Journal of Clinical Case Reports

Background: Nivolumab is a humanized IgG4 anti-programmed cell death protein-1 (PD-1) antibody. In recent years, type 1 diabetes associated with anti-PD-1 immunotherapy has been reported.

Case report: We report a 62-year-old woman with primary choroidal melanoma who developed fulminant type 1 diabetes after anti-PD-1 immunotherapy (nivolumab). She had elevated levels of blood glucose and total blood ketone body. Her hemoglobin A1c level was at the upper limit of normal, and she had decreased endogenous insulin secretion. Anti-glutamic acid decarboxylase and anti-islet antigen 2 antibody tests were negative. Endogenous insulin was still being secreted at the time of diagnosis; therefore, we administered steroids and glucagon-like peptide-1 (GLP-1). However, insulin secretion did not recover. Approximately 10 months after onset, her diabetes was under control with intensive insulin therapy and voglibose treatment.

Discussion: The mechanism of diabetes caused by nivolumab is unclear, but it may involve the excessive autoimmune response associated with PD-1 inhibition. GLP-1 has a protective effect on the pancreas by promoting differentiation and proliferation of pancreatic β cells and suppressing pancreatic β cell apoptosis. We attempted to treat with steroids and GLP-1 before depletion of endogenous insulin to suppress the hyperimmunization and protect the pancreatic β cells. Insulin secretion did not recover. However, no reports have described using these therapies to treat diabetes associated with immune checkpoint inhibitors during early onset to date. We consider this case is the meaningful report as a negative data.

Intraoperative cerebral aneurysmal re-bleeding has a deleterious effect that is associated with high mortality and morbidity. Neurosurgeons and anesthesiologists should be familiar with all methods including hypothermia, cardiopulmonary bypass, pharmacologically-induced hypotension and cardiac standstill to manage intraoperative aneurysmal rupture or clip complex aneurysms. Specifically, adenosine induced profound hypotension or cardiac arrest has been used recently. We present our experience with the use of adenosine during a case of incidentally developed intraoperative cerebral aneurysmal rupture.

Purpose: Communicate a case of late onset Gemella morbillorum keratitis after laser in situ keratomileusis. Infectious keratitis after laser in situ keratomileusis (LASIK) is a rare complication. The most common microorganisms in this infection are atypical Mycobacterium and gram-positive cocci. We treated a healthy 45-year-old man, who developed a spontaneous flap interface keratitis in the right eye 6 years after laser in situ keratomileusis (LASIK). Visual acuity represented in decimal fraction was 0.96 (19/20 feet) in the right eye and 1.0 (20/20) in the left eye. Cultures were positive for Gemella morbillorum. Topical treatment with fortified vancomycin and dexamethasone elicited a response. One month following initial treatment, the bacterial infiltrate had resolved. To our knowledge, this is the first reported case of post-LASIK infectious keratitis caused by Gemella morbillorum that occurred several years after the procedure. Conclusions: This case emphasizes the importance of lifelong follow-up care after LASIK. When one of these patients exhibits symptoms of an infectious keratitis, it’s important to suspect an atypical microorganism, and a culture should be taken to determine the best manner of treatment for each microorganism.

We describe the successful management of argatroban in non-obstructive mechanical heart valve thrombosis in a context of heparin induced thrombocytopenia (HIT) type II. A 77-year-old female with permanent atrial fibrillation and mechanical heart valve developed an asymptomatic non obstructive thrombus of mechanical mitral heart valve diagnosed while she was under argatroban for acute HIT type II. Total disappearance of thrombus was achieved with a medical antithrombotic strategy combining increase of argatroban and VKA dosages and implementation of an antiplatelet treatment with aspirin.

Cluster headache (CH) is excruciating attack of pain in one side of the head, often felt around the eye. It occurs 1 in 500-1000 people, is more common in men and tend to develop in people over the age of 20.

Background: Any foreign particle in human body need to be removed to protect from different complication. But in our case patient could not be managed surgically so close medical management was selected on a context of sterile foreign body without further side effects.

Case report: We present a case of iatrogenic transmigration of foreign body within the pericardium. Which was regularly followed for three years without complications and symptoms.

Conclusion: None operable and sterile foreign body in pericardium may remain symptomless and it can be managed conservatively on poor general condition patient with regular follow-up.

Background

Many clinicians might have encountered patient with foreign body intruding problems. Various foreign particles usually get into our body through different sort of accidents. However, during some surgery or other procedure unknowingly iatrogenic foreign body can also get into human body although the rate is least. Foreign bodies if get inside our body it may trigger the immune or inflammatory cells thereby causing inflammation and swelling, releasing symptoms. And if it is not removed may lead to further complications. Despite, depending on particle, size, location and patient general condition all foreign body may not be harmful to human. In this paper, we have presented a rare case of broken guide wire transmigration in the pericardium which remained without any signs during 3 years close follow up.

Hyperkalemia in end stage renal disease patients is a common complication. Sodium polystyrene sulfonate (Kayexalate) is a commonly used in the treatment of hyperkalemia. This case report discusses about Kayexalateinduced colonic necrosis, a rare but fatal complication of this commonly used medication.

Keywords

Sodium polystyrene sulfonate; Kayexalate; Bowel; Necrosis; Acute abdomen

Introduction

Sodium polystyrene sulfonate (SPS, Kayexalate), has been used in management of hyperkalemia since 1957 when it was first discovered. Kayexalate is a cation resin used either as oral or as an enema form in the management of hyperkalemia. Originally sorbitol was mixed with sodium polystyrene sulfonate as a cathartic to avoid constipation. Even though kayexalate is used often to treat hyperkalemia, its side effect of colonic necrosis is a rare complication that was first discussed in 1987, in a series featuring five uremic patients. The study led to the FDA advisory to discontinue the addition of sorbitol due to this associated risk of colonic necrosis [1].

Breast cancer is the most frequently diagnosed cancer in women and is the second largest cause of death by cancer in this gender, in Portugal. Several studies and international guidelines consider mammography to be the gold standard for screening of breast cancer.

Introduction: We report a patient who initially presented with behavioral changes for a short period and then succumbed to unexpected death while on psychiatric treatment. The cause of death was found to be a craniopharyngioma at medico-legal autopsy.

Case report: A previously apparently healthy, 52-year old female, started showing disinhibited behavior such as removing clothes in public and was consequently treated with antipsychotics for two weeks. Behavioral symptoms improved gradually but she complained of intermittent difficulty in maintaining balance. A week later she was found dead at home in her bed. Medico-legal autopsy and subsequent investigations revealed severe cerebral edema resulting from a well formed craniopharyngioma with surrounding cystic degeneration at pituitary gland. The optic chiasma was partially displaced by the tumor. Moderate pulmonary edema was seen. Examination of other systems, toxicology and microbiological investigations were unremarkable. The cause of death was given as cerebral edema due to craniopharyngioma.

Discussion: The patient was initially treated as having a mental illness. This reflects the importance of excluding organic causes early and considering neurological assessment in previously well patients who suddenly presented with psychiatric symptoms. Autopsy findings are consistent with acute hydrocephalus due to growing brain tumor. The enlarged gland had encroached on the basal cisterna, obstructing the cerebral spinal fluid pathway, and causing acute hydrocephalus. This was speculated to have resulted in sudden death.

Conclusion: This case exemplifies the medico-legal autopsy role in determining causes of death.

Gastrointestinal bleeding is not always easy to detect. Bleeding can come from any part of digestive tract, from mouth to the rectum. It can be from small amount that is only detectable by laboratory testing, to massive bleeding that can cause hemorrhagic shock. Benign small-bowel tumors may develop as a single lesion or as multiple lesions of several sub-types.

Background: One in six men are survivors of childhood sexual abuse. There is mounting evidence that childhood sexual abuse can lead to greater susceptibility to lifelong physical and mental health problems. Methods: Consenting male patients were identified as having a history of sexual abuse while attempting to resolve medical issues involving oral, anal or genital care, and consulting with a urologist, a dentist or a gastroenterologist. Results: Childhood maltreatment poses a substantial risk for long-term health. The results show that nonabusive relationships with a healthcare provider fosters mutual trust and promotes long-term health success by allowing a survivor to feel taken care of in an adult relationship with his physician, based on that trust. Conclusion: Healthcare providers must learn to identify survivors of childhood sexual abuse, because most survivors will not divulge this information readily. Once a history of abuse has been established, it is imperative for physicians to alter their clinical practice to accommodate survivors so their patients feel safe, empowered, and heard.

Background: Subcutaneous metastatic liposarcomas are rare. Differentiation between primary tumors and metastasis of a single liposarcoma represents the main difficulty in diagnosis. In this article, we describe the first report of Subcutaneous metastasis to the neck in the right level IB from liposarcoma originating in the thigh. Case presentation: The present 19-year-old women presented to a complaint of a rapidly growing mass, of the posterior loge of the right thigh with poor definition of adjacent structures, of 9 months’ duration measuring 188 × 97 mm. Microscopic examination of the mass following excision revealed a myxoid liposarcoma. A wide surgical resection was performed, and margins were negative. At this time, the patient showed no metastatic disease and underwent a complementary treatment including irradiation of the right thigh at a dose of 50 Gy delivered in 25 fractions over 38 days. There weren’t any local recurrence or metastases on her 12 months follow up until May 2015 when she presented with a mass in the neck (right level IB). An excisional biopsy was performed by an in June 2015 revealing a myxoid liposarcoma imposing a large re-excision of the tumor bed with 3cm free tumor margin. Microscopic examination of the surgical specimen found clear margins without an involvement of the skin. Differentiation between primary tumors and metastasis of a single liposarcoma was very difficult. The results of the disease extension workup showed no sigh of other metastases no local recurrence until now. Conclusion: To our knowledge, no case of cutaneous metastatic myxoid liposarcoma has been reported until now.

Introduction: Angle kappa is important in our clinical practice as it can give the appearance of strabismus. A vertical angle kappa is secondary to macula heterotropia as a result of retinal traction from scar tissue in the posterior pole. Case report: We present an interesting case of a 25 year-old Chinese female who presented with an abnormal vertical angle kappa due to macula ectopia from a toxocara retinochoroidal granuloma. She had an apparent right exotropia and hypotropia on Hirschberg and Krimsky but a hypertropia on alternate prism cover test. Our patient was keen for surgical correction as she was bothered by the appearance of her large angle squint. The main concern about strabismus surgery in patients with angle kappa was that it could break down the patient’s fusion and cause diplopia. Conclusion: The management of vertical angle kappa is difficult and odifficult to treat surgically. We describe this rare case of a patient who underwent surgical correction of only the horizontal recti and she achieved apparent orthophoria with a good cosmetic outcome. Patient also had no diplopia post-operatively.

Hydatid disease is endemic in Middle Eastern countries. Liver is the most involved organ, followed by the lung. We review a case of abdominal wall hydatid cyst in a 75 years old lady that was presented with bulging and redness of umbilicus mimiking umbilical hernia. After opening the abdominal wall hydatid cyst was diagnosed and removed and after irrigation with silver nitrate the abdominal wall was closed . And in one year follow up no recurrence has been detected.