disappearance of esophageal varices and the presence of a depressed lesion on the anterior wall of the lesser curvature of the midgastric body with a small orifice near the anal side of the depressed lesion, suggesting gastric gland heterotopia. A biopsy from the depressed lesion revealed group 5. Endoscopic ultrasonography revealed anechoic lesions in the third layer and type 0-IIc lesion with invasion to the third layer, suggesting that the IIc lesion invaded thesubmucosal layers. On the basis of endoscopic findings, the IIc lesion was considered to be within the submucosal layer; therefore, Endoscopic Submucosal Dissection (ESD) was performed, and pathological findings of the resected specimen revealed moderately differentiated tubular adenocarcinoma within the mucosallayer and multiple cystic dilated lesions in the submucosal layer. The post-ESD course wasuneventful and recurrence or de novo lesion has not been detected by regular gastroendoscopy

Isotretinoin (13-cis retinoic acid) is the most potent known inhibitor of sebum production and is by far one of the most effective antiacne medications for the treatment of severe and scarring acne, but it has been shown to be teratogenic when used during pregnancy. The risk of malformations in the population is 3-5%, but it has been reported to increase to almost 30% in women exposed to isotretinoin.

Cerebral venous sinus thrombosis (CVST) is an often under-diagnosed, life-threatening condition. We report the case of a 17-year-old female who presented with an acute, severe, on-going, headache. The initial head CT was negative. While the patient’s headache initially responded to pain medication and inpatient treatment, the patient subsequently developed left-sided neurological deficits. Subsequent imaging showed thrombosis in the superior sagittal sinus. The patient was treated with Lovenox, as well as thrombolysis using TPA, ballooning and mechanical removal, and soon after her neurological deficits resolved and her headache severity had significantly decreased. The aim of this case report is to provide an example of how early suspicion of CVST, even with initial negative imaging, is critical, as any delay in diagnosis and treatment can cause increased morbidity and mortality

Case report: A 73-year-old male incurred extensive third-degree burns on his abdomen. Although dysphagia had not been identified before the patient sustained burn injuries, VideoFluoroscopy (VF) performed for poor ingestion revealed severe dysphagia after skin grafting surgery and Ankylosing Spinal Hyperostosis (ASH). Although the cause of dysphagia was not identified, a Percutaneous Endoscopic Gastrostomy (PEG) tube was inserted. The patient was subsequently transferred to our hospital for rehabilitation. Direct rehabilitation for dysphagia began with jelly ingestion, and meal consistency was gradually increased. On day 50, he could completely ingest meals. However, beginning on day 70 of hospitalization, the patient began to complain of mental stress because his burns were taking too long to heal, which caused him to lose sleep at night. He was diagnosed with depression and began to choke when eating meals. VF findings again revealed aspiration after swallowing, and the patient’s state of deglutition that should have improved deteriorated again. Nutrition and fluid administration required a PEG tube to be re-introduced. After the patient’s wounds healed and his mental condition stabilized, he gradually recovered the ability to ingest food. VF findings on day 103 of hospitalization revealed an improvement compared with his previous examination, and aspiration had disappeared. Discussion: The patient’s condition improved temporarily but became aggravated with the deterioration of his depressive symptoms. Subsequently, with an improvement in his depression, dysphagia improved concomitantly. Apart from the deterioration of his depressive symptoms, we did not identify any cause that may have aggravated dysphagia in the patient. We believe that aggravation of dysphagia in the pharyngeal stage could have been caused by the deterioration of the patient’s depressive symptoms when he was barely able to swallow, such as in ASH.