Two cases of gastrointestinal perforation after radiotherapy in patients receiving tyrosine kinase inhibitor for advanced renal cell carcinoma

ABSTRACT: We report two cases of gastrointestinal perforation (GIP) after radiotherapy in patients receiving tyrosine kinase inhibitor (TKI) for advanced renal cell carcinoma (RCC). Case 1 was a 61-year-old woman with lung metastases after a radical nephrectomy for a right RCC (cT3aN0M0) treated with interferon-alpha (OIF, 5 MIU, three times per week). She developed lytic metastases of the left femur and the left acetabulum. She was treated with palliative radiotherapy to the metastatic portion (3 Gy [MULTIPLICATION SIGN] 10 fractions), and 400 mg sorafenib twice per day plus continuing interferon alpha. She experienced sudden left lower abdominal pain after four weeks of treatment, and was diagnosed with a perforation of the sigmoid colon with fecal peritonitis. Case 2 was a 48-year-old man with lung, lymph node, and bone metastases after a radical nephrectomy for a right RCC (cT2N0M0), and was treated with 400 mg sorafenib twice per day. He developed lytic bone metastases of the lumbar vertebrae, which was treated with palliative radiotherapy to L2-4 (3 Gy [MULTIPLICATION SIGN] 10 fractions). He experienced sudden abdominal pain after two months of radiation treatment, and was diagnosed with a perforation of the sigmoid colon with fecal peritonitis. These cases underwent radiotherapy, and therefore this may be related to the radiosensitivity of TKI.     

Acute abdomen due to primary omentitis: a case report

Background

Idiopathic segmental infarction of the greater omentum (ISIGO) is an uncommon cause of acute abdomen in children and adults and its etiology is rather vague and speculative. The clinical presentation is usually with atypical acute or subacute abdominal pain. In a number of cases radiologic imaging allows proper preoperative diagnosis and treatment.

Case presentation

We report a case of ISIGO in a 31 year old patient, who presented with acute abdominal pain, nausea, vomiting and leukocytosis. Radiologic investigation was non-specific. The patient underwent surgical resection of the infracted omentum with compete recovery.

Conclusion

ISIGO should be considered in the differential of acute abdomen especially when presentation is atypical and all other causes have been excluded. In cases with non-specific radiologic findings, laparotomy is necessary for proper diagnosis and treatment. Surgical resection of the infracted omentum results in uneventful recovery in the majority of cases.

     

Manganese Intoxication

We have reported two cases of chronic manganese poisoning. Case 1 followed exposure to manganese fumes in cutting and burning manganese steel. Case 2 resulted from exposure to dusts of manganese dioxide, an ingredient used in glazing of ceramics. There were initial difficulties in establishing the correct diagnosis. Prominent clinical features were severe and persistent chronic depressive psychosis (Case 1), transient acute brain syndrome (Case 2) and the presence of various extrapyramidal symptoms in both cases.Manganese intoxication has not previously been reported as occurring in California. With increasing use of the metal, the disease should be considered in the differential diagnosis of neurologic and psychiatric disease.Our observations were made in the period 1964 through 1968. Recently the prognosis of victims of manganese poisoning has been improved dramatically by the introduction of levodopa as a therapeutic agent.     

Acute transient non-physiological over-sensing in the ventricle with a DF4 lead

The DF-4 is a new defibrillator lead technology. We present two cases of non-physiological transient ventricular over-sensing in patients who underwent implantation of an ICD for secondary prevention. Case 1 had ventricular over-sensing during pacing threshold evaluation post defibrillation testing while Case 2 had the lead integrity alert triggered immediately post discharge with transient over-sensing. No lead-connector issues were found. Case 1 was likely due to improper venting of the header and trapped air. Case 2 was hypothesized to be due to intermittent header pin non-contact secondary to blood in the header. These cases reveal that DF-4 leads are subject to both reported and potentially novel causes of transient acute ventricular over-sensing.     

Fine needle aspiration cytology of primary epithelioid sarcoma. A report of 2 cases

BACKGROUND: Epithelioid sarcoma is a rare soft part tumor, the cytologic features of which have not been fully elucidated to date. We describe the cytologic features in 2 cases of primary epithelioid sarcoma with samples obtained by fine needle aspiration (FNA). CASES: Case 1 was a 50-year-old male who complained of a small mass in his left palm. Case 2 was a 56-year-old female who presented with a mass on the medial aspect of her right forearm. Preoperative FNA smears in both cases showed loose, aggregated and isolated tumor cells that were round to polygonal, with eccentrically located nuclei, against a background of inflammation and necrosis. The tumor cells showed moderate atypia, irregularity in size and many mitoses. In case 1 a presumptive diagnosis of epithelioid sarcoma was made by FNA cytology, while in case 2, FNA cytology revealed a high grade sarcoma with abundant matrix mimicking osteoids, difficult to differentiate from an extraskeletal osteosarcoma. CONCLUSION: Epithelioid sarcoma may be difficult to differentiate from an extraskeletal osteosarcoma in cases with abundant hyalinized collagen on FNA cytology.     

Application of magnetic motor stimulation for measuring conduction time across the lower part of the brachial plexus

Introduction

Medial antebrachial cutaneous nerve (MACN) neuropathy is reported to be caused by iatrogenic reasons. Although the cases describing the posterior branch of MACN neuropathy are abundant, only one case caused by lipoma has been found to describe the anterior branch of MACN neuropathy in the literature. As for the reason for the forearm pain, we report the only case describing isolated anterior branch of MACN neuropathy which has developed due to repeated minor trauma.

Case presentation

We report a 37-year-old woman patient with pain in her medial forearm and elbow following the shaking of a rug. Pain and symptoms of dysestesia in the distribution of the right MACN were found. Electrophysiological examination confirmed the normality of the main nerve trunks of the right upper limb and demonstrated abnormalities of the right MACN when compared with the left side. Sensory action potential (SAP) amplitude on the right anterior branch of the MACN was detected to be lower in proportion to the left. In the light of these findings, NSAI drug and physical therapy was performed. Dysestesia and pain were relieved and no recurrence was observed after a follow-up of 14 months.

Conclusion

MACN neuropathy should be taken into account for the differential diagnosis of the patients with complaints of pain and dysestesia in medial forearm and anteromedial aspect of the elbow.     

The 4q-Syndrome

The 4q-Syndrome: Here we report four cases of interstitial and terminal deletions of the long arm of chromosome 4. Case 1 is a 16 month old boy with del(4)(q12q21) who has soft dysmorphic features, tetralogy of Fallot, and severe developmental delay. Case 2 is a male infant with the same deletion and congenital cardiomyopathy. He suffered severe birth asphyxia and died at the age of 6 months. His father was found to have a complex chromosome 4 rearrangement. Case 3 is a female infant with del(4)(q33) who died of aspiration pneumonia. She was mildly dysmorphic and presented with heart failure and hypercalcaemia. Case 4 is a 8 month old girl who has del(4)(q33) and Pierre-Robin sequence. So far about 70 patients with microscopically visible deletions of chromosome 4q have been described. Although they vary in their phenotypes, they have several features in common. We suggest to use the term 4q-syndrome for all macrodeletions of the long arm of chromosome 4.     

AMEBIASIS MASQUERADING AS APPENDICITIS

In fifteen cases of amebiasis masquerading as appendicitis, the important findings were nausea, vomiting, epigastric pain, pain in the right lower quadrant of the abdomen, fever, and leukocytosis.Amebiasis ought to be considered and appropriate studies carried out in differential diagnosis of cases in which symptoms indicate acute, subacute or “chronic” appendicitis. Depending on indications, the studies should include radiography with barium enema, sigmoidoscopy, complement fixation test, a minimum of nine stool examinations, a stool culture, and examination of purged stools unless this is contraindicated.     

X-ray endovascular surgery of the right ovarian vein syndrome]

The author analyzes the causes of the disorders in the urodynamics and retention changes in the upper urinary routes of 43 infertile women who suffered from disordered venous reno-ovarian circulation. In chronic phlebostasis of the pelvic organs a compensatory varicose dilatation of the right ovarian vein, mediating the hemodynamic decompression of the venous bed of internal genitals, is responsible for the development of the venous compression syndrome of the right ureter. To correct the vasourethral conflict roentgenoendovascular embolization of the left ovarian vein was carried out. In the remote postembolization period 40 women presented without pain or urodynamic disorders and with normal urinalyses, in 3 women the right ureter dilatation persisted but had not progressed.     

Primary central nervous system angiosarcoma: two case reports

ABSTRACT: INTRODUCTION: Primary angiosarcoma of the brain is extremely rare; only 15 cases have been reported inadults over the last 25 years.Case presentationsWe describe two cases of primary angiosarcoma of the brain that are well characterized byimaging, histopathology, and immunohistochemistry. Case 1: our first patient was a 35-yearoldwoman who developed exophthalmos. Subtotal resection of a left extra-axial retro-orbitalmass was performed. Case 2: our second patient was a 47-year-old man who presented to ourfacility with acute visual loss, word-finding difficulty and subtle memory loss. Aheterogeneously-enhancing left sphenoid wing mass was removed. We also review theliterature aiming at developing a rational approach to diagnosis and treatment, given the rarityof this entity. CONCLUSIONS: Gross total resection is the standard of care for primary angiosarcoma of the brain. Adjuvantradiation and chemotherapy are playing increasingly recognized roles in the therapy of theserare tumors.     

Association of cytokines with endothelium dependent flow mediated vasodilation (FMD) of systemic arteries in patients with non-ischemic cardiomyopathy

Background

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levels

Case presentation

A 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.

Conclusion

Takotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.     

Rectal examination in patients with pain in the right lower quadrant of the abdomen.

OBJECTIVE--To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen. DESIGN--Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital. SETTING--District general hospital. PATIENTS--1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission. MAIN OUTCOME MEASURES--Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis. RESULTS--Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination. CONCLUSION--If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.     

急性非胆源性胰腺炎病因研究及BISAP预后评估

目的：探讨急性非胆源性胰腺炎病因并对其预后进行BISAP（Beside Index of Severe Acute Pancreatitis）评估。方法：回顾性分析2006年7月~2010年7月我院收治的108例急性非胆源性胰腺炎患者临床资料,并结合BISAP评分对其预后予初步评估。结果：发病病因：大量饮酒及暴饮暴食52例;高脂血症27例;药物12例;妊娠1例;十二指肠憩室1例;诱因不明15例。重症急性胰腺炎8例,5例由暴饮暴食、酗酒所致,2例为高脂血症,1例为十二指肠憩室引起;其中有6例BISAP评分≥3分。结论：明确病因对预防复发、降低胰腺炎并发症、病死率具有重要意义。BISAP评分有利于重症胰腺炎风险早期预测。     

阑尾残株炎9例的临床观察

目的：总结阑尾残株炎的病因、诊断方法、预防和治疗措施,为临床提供更多的参考依据。方法：回顾性分析我院2011年1月～2013年1月收治的9例阑尾残株炎患者的临床资料,并查阅相关文献,总结阑尾残株炎的病因和诊疗方法等。结果：阑尾残端过长（〉1cm）是导致阑尾残株炎发生的主要原因。结合血常规、钡剂灌肠透视、CT、彩超等检查,必要时行腹腔镜探查可确诊阑尾残株炎。及时行手术切除阑尾残株是阑尾残株炎主要治疗方法。本组5例患者行传统开腹阑尾残端切除术（残端双重结扎,保留残端0．2～0．3cm）,2例行腹腔镜阑尾残端切除术（钛夹夹闭阑尾残端,保留阑尾残端0．2～0．3cm）,2例行部分盲肠切除术,回盲部留置引流管。2例患者出现切口感染,9例患者均痊愈。结论：预防阑尾残株炎的主要措施是是尽量完善阑尾切除手术。对已行阑尾切除术的患者再次出现右下腹部疼痛时等类似阑尾炎症状时,临床医生应考虑阑尾残株炎的可能,进一步行钡剂灌肠透视检查及腹部超声等辅助检查,必要时行腹腔镜腹腔探查以确诊,并应根据患者具体情况及时行手术切除阑尾残株。     

急性非胆源性胰腺炎病因研究及BISAP 预后评估

目的:探讨急性非胆源性胰腺炎病因并对其预后进行BISAP(Beside Index of Severe Acute Pancreatitis)评估.方法:回顾性分析2006年7月～2010年7月我院收治的108例急性非胆源性胰腺炎患者临床资料,并结合BISAP评分对其预后予初步评估.结果:发病病因:大量饮酒及暴饮暴食52例;高脂血症27例;药物12例;妊娠Ⅰ例;十二指肠憩室1例;诱因不明15例.重症急性胰腺炎8例,5例由暴饮暴食、酗酒所致,2例为高脂血症,1例为十二指肠憩室引起;其中有6例BISAP评分≥3分.结论:明确病因对预防复发、降低胰腺炎并发症、病死率具有重要意义.BISAP评分有利于重症胰腺炎风险早期预测.     

Adiaspiromycosis of human skin caused by Emmonsia crescens

Two cases of cutaneous adiaspiromycosis by Emmonsia crescens are reported. This is the first human skin infection by this species and is the first report of its kind in man from India. In the first patient, the agent was demonstrated in KOH mounts, histology and culture from irregular, pigmented skin plaques on the right gluteal area. The lesion also contained calcium. In the second patient the fungus was demonstrated histologically in a knee lesion. The agent had elicited a histiocytic and giant cell reaction in the dermis in both cases. The first patient suffered from anaemia and epilepsy and the second suffered from nephropathy with chyluria. The skin lesions were surgically excised with skin grafting in the first patient.     

Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.     

Takotsubo syndrome with pulmonary embolism: a case report and literature review

Background

Takotsubo syndrome (TTS) is an acute cardiac condition with reversible heart failure which is often triggered by psychological and physical stressful events. Although pulmonary embolism (PE) was reported as a trigger for TTS, the concurrence of TTS and PE has been rarely reported, let alone that triggered by PE. Here we describe a case of a postmenopausal female presenting with symptoms similar to myocardial ischemia, which may be caused by PE, and review the available literature that may help clinicians with their practice to similar situations since no published guidelines are available.

Case presentation

An 86-year-old female was referred to the emergency department for unrelieved chest tightness, shortness of breath and back pain. Cardiac biomarkers were mildly elevated and electrocardiogram displayed pathologic Q-waves, ST-segment elevation and inverted T-waves. Unexpectedly, coronary angiography was in absence of obstructed coronary atherosclerosis or acute plaque rupture. Chest computed tomography illustrated multiple pulmonary emboli in bilateral pulmonary arteries. She had suffered from long-term right lower extremity pain and experienced a long railway journey with less activity. Both echocardiogram and cardiac magnetic resonance demonstrated regional hypokinesia of left ventricle. She received anticoagulant and diuretic therapies, three-month follow up after discharge revealed uneventful recovery without any pulmonary emboli or regional motion abnormalities, thus she was retrospectively diagnosed with TTS caused by PE.

Conclusion

TTS and PE are scarcely concurrent and PE can exert as a potential trigger for TTS. TTS is easily misdiagnosed, actively seeking possible risk factors of TTS is in favor of early diagnosis and timely intervention. TTS with PE is reversible, timely and effective treatments ensure the best possible outcome.

     

Various phenotypes of diabetes mellitus at ultimate outcome of acutely developed diabetic state induced by viral infection

For 4 to 8 years we followed up 3 diabetic patients in whom the onset of diabetes seemed to be closely related to the well-documented Epstein-Barr virus infection (Case 1) or Coxsackie B4 virus infection (Case 2, 3). Although all developed acute ketosis-prone diabetes in the convalescent stage of the viral infections, the subsequent clinical courses were quite different from each other. Case 1 has remained consistently insulin-dependent and associated with positive islet cell antibody, gastric parietal cell antibody, thyroglobulin hemoagglutinating antibody and thyroidal microsomal hemoagglutinating antibody. Case 2 restored normal glucose tolerance. Case 3 has become noninsulin-dependent diabetes mellitus after a 6 year interval. Thus, it is reasonably presumed that virus could be responsible for the occurrence of different phenotypes of diabetes.