Journal of Clinical Case Reports

We describe a 74-year-old woman presenting with right Internuclear Ophtalmoplegia (INO), horizontal gaze palsy and ipsilateral peripheral facial nerve palsy known as eight-and-a-half-syndrome. MRI and CSF findings led to diagnosis of Clinically Isolated Syndrome (CIS). One month later, the patient suffered acute myelitis. Our patient represents a rare case of late onset Relapsing-Remitting Multiple Sclerosis (RRMS) presenting with an eight-and-a-half-syndrome. Apart from the clinical rarity of eight-and-a-half-syndrome, this case serves as a reminder that MS can occur in every period of life and should be considered in differential diagnosis irrespective of age at onset of neurological symptoms [1].

Emphysematous pyelitis is a rare infection of the renal pelvis occurring alone or in association with pyelonephritis. The most common cause is E. coli and diabetes is the strongest risk factor. In a retrospective review including 48 patients who were diagnosed with either emphysematous pyelitis or pyelonephritis, the mean patient age was 60 years old and women outnumbered men 6:12. The most common initial symptoms include fever, dysuria, abdominal pain, and flank pain. The most frequent organ system involvement is hematologic and renal. Our patient, a 76 year old female, with no past medical history, presented with progressive weakness followed by the onset of jaundice. Her exam was notable for hypertension but no fever, jaundice, epigastric/right upper quadrant abdominal tenderness or peritoneal signs. Labs were remarkable for a profound leukocytosis, anemia, cholestasis, and an elevated creatinine. An abdominal ultrasound did not reveal cholecystitis or a common bile duct obstruction. Empiric antibiotics to include Ceftriaxone and Flagyl were started for possible cholangitis. On hospital day two, an abdominal endoscopic ultrasound was performed in lieu of a contrast study as renal function had worsened. This examination was normal. A non-contrasted CT scan of the abdomen and pelvis demonstrated the unusual findings of emphysematous pyelitis with a surrounding fluid collection concerning for a perinephric abscess. Subsequent management included placement of a percutaneous nephrostomy tube and antibiotics. Emphysematous pyelitis presenting as cholestasis is a novel clinical presentation of a rare illness.

Diabetic ketoacidosis (DKA) is a life-threatening condition seen in diabetes in which body cannot use glucose as a fuel instead uses fat and produces ketones (chemicals) and finally results in diabetic ketoacidosis. Bell's palsy is a sudden weakness or paralysis of the muscles on one side of the face due to mal-function of cranial nerve VII (facial nerve), which stimulates the facial muscles. Bell's palsy affects about 23 of 1,00,000 people at some time. The cause of Bell's palsy is unknown, but it may involve swelling of the facial nerve as a reaction to an immune disorder or a viral infection. Swelling causes the nerve to be compressed and its blood supply to be reduced. In this case facial nerve has got damaged due to diabetic ketoacidosis (mononeuropathy). Risk factors are the virus that have been linked to Bell's palsy include the virus that causes: cold sores and genital herpes (herpes simplex), chickenpox and shingles (herpes zoster), mononucleosis (Epstein-Barr), cytomegalovirus infections, respiratory illnesses (adenovirus), German measles (rubella), mumps (mumps virus), and flu (influenza B). Clinical features include numbness in the face, headache, eye can't get closed and gets dry resulting in eye damage. Diagnosis is done by CT-scan, MRI scan and blood tests. Treatment involves corticosteroids and anti-viral drugs. Bell's palsy can be cured in few months such as 2 to 3 months with regular medications and physiotherapy.

Constraint induced movement therapy (CIMT) is an effective rehabilitative intervention for motor recovery of the affected upper extremity in post stroke patients. However, this concept is not directly applicable in a resource scarce setting. Using the principle of CIMT in the patients' home utilizing a trained caregiver can modify this. The aim of this study was therefore to determine the role of the caregiver in modified Constraint Induced Movement Therapy in a patient with sub-acute stroke Methodology: The study was conducted at the patient's home in Uasin-Gishu County, Kenya. A 52-year-old woman, with a medical history of hypertension, and presented with left-sided hemiplegia. The unaffected hand was constrained in a mitten during working hours, except for bathing and toileting. For 6 weeks, patient spent 4.30 hours performing supervised tasks with paretic arm. Wolf Motor Function Test and the Motor Activity Log were used for data collection. Result: All except two tasks of the timed component of the WMFT had scores above the Minimal Detectable Change; however, the patient could not complete 2 tasks. The Factional Ability Scale and MAL indicated improvement. Conclusion: Support from caregiver increased therapy time, and was a significant factors in improved upper-limb functions.

We present the case of 35 years old female patient who came to our Institute with an unspecified abdominal pain, hepatosplenomegaly and a previous alleged diagnosis of Budd-Chiari syndrome. Magnetic resonance imaging (MRI) was crucial to identify a diffuse and infiltrating mass involving the liver in a misleading diagnosis. A discussion about the imaging findings and differential diagnosis of a rare case of diffuse epithelioid hemangioendothelioma (EHE) is provided as follows. MRI was the most important instrument to guide the diagnostic and therapeutic path, helping to define the typical signal intensity of EHE, mainly with a hepatobiliary contrast agent. The differentiating between other primary tumors, however, remains a complicated issue. Our purpose was to highlight the radiologic and MR characteristics of this rare tumor in order to evaluate the diffuse EHE in the diagnostic process.

Salivary duct carcinoma (SDC) is a rare malignancy that most commonly affects males in the fifth and sixth decades of life. Patients commonly present with a fast-growing form mass, often around the facial nerve. There are no known etiologic factors. Their most peculiar feature is morphological and immunohistochemical similarity to ductal carcinoma of the breast. Therapeutic approach is non-consensual because of the limited data but an extensive surgical resection has been advocated, along with postoperative chemoradiation in selected cases. Antiandrogen therapy may be useful in patients with advanced SDC. The rate of locoregional recurrence is high and the prognosis for survival is poor. We present the case of a 43 years-old patient with a right parotid lump of small dimension and rapid growth. Facial nerve deficits were not apparent and neck palpation identified no enlarged lymph nodes. MRI described a small lesion of oval shape and well defined contours. Fine-needle aspiration biopsy raised the possibility of a myoepithelial tumour and a superficial parotidectomy was performed. The patient experienced no complications during the postoperative healing. There were no facial nerve deficits. Microscopic examination concluded to a SDC. It was decided by a multidisciplinary team to apply radiation therapy to the surgical bed. At two years of follow up the patient remains with no clinical or imagological evidence of tumour recurrence.

Aim: The most commonly reported adverse reactions of docetaxel are neutropenia, anaemia, alopecia, nausea, vomiting, stomatitis, diarrhoea and asthenia. Alopecia is a distressing side-effect of cancer treatment and can have a significant negative impact on self-esteem and quality of life. The incidence of permanent alopecia with docetaxel is unclear. We reviewed available evidence relating to permanent alopecia associated with docetaxel given for the treatment of breast cancer. Method: A full literature search was performed using Medline with key words docetaxel and alopecia. Studies were included if they reported the use of docetaxel either alone or in combination regimens in breast cancer and provided information on permanent alopecia. Results: In total three papers were found. Tallon et al. reported a case of permanent alopecia in a 72-year-old caucasian female who was treated with 3 weekly adjuvant carboplatin (AUC6 650 mg), docetaxel (75 mg/m2) and trastuzumab (4 mg/kg) for 6 cycles. This was followed by a year of 3 weekly trastuzumab. After her first cycle carboplatin was removed from the regimen because of severe neutropenia. She experienced scalp hair loss 2 weeks into treatment and this persisted at 13 months after completion of treatment with only minimal re-growth. A punch biopsy showed a reduction in hair follicles. She had no previous history of alopecia but was treated for hypothyroidism.

Enoxaparin, a low-molecular-weight heparin, is one of the most useful anticoagulant. Treatment that have large using area including myocardial infarction. In this case a 65 years old male patient presenting with myocardial infarction and hemarthrosis caused by enoxaparin to be told. Patient admitted to the emergency service by angina and referred to us. After the first evaluation he hospitalized because of subacute anterior myocardial infarction. Including liver and renal function tests, platelets were normal. Medical treatment put in order. Enoxaparin was choosing as anticoagulant. During the treatments there was no problem but after last enoxaparin dose oedema was occurred at is left knee. We consulted him to orthopaedics. They did arthrocentesis to determine if it was hematoma or septic arthritis. Complete blood cells count evaluated. WBC 6.1, plt 45, Hb 10.6 detected. So it was hemarthrosis accepted. They recommend elastic bandage, elevation and cold execution. Enoxaparin treatment maintained. The day after oedema regressed. Coronary angiography done and stent implanted. Enoxaparin stopped Oedema followed by daily period, it gone back day by day. After the end of myocardial infarction treatment, he discharged.

Organophosphate insecticide compounds inhibit both acetyl cholinesterase and pseudocholinesterase activities. Acute organophosphate insecticide poisoning can manifest three different phases of toxic effects namely, acute cholinergic crisis, intermediate syndrome (IMS), and delayed polyneuropathy. Diagnosis is based on history of exposure and clinical manifestations. Management is beneficial with supportive measures along with specific antidotes. In this case reports, two patients with organophosphate insecticide poisoning are described. Both patients tried to commit suicide by ingesting an unknown amount of organophosphorus poison and both of them have developed intermediate syndrome. But one patient collapsed due to cardiac arrest and other patient was discharged with no complaints. Treatment for both patients mainly included atropine and parlidoxime.

Zellweger syndrome (ZS) disorders are autosomal recessive peroxisomal biogenesis diseases mainly characterized by neonatal onset severe neurodevelopmental delay, profound hypotonia, craniofacial dysmorphism, hepatic dysfunction, polyneuropathy and loss of hearing and vision. There is a wide genetic heterogeneity that while most ZS disorders are rapidly progressive and incurable, and patients rarely survive through their first birthday, many patients have late-onset and mild ZS phenotypes. Human PEX16 is an integral membrane protein first isolated by Honsho and plays a central role in peroxisomal membrane biogenesis. According to the few existing reports, the severity and the natural course of PEX16-mutated patients are unclear, and therapy has not been discussed. Herein and based on existing research, we report and discuss the case of a young female diagnosed with slowly progressive ZS involving a novel PEX16 mutation.

Objective: To investigate infection distribution of Pseudomonas aeruginosa on burned patients in our hospital as well as its drug resistance in order to provide reference of clinical use of antibiotics. Methods: Statistically analysed 481 Pseudomonas aeruginosa and their drug sensitive test results from burned patients who were sent to hospital from January 2004 to December 2006. Results: In our hospital, among those who were infected with pathogenic bacteria, the number of burned patients who suffered from Pseudomonas aeruginosa has increased each year. Such pathogen is resistant to a variety of broad-spectrum antibiotics at different degrees. From January 2004 to December 2006, the multiple drug resistance rate of Pseudomonas aeruginosa has also been increased. Conclusion: Pseudomonas aeruginosa is one of the major multiple drug resistant pathogenic bacteria that infects burned patients. This research shows that using antibiotics on patients who are infected with Pseudomonas aeruginosa is still the best way to slow its drug resistance.

Background: There is very little data in the literature on how to handle Dual Antiplatelet Therapy (DAPT) and newly adapted Drug Eluting Stents (DES) in patients in need of liver surgery due to malignant disease.

Case report: A man, 79 years of age, with a bleeding hepatocellular carcinoma in a normal liver, bleeding duodenal ulcer and Acute Coronary Syndrome (ACS). Coronary angiography showed significant stenoses in the left main coronary artery (LM), Left Anterior Descending (LAD), first and second diagonal branches (D1, D2), Circumflex (Cx) and Right Coronary Artery (RCA). The patient was treated with Percutaneous Coronary Intervention (PCI) including six everolimus eluting coronary stents, aspirin and ticagrelor followed by portal embolization two months after stenting and another two months later liver resection, bridging with the Glycoprotein Receptor Inhibitor (GPI) tirofiban. The portal embolization was uneventful but there were bleeding complications after liver surgery, calling for very close monitoring of the antithrombotic treatment under these complex conditions.

Discussion: Close monitoring and individualization of therapy was essential to make portal embolization and liver tumor surgery possible in this patient with DES and DAPT.