Journal of Clinical Case Reports

We here reported a chronic schizophrenia patient who occurred neutropenia 13 years after starting clozapine. Thus, once clozapine is administered, the lifelong regular monitoring of the patient’s total WBC count should be done.

A 46-year-old Japanese woman on dialysis for type 1 diabetes and chronic renal failure underwent simultaneous pancreas and kidney transplantation from a brain-dead donor. On postoperative day 3, ilio-femoral deep vein thrombosis on the side of pancreatic transplantation was diagnosed from swelling of the right leg, an increased D-dimer level, and imaging findings. Anticoagulant therapy was initiated to prevent proximal propagation of the thrombosis and pulmonary thromboembolism. However, gastrointestinal bleeding occurred, which was thought to be due to mucosal bleeding from the duodenal graft. Her anticoagulant therapy was adjusted and hemostasis was conducted, controlling the gastrointestinal bleeding without surgical intervention. Blood flow was maintained to both grafts and graft function was good. When gastrointestinal bleeding occurs during anticoagulant therapy for deep vein thrombosis after combined pancreas and kidney transplantation, bleeding can be controlled by adjusting anticoagulant therapy and other appropriate measures.

Introduction: Adult onset Still’s disease (AOSD) is an inflammatory disorder of unknown etiology. Macrophage activation syndrome (MAS) is a complication of AOSD and may present with multiorgan failure including cerebral involvement.

Clinical presentation: We describe a 43-year-old female patient with major depression treated with electroconvulsive therapy (ECT). She presented with febrile pharyngitis, arthralgia, rashes, lymphadenopathy, hepatosplenomegaly, liver failure and aseptic meningitis. Elevated serum ferritin and negative blood cultures were consistent with the diagnosis of AOSD complicated by MAS. The patient was treated with corticosteroids and anakinra and recovered rapidly.

Conclusion: The case highlights aseptic meningitis, depression and multiorgan failure as a feature of AOSD/ MAS possibly triggered by ECT. Anakinra is an effective treatment in severe MAS.

The need to manage acute pain in older patients is becoming increasingly frequent in postoperative intensive care units. Older population is extremely sensitive to opioid adverse effects. Therefore, intravenous infusion of lidocaine might be a useful tool in this scenario. We present the case of an ICU older patient after urgent abdominal surgery. Pain management with opioid therapy was extremely complex with serious adverse effects. Intravenous lidocaine infusion not only proved to be effective but also allowed an enhanced postoperative recovery.

Background: Diaphragmatic hernia is a rare complication after hepatic radiofrequency ablation (RFA). We herein present a case of a patient who underwent laparoscopic repair of diaphragmatic perforation with colonic herniation occurring 12 months after hepatic RFA.

Case presentation: An 80-year-old man underwent RFA under computed tomography guidance using a cool-tip radiofrequency probe with a short trans-thoracic root for hepatocellular carcinoma in segment VIII. Twelve months later, he developed a large amount of right pleural effusion and a right diaphragmatic hernia containing the colon and mesentery. After drainage of the right pleural effusion, the patient underwent laparoscopic repair of the diaphragmatic perforation with colonic herniation. Severe adhesion was noted between nearly the entire herniated colon and lung; however, we were able to remove the herniated colon from the thoracic cavity safely. Bowel resection was not required. Finally, simple running sutures of the diaphragmatic defect using 2-0 Vicryl were laid down. There were no postoperative complications, and the patient was discharged nine days after surgery.

Conclusions: Diaphragmatic hernia is rare but should be recognized as a late complication following hepatic RFA. Surgical repair of a diaphragmatic hernia, including minimally invasive surgery using the laparoscopic approach, especially for patients with cirrhosis, should be considered in order to avoid acute intestinal obstruction or perforation.

An 80-year-old fit male with known long-standing stable chronic lymphatic leukaemia (CLL) presented with a rapidly enlarging left neck mass. The mass invaded the neck skin and began to fungate reaching to 10 cm in less than 3 weeks. Whilst head and neck skin SCC can metastasise to the regional lymph nodes (including to the contra-lateral side) rapid growth as occurred in this case is exceptionally rare and to our knowledge has not been previously reported.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an important treatment option for patients with abdominal neoplasms and peritoneal dissemination of disease. However, there are considerable anesthetic risks to the procedure due to the significant temperature fluctuations and fluid shifts. We present a case of a patient with newly diagnosed severe mitral regurgitation who successfully underwent CRS/ HIPEC.

A 64 year old male patient presented to our hospital for evaluation for CRS/HIPEC due to mucinous appendiceal neoplasm with peritoneal dissemination. The preoperative assessment found a severe mitral regurgitation with preserved left ventricular systolic function. The patient was asymptomatic and it was decided to proceed with CRS/ HIPEC. However, the hyperthermia and significant intraoperative fluid shifts associated with a HIPEC procedure were concerning for potential cardiac decompensation and pulmonary edema. The intraoperative goals were to maintain heart rate, reduce afterload, and avoid volume overload. A preoperative thoracic epidural catheter was placed for pain management. Additional monitoring included the post-induction placement of a pulmonary artery catheter and transesophageal echocardiography probe. Anesthesia was maintained on isoflurane and an epidural lidocaine infusion with intermittent epidural fentanyl boluses. Fluid management was guided by cardiac filling pressures, urine output, serial arterial blood gases, and transesophageal echocardiography. Nitroglycerin boluses and infusion were used to decrease afterload. The patient tolerated the surgery well without any cardiac decompensation; he was extubated in the operating room and taken to recovery. No immediate postoperative complications were observed.

The case report documents that patients with significant cardiac co-morbidities can successfully undergo CRS with HIPEC. Pre-HIPEC systemic hypothermia can be utilized in these patients with advanced hemodynamic monitoring. It appeared advantageous to involve the complete anesthesia team early to allow multi-disciplinary planning of the perioperative course.

Background: Solid-pseudopapillary neoplasms (SPNs) of the pancreas are a relatively rare type of tumor with low-grade malignant potential. Although surgical resection provides a cure in most of cases, the safety and efficacy of surgical treatment for tumors with major arterial involvement remains unknown.

Case presentation: A 30-year-old man with a preoperative diagnosis of SPN was referred to our department. Abdominal computed tomography (CT) revealed a lobulated mass located at the pancreatic body, with a maximum diameter of 11 cm. The celiac artery (CA) and splenic artery (SA) were surrounded (by approximately 270° and 360°, respectively) by an expansively growing tumor, while the common hepatic artery (CHA), superior mesenteric artery (SMA) and superior mesenteric vein (SMV) were contacted by the tumor for a distance of 26.6, 42.8, and 43.5 mm, respectively on CT. The arterial walls of the CHA and SMA were smooth without any irregularity; however, narrowing and irregularity of the SA was present. The imaging findings strongly suggested an SPN of the pancreas; the involvement of the SA, CA, SV and SMV by the tumor was suspected. Distal pancreatectomy with celiac axis resection was planned. After laparotomy, the CHA, SMA, CA, and SMV were safely preserved, and the tumor was resected by distal pancreatectomy alone. A pathological examination confirmed that the tumor was an SPN with a malignant component. Although the tumor pathologically invaded the retropancreatic tissue, splenic artery and splenic vein, the resected margin was negative.

Conclusion: Although the preoperative examination delineated the gross expansion of an SPN around the CA, CHA, and PV, these vessels were safely preserved during pancreatectomy. This case suggests that the surgical resection of the SPN may occasionally be attempted; even in cases with compressed and deviated by the tumor.

Blastomycosis-like pyoderma (BLP) is a rare, exaggerated, vegetative tissue reaction that occurs in patients with local or systemic immune dysregulation. Reported causes of immune compromise include human immunodeficiency virus, malnutrition, alcoholism, leukemia, immunosuppressant use, radiation therapy, and others. Nearly all cases involve an underlying, prolonged pyogenic bacterial infection. Historically monotherapy with systemic antibiotics requires long-term treatment and often fails. We describe a case of a male patient with BLP of the face and scalp, which cultured positive for methicillin-resistant Staphylococcus aureus (MRSA). Subsequent evaluation uncovered a concurrent Treponema pallidum and HIV infections. Treatment of the MRSA with a short course of doxycycline and the syphilis with penicillin, resulted in complete resolution of the skin lesions. Highly Active Anti-Retroviral Therapy for HIV was initiated after the skin lesions had cleared. Resolution of BLP by antibiotic therapy alone in the context of untreated HIV leads the authors to postulate that syphilis may have been the relevant factor contributing to his immune dysregulation.

Manifest accessory pathways that conduct antegrade-only account for less than 5% of all bypass tracts. We present a case of a 25-year-old patient presented with manifest accessory pathway. During electrophysiological study, there was no retrograde conduction over the accessory pathway that was successfully ablated through a subclavian venous access.

Hydatidosis is a parasitic infection due to the development of the larval form of Echinococcus granulosus. It is still a public health problem in endemic countries, particularly around the Mediterranean. The diagnosis is sometimes delayed. This depends on the hydatid site and the on the symptoms. But it relies essentially on the existing imaging techniques. The cardiac localization is rare. In most of the cases it is found on the left ventricle (LV). We report the case of an intramyocardial hydatidosis in a 57-year-old patient who had been suffering from an on-exertion dyspnea with chest pain for over 5 years. The patient underwent a resection of the cyst by sternotomy under extracorporeal circulation. Albendazole, an anti-parasitic medical treatment, was prescribed postoperatively. Histopathological examination confirmed the diagnosis of pericardial hydatid cyst. Postoperative control imaging demonstrated an intra-myocardial residual cyst.

Jejunogastric intussusception (JGI) is a rare life-threatening complication of gastrectomy or gastrojejunostomy. Diagnosis of this condition has been reported to be difficult in most of the cases. An early diagnosis and urgent surgical intervention are essential to avoid mortality. We present a case of the characteristic US and CT findings of this entity.

Snapping pes syndrome is rarely seen after total knee arthroplasty which can be confused as periprosthetic joint infection. In our case report; after the exclusion of the possible pathologies, we performed dynamic ultrasound for detection of snapping. After the confirmation, we chose a different treatment modality other than the only case report in the literature which suggests the revision of the components. We preferred a minor approach without arthrotomy by the excision of the ostophyte and tenotomy made by different incision than the index surgery. The patients complaints and pain have been improved dramatically after the time of surgery.