Year 2020, Volume 4 - Issue 11

Background: The incidence of acute upper gastrointestinal bleeding (UGIB) has declined over the recent decades, and nowadays, due to improved endoscopic treatment options, only 2.6% of the patients with UGIB need additional surgical or angiographic intervention. In this report, we present the case of UGIB, refractory to endoscopic treatment, caused by a primary aortoesophageal fistula. Case Presentation: A 72-year-old man with acute UGIB was referred to our clinic after unsuccessful endoscopic and surgical treatment in an external hospital. On admission, the patient showed prolonged hemorrhagic shock and abdominal compartment syndrome. An immediately conducted thoracoabdominal CT scan revealed a penetrating aortic ulcer of the descending aorta and the patient was transferred to the OR to undergo laparotomy. After confirmation of a primary aortoesophageal fistula as the origin of hemorrhage, an aortic stent graft was successfully placed to occlude the lesion. Despite severe blood loss and prolonged hemorrhagic shock, the patient recovered quickly and could be discharged on the 18th postoperative day. Conclusion: Primary aortoenteric fistula is an uncommon clinical condition with a high mortality requiring an interdisciplinary treatment approach.

Background: Kaposiform hemangioendothelioma (KH) is an uncommon tumor in infants and children. The typical clinical presentations include ill-demarcated, red to purple, indurated plaque and are frequently complicated by the Kasabach-Merritt phenomenon (KMP), a condition of severe thrombocytopenia and consumptive coagulopathy. It might be misdiagnosed as infantile hemangioma at birth, leading to a delay in delivering optimal treatment. Therefore, imaging differential diagnosis of KH should be included in pediatric patients presented with atypical vascular lesion for timely management. Case Presentation: We present a case of a 2-month-old male child, born with right lower limb hypertrophy and bluish discoloration, initially diagnosed as a hemangioma. Magnetic resonance imaging diagnosis was suggestive of KH complicated with KMP in correlating with clinical history. Therefore, optimal treatment is possible at a time if correct diagnosis is made early. Conclusion: KH should be retained as one of the differential diagnoses in pediatric patients presenting with vascular tumor. Imaging could help in reaching the diagnosis without invasive surgical interventions in order to initiate proper treatment.

Background: In some medical cases, psychotic symptoms can be part of the clinical picture, and sometimes it can even be the only clinical appearance of the medical condition. Psychotic disorders secondary to organic pathologies affecting the central nervous system are called psychotic disorders due to a general medical condition. While some of these secondary causes can easily be detected by laboratory and imaging methods, anamnesis or neurological examination (substance use, trauma, and tumors), others are often overlooked in the presence of rare medical conditions (autoimmune disease and viral encephalitis), when laboratory and examination findings are not clear and psychiatric symptoms are in the foreground. Case Presentation: In this case, we tried to reveal the differential diagnosis and treatment processes of a patient who was admitted to the emergency department with psychotic symptoms, such as agitation, aggression, and paranoid delusions, and was admitted to the psychiatry clinic after an urgent medical evaluation. After his admission to the psychiatry clinic, the medical evaluation of the patient was re-evaluated in detail due to memory and orientation deterioration, and as a result, clinical pictures such as Hashimoto’s encephalopathy, herpes encephalitis, and epileptic seizures were found to be together in the patient. As a matter of fact, both general medical and psychiatric statuses of the patient improved with the application of low doses and short term antipsychotic treatment for psychiatric symptoms together with the treatment for this underlying general medical condition. Conclusion: Since the treatment of psychiatric symptoms caused by secondary medical factors is quite different from the treatment of primary psychiatric disorders, it is important to make full medical evaluations, especially in patients presenting with psychiatric symptoms for the first time or presenting with emergency psychiatric symptoms.

Background: Rectus sheath hematoma (RSH) results from the accumulation of blood in the rectus sheath. It is often self-limiting but might be fatal sometimes. The aim of this study was to present two patients with RSH post-laparoscopic cholecystectomy (LC) who were managed expectantly with a long length of stay and blood transfusion. Case Presentation: Two females (47 and 52 years old) had undergone LC and developed RSH on postoperative days 1 and 3, respectively. Both were anemic and slightly tachycardic, with no other abnormalities. RSH was diagnosed in both cases with sizes 5.52 × 3.62 cm and 2.7 × 1.4 cm, respectively, shown on ultrasonography and CT scan of abdomen. The patients were treated conservatively, with blood transfusion. The patients were then discharged. Conclusion: RSH might develop post-LC; hence, surgeons should assess the patient’s complaints, labs, and physical examination to find RSH.

Background: Hemophilia B is a rare entity than other coagulation disorders. It is an X-linked disorder characterized by a deficiency of functionally active coagulation factor IX (FIX), resulting in spontaneous or trauma-induced bleeding primarily in joints, muscles, and soft tissues. Case Presentation: We report a case of a female who presented with a surgical problem. She had a history of massive transfusion many years back. She bled perioperatively and then we investigated her and luckily found the deficiency of FIX. She was managed and discharged home well. Conclusion: Surgeons rarely comes across this rare coagulation disorder, so this was an intriguing case in view of the unusual presentation, initial diagnostic dilemma, and challenges in management.

Background: Pregnant mothers with babies diagnosed to have Beckwith-Wiedemann syndromes (BWSs) have been reported in very few case reports in the literature. Case Presentation: This case report describes the course of two pregnancies in a woman with BWS. The main metabolic issues encountered were recurrent episodes of hypoglycemia and suspected diabetes insipidus in pregnancy. Labor and delivery were uneventful, but she had significant secondary postpartum hemorrhage on both occasions. Conclusion: This syndrome has not been studied in the antenatal period and its course in pregnancy is not well known. We discuss possible complications that women with this syndrome could present with, the need for blood glucose and urine monitoring, a multidisciplinary approach, and close liaison with medical colleagues to identify and treat metabolic complications early.

Background: Chronic myelomonocytic leukemia (CMML) is a rare malignant disorder that presents with splenomegaly in about 30% of cases. Case presentation: A 71-year-old man complained of abdominal pain, left hypochondrium distension, and weight loss. After work-up, a diagnosis of CMML was conducted, and the patient started chemotherapy. After about 2 years, he experienced clinical worsening compatible with symptomatic splenomegaly, and was proposed for radiotherapy. The patient underwent palliative splenic irradiation (SI), initially with 0.25 Gy fractions, delivered every other day, but the treatment was suspended after four fractions due to thrombocytopenia; 4 weeks later, the treatment was resumed, but was suspended again after 4 × 0.25 Gy fractions due to hematological changes. The patient was kept in palliative care and died 6 weeks later. Conclusion: SI has emerged as an alternative, widely used for palliation symptomatic splenomegaly in patients with hematological malignancies. This is the first report of SI for symptomatic splenomegaly on a patient with CMML.

Background: Gas emboli are both a rare cause of stroke and a rare complication following thoracoscopic surgery. There are only few case reports of this condition in the literature. Case Presentation: A 70-year-old female developed an acute alteration of conscious state with quadriparesis after thoracoscopic lung resection that used carbon dioxide insufflation. She developed clinical and radiological signs consistent with an embolic stroke of central origin. Progressive, partial neurological recovery was observed over several weeks. Conclusion: This case illustrates the usefulness of magnetic resonance imaging in diagnosing an unusual form of acute ischemic stroke and illuminating its pathophysiological mechanism.

Background: Atypical fibroxanthoma is a cutaneous benign tumor of uncertain lineage, occurring more frequently in elder men, in sun-exposed or irradiated skin. It appears as a slowly progressing nodule, and it is treated by total excision. Several histological types have been described including the myxoid atypical fibroxanthoma. Case presentation: A 73-year-old male presented at the plastic surgery department for excision of a single hard, centrally ulcerated, nodule on the right side of the scalp, 4.1 cm in maximum diameter growing slowly during the last years. The microscopical examination revealed a circumscribed, cellular tumor developing in the dermis. The cellular population consisted of spindle cells and histiocytes, without a specific growth pattern. Moderate cytologic and nuclear atypia were observed, combined with a relatively high mitotic rate. Also, many positive areas of myxoid degeneration detected with periodic acid Schiff and Alcian Blue stains were revealed. Immunohistochemistry showed positivity of the tumor cells for CD10, FXIIIa and focally for CD68, CD117, smooth muscle actin (SMA), and CD99. Tumor cells were negative for all the other assessed markers, including S-100 and Desmin. Ki-67 was 20%. Based on these morphological findings, the diagnosis of myxoid atypical fibroxanthoma was made. Conclusion: Atypical fibroxanthoma is a benign lesion, the diagnosis of which may be proved difficult and challenging. Moreover, when we deal with a rare histologic variant, such as the atypical fibroxanthoma with myxoid change, only the strict application of histological criteria combined with the immunohistochemical findings can lead us to the correct diagnosis, excluding malignant, easily recurring, and metastasizing neoplasms.

Background: Although peripheral precocious puberty has been reported due to untreated long-standing hypothyroidism in children with Down syndrome (DS), central precocious puberty (CPP) has been scarcely reported. The aim of this study is to describe our experience with this rare condition. Case presentation: Three patients (two males and one female) who were receiving treatment for hypothyroidism and admitted with signs of precocious puberty were recruited in the study. Clinical and laboratory findings were compatible with CPP in all three patients with DS. They were euthyroid during investigations for CPP. A male patient had periventricular millimetric focuses in the supratentorial region in cranial magnetic resonance imaging. The other male patient developed central adrenal insufficiency during fallow-up and hence hydrocortisone was added to the treatment. All patients were successfully treated with gonadotropinreleasing hormone analogs; no adverse effects have been observed. Conclusion: Our findings emphasize that CPP might be seen in rare cases with DS and hypothyroidism.