Journal of Clinical Case Reports

67-year-old male with no significant medical history was admitted with complaints of chronic fatigue, splenomegaly, and gingival bleeding for the past six months. On admission, our patient was pancytopenic with a critical platelet count of 15 K and mean corpuscular volume of 102. Work-up for medication-induced, infectious, and malignant etiologies were pursued.

A 29-day-old, full-term male infant was brought to our pediatric emergency department to investigate arcuate macules and annular erythematous lesions with slight central atrophy and active raised margins, located on the face.

In the 1960s and 70s hip arthroplasty was in its infancy. During that time the occurrence of post-operative prosthetic femoral stem fracture was much greater than it is today. However as stem design and materials evolved along with superior cement and cementing techniques, rates of femoral stem fracture radically decreased, at present it is considered a rarity. We present two cases of fractured prosthetic femoral stems, detail the method of failure and the risk factors all surgeons should be aware of to minimize the risk femoral stem fracture.

Objectives: Rhabdomyolysis is a potentially life-threatening syndrome. Hypothyroid patients may present with myopathy and mild elevation of CK levels; however, overt rhabdomyolysis is extremely rare, and few cases have been described. Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis. Case report: A 24-year-old young man with accidently discovered hypothyrodism on admission presented with generalized myalgia, profound proximal muscle weakness of the bilateral lower extremities, anuria, vomiting and dark colored urine lasting for three days. Neurological examination revealed bilateral marked weakness and tenderness of muscles of both lower and upper extremities. Urine had dark red appearance and urinalysis showed blood reaction with dipstick test, but there were no erythrocytes on microscopic examination. Serum creatine phosphokinase and myoglobin levels were elevated. Thyroid stimulating hormone (TSH) levels were high, and Free Thyroxine (T4) and Triiodothyronine (T3) levels were low, renal function tests showed acute kidney injury. Other causes of rhabdomyolysis such as muscular trauma, drugs, toxins, infections, vigorous exercise, and electrolyte abnormalities were excluded. Hemodialysis was administered for five sessions. After L-thyroxine therapy, thyroid function tests normalized, muscle strength improved, serum muscle enzyme levels returned to normal levels, and renal function tests recovered. Conclusion: Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis.

Shotgun injuries are serious but uncommon type of injury in India. Embedded shotgun pellets have widespread functional and aesthetic implications. No specific guidelines are available as to which pellets need immediate removal. Most pellets are known to lie dormant in the body while some present with complications and warrant removal many years after injury. We hereby report a case of homicidal shotgun injury that was sustained 22 years ago and needed pellet removal due to excruciating pain.

Herein we describe a case using multiple images of a transjugular intrahepatic portosystemic shunt which is in direct communication of the biliary tree.

Olanzapine, a second generation or atypical antipsychotic, is one of the commonly prescribed antipsychotics and has lower incidence of extrapyramidal side effects, sedation and anticholinergic side effects. Atypical antipsychotics like olanzapine are now widely prescribed for treatment of schizophrenia as well as for schizoaffective disorder, bipolar affective disorder, depression and dementia. Olanzapine, has been reported to cause metabolic dysregulation like weight gain, type II diabetes mellitus and hyperlipidemia as compared to conventional antipsychotics. Sometimes patient taking olanzapine may present in acute deterioration like diabetic ketoacidosis complicated with acute pancreatitis. Hereby we are reporting a young patient who presented with life threatening severe diabetic ketoacidosis complicated with acute pancreatitis and acute kidney injury which resolved after withdrawal of olanzapine and with supportive care and Insulin. Combination of diabetic ketoacidosis, acute pancreatitis and acute kidney injury induced by olanzapine is very rarely reported.

As a result of improved cancer detection and greater life expectancy, diagnoses of synchronous primary lung cancers are becoming more common. We present a unique example of three distinctly different histologic tumors in one lobe. A 63 year-old female with suspicious lung nodules opted for short term CT-scan follow-up for two separate right upper lobe (RUL) nodules. In the two months interval a new subcentimeter RUL nodule developed. All three nodules were hypermetabolic on PET-CT. After wedge resection, that revealed a large cell neuroendocrine carcinoma, a formal right upper lobectomy was performed. Pathology revealed: a Sarcomatoid carcinoma, an adenocarcinoma with intracellular mucine, and a large cell neuroendocrine caricnoma. Interestingly, the third tumor was discovered during post-surgical tumor board discussion requesting a reexamination of the lobectomy specimen, emphasizing the importance of multidisciplinary review. This case might indicate that such synchronicities may occur at a greater rate than currently estimated.

There is no level A evidence to determine open repair (OR) or endovascular repair (ER) intervention to treat popliteal artery aneurisms. This article addresses a case of endovascular treatment of both popliteal artery aneurysm (PAA) and below knee peripheral atherosclerotic occlusive disease (PAD) in which we opted for endovascular treatment with satisfactory outcome, as well as a discussion about indications and expected results. We concluded that endovascular treatment is effective in treating this for it resolves the symptoms by recanalization of the artery system with little risks during the procedure and with short hospital stay.

Congenital absence of the portal vein (CAPV) is such a rare malformation of the splanchnic venous system. Also it can be a reason for hepatic tumors, for example adenoma, hepatoblastoma or hepatocellular carcinoma (HCC). The cooccurence of CAPV and HCC in adult patients have been reported in the literature. It is the second case of a pediatric patient whom has also CAPV and HCC.

The diagnosis of post-polio syndrome (PPS) might be difficult as the diagnosis PPS mostly depends on the patient’s subjective description of the symptoms. Furthermore, the PPS patients have reached an age when concomitant diseases are common. However, an adequate diagnosis is important for treatment and prognosis. The aim of this case report is to describe the complexity of the PPS diagnosis.

Carcinoma rectum often presents as painless bleeding per rectum, altered bowel habits, abdominal discomfort, and rarely as intestinal obstruction or bowel perforation. Here is a case of a patient with long standing fistula in ano who presented to Regional Cancer Centre, Thiruvananthapuram with a gluteal mass and was later diagnosed to be adeno carcinoma rectum. So far only very few cases of adeno carcinoma rectum reaching the gluteal space through peri-anal fistula has been reported in the literature.

Treatment of infected gap non-unions of tibia can be challenging. Subcutaneous bone causes susceptibility to non-responsive infection, nonunion, fibrosis, sinuses, deformities, shortening and various other sets of problems which are associated with it. Different methods of treatment have been recommended for management of infected nonunions. The first is the “conventional” or classic method. The objectives of the conventional method are to convert an infected and draining nonunion into one that has not drained for several months and to promote healing of the nonunion by bone grafting. This method of treatment often requires one or more years to complete and usually results in stiffness of adjacent joints. The objective of the second i.e. active method is to obtain bony union early and shorten the period of convalescence and preserve motion in the adjacent joints.

Introduction: Guillain-Barré syndrome (GBS) is a frequent cause of neuromuscular paralysis and usually occurs after an immunoallergic reaction, most often after respiratory or gastrointestinal infection. However, rare cases of Guillain-Barré syndrome are described, associated with hematopoietic stem cell transplantation.

Observation: Patient n° 20452690. The authors report the case of 21 years old man, treated for Hodgkin lymphoma with a recurrence at 18 months, who enjoyed second autologous hematopoietic stem cell transplantation after conditioning chemotherapy, then developed a Guillain-Barré syndrome. Plasma exchanges were made before a neurological worsening. Thereafter, five cycles of intravenous immunoglobulin were performed monthly. Unfortunately this development was hampered by mechanical respiratory complication that led to the death of the patient, the 237th day of evolution. The final diagnosis of Guillain-Barré syndrome, occurred in a context of post-transplant immune reconstitution in a patient treated for Hodgkin lymphoma was retained.

Discussion: GBS is a rare complication of hematopoietic stem cell transplantation. After literature review, we collected 33 cases related to this disease, 10 occurred after autograft. Etiopathogenic mechanisms remain obscure. Despite the use of immunomodulatory treatment, the prognosis is often severe and dark.

Conclusion: GBS is possible after autologous hematopoietic stem cell transplantation indicated for the treatment of Hodgkin lymphoma. The initial clinical severity, despite safeguards and use of immunomodulatory therapy, will cause often deleterious and poor outcome. To our knowledge, this well documented observation is the first case indicated for Hodgkin lymphoma.

Introduction and objectives: Genomic integrity of gametes is important for birth of healthy offspring. As compared to ova the sperm is more susceptible to mutation due to limited DNA damage detection and repair mechanism. Life style habits adopted by father before conception may adversely affect genomic DNA integrity in male gametes. Oxidative stress damages sperm nuclear and mitochondrial DNA. Complementary and alternative medical therapies such as yoga/meditation are being increasingly used as adjuncts to modern medicine in treatment of several clinical conditions. Therefore, in this pilot study, we analyzed the effects of yoga and meditation on seminal oxidative stress and sperm DNA integrity in fathers of children with non-familial sporadic heritable retinoblastoma (Rb) after intervention (3 and 6 months).

Methods: A total of 10 men (father of children with sporadic non-familial Rb) were recruited in this study. Semen samples were collected at base line (day 0), 3 months and after 6 months of yoga practice. Reactive oxygen species (ROS), DNA fragmentation index (DFI) and 8-hydroxy-2’-deoxyguanosine (8-OHdG) levels were estimated at day 0.3 months and 6 months interval.

Results: There was reduction in mean DFI levels [p>0.05] at 3 months and 6 months [p<0.05] compared to base line level (day 0). Seminal mean ROS levels were significantly reduced after 3 months [p<0.05] and 6 months [p<0.01]. We also observed reduction in levels of 8-OHdG both after 3 months [p>0.05] 6 months [p<0.05] with respect to the base line levels (day 0).

Conclusions: Yoga/meditation significantly lowers oxidative stress and oxidative nuclear DNA damage, and levels of the mutagenic base 8OHdG. Thus yoga and meditation are simple life style interventions which are therapeutic for maintaining/restoring sperm DNA integrity

A 61-year-old male patient presented with the complaints of severe breathlessness, difficulty in swallowing and progressively increasing swelling all over face and neck to a local hospital where he underwent emergency tracheostomy and percutaneous endoscopic gastrostomy (PEG) for feeding. Eight years earlier, he was diagnosed to have carcinoma left tongue and underwent left hemiglossectomy with supraomohyoid dissection followed by radiotherapy (60 Gy in 30 fractions). Thereafter, he remained asymptomatic for six years.

The spectrum of androgen insensitivity syndrome (AIS) is well characterized, ranging from complete androgen insensitivity (CAIS) to varying degrees of partial and mild insensitivity (PAIS). There is evidence correlating loss of androgen receptor function caused by mutations with the clinical phenotype. We present a patient with phenotypic and biochemical evidence of partial androgen insensitivity who has a c.2746 T>C base pair substitution causing a p.Tyr916 His sequence variant in the androgen receptor that has not been previously reported. Furthermore, this mutation is in an atypical site, and the phenotype does not correspond with previous reports of complete androgen insensitivity caused by mutations in this region. This highlights potential deficiencies in our molecular understanding of this syndrome, and re-enforces that it is not appropriate to consider all patients with partial androgen insensitivity as a single cohort; we should instead consider different sub-groups when considering the molecular basis and subsequent therapy.

Though endovascular interventions for venous obstructive lesions have evolved, chronic total occlusions are difficult to negotiate. We are describing our experience of successfully using modified sharp recanalization technique in which the Brockenbrough needle in the Mullin sheath was used to negotiate the chronic total occlusion of inferior vena cava in a case in which the lesion was not crossed with repeated attempts with a guide-wire. Finally the lesion was predilated with mitral valvuloplasty balloon. A balloon-mounted stent was deployed with optimum postprocedural results. At the follow-up of 6 months, the patient was asymptomatic with optimal clinical outcome in form of patent stent on Doppler and computed tomography studies.