Journal of Clinical Case Reports

To reveal Cushing’s syndrome in pregnancy is difficult since there are no worldwide consent guidelines for making a definitive diagnosis. Some advocate using urine free cortisol as more than four times the upper limit of normal or salivary cortisol is two to three times above. It is also difficult to evaluate the optimal time of surgical intervention because most cases are diagnosed at or beyond their second trimester. In the case describe below, the disease was being suspected because there was a lost circadian variation of serum cortisol, which could be a reasonable initiate test for clinical suspicious cases in our further practice.

Delayed neuropsychiatric sequelae (DNS) after acute carbon monoxide (CO) poisoning is a complication of CO intoxication. Hyperbaric oxygen (HBO) therapy is one of the only established treatments for CO poisoning, but as there is no specific treatment for DNS, the prognosis of DNS patients is generally poor. A 40-year-old male patient, following attempted suicide by CO poisoning, was referred to our department after having received HBO therapy at another hospital, but treatment had been subsequently discontinued due to patient agitation. The patient was diagnosed with DNS after acute CO poisoning, and we reinitiated HBO therapy. However, due to manifestation of symptoms of severe dementia, treatment was discontinued. After initiating thyrotropin-releasing hormone (TRH) therapy, psychiatric symptoms, such as difficulty in following instructions, improved, enabling the resumption of HBO therapy. Daily activities returned to premorbid levels following treatment. Thus, TRH therapy could be effective for patients with DNS due to acute CO poisoning who experience difficulty with HBO therapy.

We here report a case of esophageal perforation at the first esophageal stenosis in a 73-year-old patient with right aortic arch and permanent pacemaker. Although treated with fasting, gastrointestinal decompression, antiinflammation and fluid replacement etc., the symptom is not improved. So, surgery is taken to clean the mediastinum abscess and used mediastinal drainage under the thoracoscope. The patient was discharged on postoperative day 30. Multiple factors restrict the treatment plan of this disease. The most important points are early diagnosis, applicable operation scheme and efficient chest drainage.

Introduction: Gossypiboma is a serious but uncommon complication of surgical interventions. Most case reports and reviews refer to abdominal or thoracic surgery. Retained postoperative foreign bodies in limb or spine surgery are less commonly encountered. We present a case of gossypiboma in a paraplegic patient originating from pararectal surgery and detected 15 years after index surgery for infectious migration to the left thigh.

Case Presentation: A 56-year-old paraplegic patient with complete sensory deficit in both legs presented with signs of an infected haematoma at the left thigh. At the time of surgical evacuation cotton tissue originating from a surgical gauze swab was retrieved. After a thorough investigation of the patient’s medical history, polytrauma treatment consisting of emergent laparotomy with abdominal gauze packing in 1986 and surgical treatment of a fistulating pararectal abscess in 2001 were stated possible origins of the intraoperative findings. Further surgical interventions with a more extended approach were necessary. Another gauze tissue conglomerate was found next to the ischial tuberosity, revealing the surgical treatment of a pararectal abscess (developed from sacral decubiti) as the origin of the retained gauze swabs.

Conclusion: Retained surgical gauze (RSG) swab is a serious and, due to medicolegal reasons, underreported complication of surgical intervention. Diagnosis can be challenging because patients may present with only vague symptoms. In the presented case, the patient remained asymptomatic for 15 years, mainly due to his paraplegia. Prevention of RSG is far more important than cure. Awareness of the problem, staff training and the use of preventive measures as radiopaque labelled gauze swabs or monitored counting should be mandatory in every surgical intervention.

Introduction: Gossypiboma is a serious but uncommon complication of surgical interventions. Most case reports and reviews refer to abdominal or thoracic surgery. Retained postoperative foreign bodies in limb or spine surgery are less commonly encountered. We present a case of gossypiboma in a paraplegic patient originating from pararectal surgery and detected 15 years after index surgery for infectious migration to the left thigh. Case Presentation: A 56-year-old paraplegic patient with complete sensory deficit in both legs presented with signs of an infected haematoma at the left thigh. At the time of surgical evacuation cotton tissue originating from a surgical gauze swab was retrieved. After a thorough investigation of the patient’s medical history, polytrauma treatment consisting of emergent laparotomy with abdominal gauze packing in 1986 and surgical treatment of a fistulating pararectal abscess in 2001 were stated possible origins of the intraoperative findings. Further surgical interventions with a more extended approach were necessary. Another gauze tissue conglomerate was found next to the ischial tuberosity, revealing the surgical treatment of a pararectal abscess (developed from sacral decubiti) as the origin of the retained gauze swabs. Conclusion: Retained surgical gauze (RSG) swab is a serious and, due to medicolegal reasons, underreported complication of surgical intervention. Diagnosis can be challenging because patients may present with only vague symptoms. In the presented case, the patient remained asymptomatic for 15 years, mainly due to his paraplegia. Prevention of RSG is far more important than cure. Awareness of the problem, staff training and the use of preventive measures as radiopaque labelled gauze swabs or monitored counting should be mandatory in every surgical intervention.

Paragangliomas are rare tumors representing a therapeutic challenge. We present a case report of surgical resection of carotid body tumor without preoperative embolization. Our therapeutic attitude is based on controversial benefits of the embolization for those tumors. The major indication for the preoperative embolization is to reduce intraoperative blood loss, but this benefit is not demonstrated. Also, because the relative rarity of this tumor, the confounding factors relative to the surgeon and radiologist experience, no randomized trial can be performed. So, our case report can be useful to participate to increase the number of reported cases, and define the therapeutic approach for this rare tumor.

Grave’s disease is an autoimmune thyroid disease with multi-system involvement. It’s manifestations are diverse, including liver function abnormalities and association with other autoimmune disease. The objective of this report is to present an unusual case of Grave’s disease with PSC. This is a 28-year-old woman that present with cholestatic jaundice along with signs and symptoms of thyrotoxicosis. She diagnosed to have Grave’s disease with PSC. Despite an initial high bilirubin, treatment with antithyroid agents in addition to Ursodeoxycholic acid led to marked improvement in her clinical status and bilirubin level. The proposed mechanisms underlying the association of Grave’s disease with PSC are discussed and the literature on similar cases is highlighted. Both Grave’s disease and PSC have been shown to be associated with other autoimmune mediated diseases. This case report shows an association between Grave’s disease and PSC whether due to an underlying immune-genetic predisposition or coincidence. Further studies are needed to investigate this association.

Background: Severe nausea and vomiting in the first and second trimester of pregnancy is often diagnosed as hyperemesis gravidarum (HG), although true HG only appears in very few pregnancies. Anchoring, the tendency for clinicians to stick with an initial diagnosis even as new information becomes available, can lead to hesitation to perform MR-imaging in pregnant patients. As prompt diagnosis of intracranial neoplasm increases the chance on a favourable outcome, awareness among doctors is needed. Scant data on pregnant patients diagnosed with brain tumours is available; this case report pays attention to possible pitfalls for doctor’s delay.

Case summary: A 36-year-old G2PO presented with severe nausea, vomiting and vertigo in the first and second trimester of pregnancy after IVF-treatment. An increase of symptoms, headaches and a lurched walking pattern were initially attributed to dehydration, orthostatic hypotension and later to a proven B12 deficiency. When symptoms worsened despite vitamin suppletion and drowsiness and bradyphrenia developed, a MR-scan of the brain showed severe obstructive hydrocephalus caused by a mass in the fourth ventricle. Surgical resection of a ganglioglioma (WHO grade I) was performed at a gestational age of 25 weeks.

Conclusion: HG typically resolves around the 20th week of gestation, therefore persistent nausea and vomiting during pregnancy warrants a cerebral MR-scan in order to exclude neurological causes.

NPHS1 gene is the gene responsible for production of Nephrin, which has role in the structure of glomerular filtration barrier. Nephrin located in slit diaphragm, which has a role in preventing passage of plasma proteins out of glomerular capillaries.

Objective: To determine the frequency of upper gastrointestinal bleeding in elderly patients with iron deficiency anemia present at Liaquat University Hospital Jamshoro.

Subject and methods: Total 100 subjects of conformed upper gastrointestinal bleeding aged 60 years and above, with iron deficiency anemia were enrolled in the study. All other patients who were not meet to inclusive criteria were excluded from study, all patients were subjected to thorough checking of blood CP, ferritin. All patients were than undergone, upper GI endoscopy in which presence/absence of bleeding site determined, data were analyzed on SPSS version 16.

Results: A total of 100 subjects with iron deficiency anemia were examined in this study. Overall 91% had upper gastrointestinal findings at endoscopy. Out of 100 subjects, 62 (62%) were males and 38 (38%) were females. Out of these 42 (42%) had got bleeding source in the stomach, 36 (36%) patients had bleeding source in the duodenum, 13 patients had got bleeding source in the esophagus the remaining 9 patients had got no source of bleeding after thorough upper GI endoscopy. Out of 62 males, 26 (41.93%) had bleeding source in the stomach, 22 males (35.48%) had Bleeding source in the duodenum, 8 (12.90%) had bleeding source in the esophagus and 6 (9.67%) males had no lesion identified. While in total 38 females, 16 (42.1%) had bleeding source in the stomach, 14 (36.84%) had bleeding source in the duodenoum, 5 (13.15%) had Bleeding source in the esophagus and 3 (7.89%) had no bleeding source identified. The mean age of the patients recruited in this study was 66.9 with standard deviation of 6.47 with minimum 60 and maximum 80 years. Males are affected more than females. Maximum number of the patients with UGIB fall in 60-65 years age groups. Males and females between 60-65 years were found to have UGIB in stomach.

Conclusion: In this study, it was conducted that frequency of blood loss in elderly is from stomach followed by duodenum and esophagus. Upper GI endoscopy is investigation of choice in evaluation of patients suspected as bleeding from Upper gastro intestinal tract.

A postoperative maxillary cyst (POMC) is a benign lesion arising from trauma or surgery involving the midface, specifically the maxillary antrum, as a late complication. It is usually locally aggressive, and accounts for approximately 20% of the lesions seen in Japanese patients undergoing extensive maxillary sinus surgery. According to the available literature, the insertion of mucosal cells between the bony edges of a fracture or osteotomy may result in the cystic degeneration that precedes this type of lesion. The clinical and histological characteristics of a POMC are often mixed, with fibrous connective and myofibroblastic tissue in the surrounding anatomy, which could make the diagnosis difficult or misleading.

Maxillary obturator prosthesis is the most frequent treatment option for management of partial or total maxillectomy. In cases of larger defects, a hollow bulb obturator is used. But what if there is a limited mouth opening is added to it? In such cases the use of an inflatable obturator is advised. This case report presents a method to fabricate the inflatable obturator.

Introduction: Pancreatic heterotopia is a rare pathological entity and its localization in gall bladder is extremely rare. It is mostly asymptomatic incidental finding and rarely gives rise to complications. It can be associated with incidental finding or can be symptomatic or may cause complication. Heterotopic pancreas (HP) also referred to as ectopic pancreas, pancreatic choristoma, or pancreatic rest, is defined as the aberrantly located pancreatic tissue in an anomalous location without any anatomic, vascular, or neural continuity with the main body of the normal pancreas. The most common location for HP is the duodenum, upper jejunum and stomach.

Case report: A 35 year male was admitted to the Surgical Department of Era’s Lucknow Medical College and Hospital for an elective laparoscopic cholecystectomy. He had complains of sporadic flatulence after meals and belching. His gall bladder was resected post an USG revealing Gall stones and sent for histopathology where he was diagnosed as a case of heterotopic pancreas in the GB neck with chronic cholecystitis.

Discussion: Localization of pancreatic heterotopia in gall bladder is the second most prevalent pancreatic anomaly but an extremely rare finding. The incidence in gastrointestinal tract is estimated to be from 0.55% to 13.7% on autopsy, and 0.2% in laparatomy. Most commonly these are incidental findings but some studies have implicated them as causative factors in the genesis of cholecystitis, obstructions etc.

Conclusion: HP of the gallbladder may cause clinical symptoms such as cholecystitis as well as complications which can be fatal and hence this condition should be taken into consideration in patients with symptomatic gallbladder disease.