Carotid cavernous fistula in a patient with coronary artery disease

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting [CABG] for coronary artery disease [CAD] is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease

Life threatening mediastinal haematoma: a complication of central venous catheterization

Central venous catheterization [CVC] has established risks and benefits in its application as a vascular access source, particularly in situations involving temporary cannulation. We present a rare case of life-threatening mediastinal haematoma resulting from CVC usage. Even though aggressive intervention yielded survival, the patient was left with permanent vocal compromise owing to traumatic palsy of the right recurrent laryngeal nerve. One should be careful in selection of venous access and be aware of alternatives routes

Colorectal carcinoma preoperative evaluation by spiral computed tomography

To assess the capability of spiral computed tomography [CT] scan in preoperative evaluation of colorectal carcinoma [CRC]. A cross sectional study on 52 patients with recent histopathologic diagnosis of CRC was conducted over a period of one year at the Aga Khan University Hospital, Karachi. All these patients underwent spiral CT with oral and intravenous contrast administration. Surgery was subsequently done in all cases and surgical specimens were sent for detailed pathologic analysis. The radiologic findings on the CT scans were compared with the pathological findings. The results proved that spiral CT had 60% sensitivity and 83% specificity for assessment of local spread of disease, 66% sensitivity and 76% specificity for the evaluation of lymph nodal metastases and 89% sensitivity and 94% specificity for hepatic metastases. In all the cases, the visualized tumour growth with wide zone of resection and regional nodal chains were surgically removed. It was however, the distant metastases which made a difference to the type of curative or palliative surgery planned and in this study spiral CT had 92% accuracy for detection of hepatic metastases. With technological advances and improvement in imaging protocols the results for local tumor spread are expected to improve, however based on the accuracy in detecting hepatic metastases in clinically unsuspected patients, this study proves that spiral CT has a significant role in preoperative evaluation and subsequent management of CRC

Psoas abscess secondary to Pott's disease an unusual presentation in a young child

Psoas abscess in neonates and infants are rare. Primary psoas abscesses are said to be more common in young children. Limping, fever and abdominal pain has been described to be the way psoas abscesses usually present. The authors describe the unusual presentation and successful treatment of a young child with a unilateral psoas abscess secondary to advanced spondylodiscitis

Role of focused appendiceal computed tomography in clinically equivocal acute appendicitis

To determine the accuracy of FACT [focused appendiceal computed tomography] in evaluation of acute appendicitis. The study was conducted in Aga Khan University Hospital, Karachi, over a period of one year. Sixty-three patients with clinically equivocal acute appendicitis underwent thin-section non-enhanced helical CT. Axial scans were obtained in a single breath hold from L2 vertebral level to the pubic symphysis with 5-mm collimation and a pitch of 1.5. All scans were obtained without oral, intravenous, or rectal contrast material. Criteria for diagnosis of acute appendicitis included an enlarged appendix [>6 mm diameter] and periappendiceal inflammation. Final diagnoses were established with the results of surgical or clinical follow-up. There were 21 true-positive diagnoses, 38 true-negative diagnoses, no false-positive diagnoses, and 2 false-negative diagnoses, which yielded a sensitivity of 91% and a specificity of 100%. Non-enhanced FACT is a highly accurate problem solving technique in clinically equivocal cases of acute appendicitis

case of transient diabetes insipidus following cardiopulmonary bypass

Cardiopulmonary bypass surgery has been linked with a number of postoperative complications. One of the frequently reported physiological alterations is the relative diuresis seen in the immediate post-op period. Rarely reported though is the development of full-blown diabetes insipidus in such patients. The etiology is unknown and has only been hypothesized in the past. We present the clinical course of a 54 year old male who developed transient diabetes insipidus post bypass surgery with subsequent recovery following exogenous vasopressin administration. The physiological alteration leading to the development of diabetes insipidus in a small fraction of bypass patients remains unknown. We propose that the variation in natriuretic peptide levels in the post-bypass period could account for the transient event

case of non - resolving cough and Weight loss

Sarcoidosis is a chronic granulomatous multi-system disease with a clinical picture often mimicking tuberculosis. We present a case of a patient who presented with a clinical picture akin to both of these granulomatous disorders and was started on anti-tuberculous regimen despite the lack of any solid evidence pointing towards tuberculosis. As a result her clinical condition continued to deteriorate for months until finally a bronchoscopic biopsy established her disease process as sarcoidosis. She was then started on systemic corticosteroid therapy for sarcoidosis and during the ensuing period has shown marked improvement in her clinical picture with near normalization of the biochemical and radiographic parameters of her pathology. This case illustrates the need for vigilant interpretation of the clinical scenario in patients such as these where a misdiagnosis may lead to significant patient distress as well as weighing down on the economic and health resources

Pulmonary embolism in Pemphigus Vulgaris, the need for judicious immunotherapy

Pemphigus vulgaris is a serious chronic mucocutaneous ailment. In recent decades advances in diagnostic and therapeutic measures have led to a significant decline in morbidity and mortality. However, with the advent of active and prolonged immunotherapy involving corticosteroids, there has been a rise in steroid-associated complications. This has led to significant concern globally over the sensible use of treatment regimen in pemphigus patients. We present a patient who underwent a massive pulmonary embolism following over usage of corticosteroid therapy for pemphigus vulgaris. Whilst the patient survived owing to timely assessment and aggressive surgical intervention, the need for cautious and judicious immunotherapy in pemphigus is emphasized