Year 2018, Volume 2 - Issue 3

Background: Pain is the most common symptom present at any stage of life. The pain can be divided into acute or chronic considering the duration of symptoms. Chronic pain approach is complex and it is a clinical challenge. Two main mechanisms are traditionally described: pain nociceptive (caused by ongoing tissue damage, somatic, or visceral) or neuropathic (damage or dysfunction in the nervous system). For the treatment of chronic moderate-severe pain, opioids are the standard treatment but the undesirable side effects cause a high discontinuation rate. Tapentadol was developed to improve the therapeutic range of opioids by adding two complementary mechanisms of action which seem to contribute to the reduction of side effects. Case Presentation: The authors describe three cases of neuropathic chronic pain. One case describes neuropathic pain caused by degenerative changes and osteoporotic fracture, the second case was a woman with an important renal impairment, who complained of generalized arthralgia (under cancer treatment), and a third case of a man presented with diminished muscle strength in the lower right limb, most probably due to chemotherapy-induced peripheral neuropathy. Conclusion: The management of chronic pain requires a multimodal approach, that is part of the individual as a whole, and a multidisciplinary approach is needed to relieve chronic pain with minimal side effects.

Background: Thyroid abnormalities may be the cause of unexplained pancytopenia. Routine hematologic evaluation should be performed before administration of anti-thyroid drugs in cases of clinical hyperthyroidism, to clarify any occurrence of unexplained pancytopenia. Case Presentation: An 82-year-old woman presented to the emergency department with general weakness, palpitations, excessive sweating, and weight loss. A complete work-up suggested the existence of hyperthyroidism due to toxic multinodular goiter with depletion of all three cell lines in peripheral blood count. Abdominal ultrasonogram showed no abnormal findings, including hepatosplenomegaly. Normocellular marrow was noted in bone marrow aspiration and biopsy. Conclusion: A combined drug therapy with methimazole 30 mg/day, parenteral dexamethasone 8 mg/day, beta-blockers, and digoxin was administered to the patient. Free Triiodothyronine (FT3) and Free Thyroxine (FT4) levels decreased gradually and pancytopenia improved within 2 weeks of treatment.

Background: Sex cord-stromal tumors are rare tumors of the testis and are often seen in the pediatric age group. Case Presentation: Right testicular mass was detected in the ultrasonography of a 19-year-old male patient who complained of pain and enlargement of the testis for 2 weeks. Tumor markers such as β-human chorionic gonadotropin, lactate dehydrogenase, and alpha-fetoprotein were within normal levels. The patient was diagnosed as undifferentiated type sex cord-stromal tumor after orchiectomy. Conclusion: Undifferentiated-type sex cord-stromal tumors are characterized by proliferations of incompletely differentiated sex cord or stromal elements. In the literature, reported cases histologically have predominantly spindle cell areas, but we did not identify any spindle cell areas in our case. Due to the limited number of published studies of these cases, the estimation of their frequency and behavior is difficult and their diagnosis may be challenging.

Background: Actinomycosis is a chronic granulomatous disease caused by an obligate anaerobic species from the genus Actinomyces. Case Presentation: We describe the case of a 36-year-old woman, who presented with recurrent episodes of abdominal pain since 2002. These bouts of abdominal pain increased in severity over the last 4 years, and the patient was subsequently diagnosed to have actinomycosis. Conclusion: Although intra-abdominal actinomycosis is very rare, it should be considered in the differential diagnosis of abdominal pain, particularly in any women using an intra-uterine device and presenting with abdominal pain or a pelvic mass. If actinomycosis is suspected preoperatively, appropriate handling and processing of cultures can increase the diagnostic yield and may save the patient from an extensive surgery.

Background: Ocular involvement, although common in sarcoidosis, granulomatous infiltration of the orbital tissue remains very rare. Case Presentation: We describe the case of a 55-year-old man who presented bilateral protrusion of eyeballs that had been evolving for 1 year. Clinical examination found an axial and non-pulsatile bilateral exophthalmos with cervical lymphadenopathy. CT and MRI showed infiltration of oculomotor muscles. Biopsy of salivary glands showed chronic inflammatory granulomatous infiltration without caseous necrosis. There was a significant rapid improvement with the use of a steroid as primary therapy. Conclusion: Sarcoidosis may be a part of exophthalmos causes, after ruling out the main causes which include: Graves' disease, carotid-cavernous fistula, tumors, and infectious causes.

Background: Popliteal artery entrapment syndrome is a common vascular pathology in young athletes which is usually diagnosed based on magnetic resonance angiography findings. Although three-phase bone scan is a sensitive imaging modality in high turnover osteoblastic conditions, it does not have an established role in evaluating chronic pain syndromes and vascular pathologies. Case Presentation: We report an atypical case of popliteal artery entrapment syndrome which was incidentally found in a patient who was evaluated for skeletal malignancy. Conclusion: This case emphasizes the importance of attention to the first two phases of bone scan despite normal whole body images.

Background: Iodine-131 (I-131) therapy is a well-established method for the treatment of differentiated thyroid cancer [carcinoma (CA)]. Following such therapy, patients may experience complications classified as early/intermediate or delayed side effects. We report an unusual side effect after oral I-131 therapy in the form of a skin eruption (iododerma). Case Presentation: We describe a case of a 60-year-old female, presented with pustular lesions all over skin after radioiodine therapy for CA thyroid. On the basis of history and clinical examination, diagnosis of iododerma was made. Conclusion: Iododerma is a very rare complication of radioiodine therapy. When pustular lesions develop after radioiodine therapy, iododerma should be kept in mind after the exclusion of other differentials. It appears within 4-6 weeks after therapy and is a self-limiting condition.

Background: Hippocrates advocated the use of a seton. Ksharsutra works as a cutting and draining seton, besides that, it has antimicrobial property and chemically cauterizes the unhealthy tissue lining the fistulous tract; and thus, decreasing the recurrence rate in cases of complicated fistula-in-ano. This study aims to diagnose the recurrent complicated case of fistula-inano, to treat the case by integrated method (Partial fistulectomy with Ksharsutra), to improve the quality of life of the young patient, and assess the result of Ksharsutra with trans rectal ultrasonography (TRUS). Case Presentation: This was a case of a 32-years-old male patient with recurrent horseshoe high anal fistula operated twice at a reputable hospital in Vellore (Tamil Nadu) arrived with seton in situ. On examination, a seton was seen at 6 o'clock and a scar was seen at 2 o'clock position. Partial fistulectomy was done along with Ksharsutra. On the 20th week, the Ksharsutra got cut through and the wound healed completely. There was no pus discharge and sphincter tone was within the normal limit. Post-operative TRUS showed no evidence of fistula. Conclusion: Ksharsutra was a successful integrated intervention in recurrent horseshoe fistula-in-ano.

Background: Rheumatoid arthritis (RA) is an immune-related inflammatory disease which affects almost 1% of the general population and which is ranked among the top 15% of diseases causing major disability worldwide. RA shares some pathologic features, genetic predisposition, and risk factors with atherosclerosis, and inflammation plays a central pathophysiologic role in both diseases. RA is associated with an increased risk of cardiovascular mortality. In RA, pericardial involvement is a frequent complication but rarely occurs as the first manifestation. Case Presentation: A 63-year-old male patient with RA presented with an acute chest pain and in the Electrocardiography (ECG) ischemic ST-down-sloping in multiple leads. Echocardiography showed an abnormal "bounce" of the interventricular septum and a small-medium size pericardial effusion. The laboratory values showed high inflammatory parameters and confirmed the presence of active RA. Troponin T was normal and NT-proBNP was at level 2. There were no signs for vasculitis. Coronarography found only small non-stenotic changes in the coronary arteries. A rheumatologic consultant recommended prednisone and later on, tocilizumab. He was also treated with colchicine. The clinical condition improved within 2 weeks and the ECG changes normalized within a month. Three months later, an echocardiographic follow-up showed that the pericardial effusion and the left ventricular bounce had disappeared. Conclusion: Small-medium size pericardial effusion manifesting as an acute coronary syndrome and with ischemic ECG changes is the most unusual finding. Indeed, the proper diagnosis of a pericardial effusion was made retrospectively