जर्नल ऑफ़ क्लिनिकल केस रिपोर्ट्स

Background: Long term Capsule Endoscopy (CE) retention is an uncommon, but potentially serious complication of CE. It is most frequently due to Crohn’s related small bowel strictures or neoplastic lesions but can be caused by post-surgical stenosis and non-steroidal anti-inflammatory drug (NSAID) enteropathy. We present a case of retained CE in the distal ileum due to NSAID enteropathy with striking photographs of the small bowel stricture and the moment of laparoscopic device retrieval.

Case report: An 83-year-old female on amlodipine and esomeprazole presented with a month-long history of melaena and was found to have iron deficiency anaemia. She had been investigated two years prior for a similar episode with gastroscopy, colonoscopy and CE without finding an underlying cause. Gastroscopy and colonoscopy were repeated, revealing gastritis and diverticular disease but no bleeding source. CE showed an inflamed distal ileal stricture, which prevented capsule passage. The patient was asymptomatic and X-ray and computed tomography (CT) confirmed retention of the capsule with no bowel obstruction. On directed questioning she admitted to infrequent use of a COX-II inhibitor for arthritis over the previous 3 years. She underwent double balloon enteroscopy with dilatation, which identified the stricture and the retained capsule, but it could not be safely retrieved at that time or one week later. She developed abdominal pain and ultimately proceeded to laparoscopic removal of the capsule and resection of the stricture. Histology was consistent with an NSAID etiology.

Conclusion: CE retention is a serious complication and can be caused by strictures related to occult NSAID use. Directed history taking and use of patency capsules could reduce the incidence of this problem.

Osteoporosis is a common manifestation of Cushing’s syndrome, and fractures, particularly of vertebra and ribs, are frequent complications. Lower extremity insufficiency fractures, in the absence of other overt Cushingoid features, are a rarely reported presenting feature of endogenous Cushing’s syndrome. Adrenocorticotrophic hormone (ACTH) dependent Cushing’s syndrome accounts for the majority of endogenous Cushing’s syndrome, and includes ACTH-secreting pituitary adenomas, ectopic ACTH production and corticotrophin releasing hormone (CRH)-producing tumors. Bilateral Inferior Petrosal Sinus Sampling (BIPSS) is the gold standard to confirm ACTH excess of pituitary origin and lateralization within the gland. It is generally regarded as an accurate and safe procedure, and serious adverse effects are rare. We report a case of Cushing’s Disease presenting with a metatarsal fracture with minimal other clinical signs of hypercortisolism, and a novel case of cavernous sinus syndrome and pituitary macroadenoma infarction complicating BIPSS, with subsequent temporary improvement of hypercortisolism.

Mycobacterium abscessus is a rare, but increasingly frequent cause of petrositis and otomastoiditis. Over the last 40 years, the therapeutic focus of petrositis has shifted from surgical to medical modalities; however, M. abscessus infections provide a distinct challenge to the medical management of petrositis due to the species’ predilection for extensive drug resistance. We describe a case in which petrositis due to M. abscessus is effectively managed in a patient with significant comorbidities through conservative medical therapy.

Background: Uterine leiomyomas (fibroids) are the most common neoplasm affecting women. Extrauterine leiomyomas are rare and may arise in any anatomic site; their unusual growth pattern may mimic malignancy and can result in a clinical diagnostic dilemma. Uterine fibroids are not well known to cause acute urinary retention (AUR) and subsequent urosepsis in women, and there have been few published cases of parasitic fibroids causing AUR. We present a case of a parasitic fibroid in the posterior vaginal wall occupying the rectouterine pouch (of Douglas) in a grand multiparous woman causing AUR and urosepsis requiring total abdominal hysterectomy and removal of the parasitic fibroid.

Case report: A 45-year-old business woman, P₈ ⁺⁰ who presented with abdominal swelling and pains and recurrent difficulty in passing urine with total urinary obstruction of five months duration. Abdominal examination revealed 20-weeks uterine size mass that was nodular, firm, non-tender and mobile from side to side. Pelvic examination revealed a healthy-looking cervix that was displaced anteriorly by the huge pelvic mass and occluded the pouch of Douglas. She was resuscitated and had exploratory laparotomy with removal of the mass and total abdominal hysterectomy. She had post-operation septic shock that was managed with intravenous and oral antibiotics. She had quick recovery and was discharged after four days of surgery. Histology confirmed the mass to be fibroid.

Conclusion: Parasitic fibroid can present as a case of bladder outlet obstruction and diagnosis can easily be missed. High index of suspicion, good investigation and institution of appropriate management protocol will ensure quick recovery and reduce further complications as in the case presented.

Dislocation of the knee is a serious and potentially limb threatening injury. There are 3 types of dislocation around the knee joint: patellofemoral, tibiofemoral and tibiofibular. Tibiofemoral dislocation is the variant that is deemed the most serious, with a higher risk of compromise to the popliteal artery and common peroneal nerve. Although simultaneous dislocations of two types have been described, there has been no such description of all three types occurring simultaneously. In this case we present a case of simultaneous dislocations of all 3 articulations around the knee. Diagnosis was achieved with clinical examination, plain films, CT and MRI scans. Management consisted of initial surgical debridement and reduction with stabilisation of the affected joints.

Aims: The purpose of our study was to research the clinical and pathological aspects of metaplastic breast cancer (MBC).

Material and methods: This is a retrospective study of four cases of MBC conducted at the department of pathology of Mohamed Taher Maamouri Hospital in Nabeul, between January 2016 and February 2018. Characteristics of clinical and pathological features were collected from the patient files and histopathological reports.

Results: In our study, the mean age of patients was 53 years with extremities ranging from 19 to 89 years old. The most frequent reason for consultation was a nodule with a mean size of 3.87 cm (3 - 4.5 cm) and a localization in the left breast in 75% of cases (n=3). These tumors were classified ACR 5 in 75% of cases. The diagnosis was made in 50% of cases on lumpectomy and 50% of cases on micro biopsies.

Conclusion: A metastatic lymph node location was found in only one case (25%). All patients (n=4) had squamous type of metaplastic cell differentiation and only one case was associated with a predominant NST carcinoma. In 100% of cases, it was an SBR grade III carcinoma. At immunohistochemistry, 50% of cases (n=2) had a triple-negative profile (RO, RP and Her2 negative).

Propofol Related Infusion Syndrome (PRIS) involves cardiac failure, rhabdomyolysis, metabolic acidosis, and renal failure in critically ill patients receiving long-term propofol infusions at high doses. It carries a high mortality rate of up to 81%. We present a case of a young adult who developed PRIS and survived. A 19-year-old male involved in a motor vehicle collision was intubated and sedated with Propofol. On hospital day 7, the patient suddenly became hypotensive, tachycardic, hyperkalemic, had cardiac arrhythmias, and profound metabolic acidosis. PRIS was suspected and propofol discontinued. The patient was managed expectantly and ultimately discharged on hospital day 22. PRIS is a complex syndrome and requires prompt recognition of its key features including changes in cardiac rhythm, decreased blood pressure, increased oxygenation requirements and derangements in laboratory data. A high clinical suspicion of PRIS should most readily be recognized by the critical care team.

The ureter is a common site of congenital anomalies which may be associated with a considerable morbidity particularly among young patient. The congenital anomalies of the ureter coexist with multitude of other urinary tract anomalies, but it may occur independently. It is more common in females. The complete duplication of the ureter may not produce symptoms which would suggest the presence of malformation. Therefore, such anomaly may not become apparent until later in life. Further, this anomaly might not be recognized prior to the surgery and hence, missing of the stone is highly possible. Herein we present a case of complete ureter duplicate with an obstructive stone located close to VUJ of one limb of the duplicate. A sound knowledge of the surgical anatomy and of the congenital ureter anomalies is essential for correct diagnosis and appropriate management.