L-Ornithine-L-Aspartate and Intermittent Renal Replacement Therapy in Fulminant Hepatitis A: A Case Report

Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).

Recurrent intussusception with ileal perforation as a complication of Blue Rubber Bleb Nevus Syndrome in a pediatric patient

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital condition, characterized by multiple venous malformations that may involve any organ system, most commonly the skin or the gastrointestinal tract. These lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may cause severe complications such as intussusception, volvulus, and intestinal infarction. Intussusception as a complication of BRBNS, although a known complication of the disease, has rarely been reported, especially in the Philippines. In the Philippine Society for Orphan Disorders, only 2 cases of BRBNS are currently included in the organization, including the patient presented in the case report. The treatment of BRBNS that involves the gastrointestinal tract depends on the extent of intestinal involvement and severity of the disease. The treatment aims to preserve the GI tract as much as possible due to the high recurrence in the disease. In this case report, we present a 13 year-old male with BRBNS with previous history of intussusception, successfully managed conservatively;however, upon recurrence, underwent exploratory laparotomy wherein a subcentimeter perforation in the antimesenteric border of the proximal ileum was noted, together with a gangrenous intussuscipiens, and multiple mulberry-like formations on the antimesenteric border of the small bowels. Histopathological findings of the resected bowels showed multiple cavernous hemangiomas consistent with BRBNS. The postoperative course of the patient was unremarkable.Copyright © 2023 The Authors

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

A Clinical Case of Pheochromocytoma Presenting with Decompensated Diabetes Mellitus and Paroxysmal Hypertension

Introduction: Pheochromocytoma is a rare neuroendocrine tumor that originates from the adrenal medulla, less commonly from extraadrenal chromaffin cells (paraganglioma). In about 90% of cases, the tumor produces abnormal amounts of catecholamines. Pheochromocytomas are usually benign, but in rare cases can be malignant. Typical clinical manifestations are the result of the haemodynamic and metabolic effects of catecholamines and usually include paroxysmal hypertension with the classic triad (headache, excessive sweating, palpitations), carbohydrate disorders, etc. Elevated levels of catecholamine metabolites (metanephrine and normetanephrine) tested in plasma or in 24-hour urine confirm the diagnosis. Surgical removal of the tumor is the only radical treatment. Follow-up of patients postoperatively should be lifelong and performed by a multidisciplinary team in a specialized center of expertise. Case report: A 36-year-old female patient referred to the clinic for decompensated diabetes mellitus. Detailed history revealed paroxysmal hypertension and the classic triad of pheochromocytoma. The diagnosis was confirmed by high urinary metanephrine levels and an abdominal CT scan, showing a tumor in the right adrenal gland with features typical of pheochromocytoma. Surgical removal of the pheochromocytoma and normalization of catecholamine levels led to normalization of blood pressure and reversal of diabetes mellitus. Conclusion(s): Pheochromocytoma is a difficult diagnosis in endocrinology practice as it can mimic many other diseases. Early detection and surgical removal of the tumor are crucial to avoid complications caused by elevated serum catecholamine levels.Copyright © 2022 Medical Information Center. All rights reserved.

Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

T-branch endovascular graft, a good option to treat acute aortic mycotic aneurysm?

Background: Complex mycotic aortic aneurysm (MAA) is a rare and life-threatening disease with a high mortality rate. Open surgical treatment has always been considered as gold standard. However, it carries a high mortality and morbidity rate. Endovascular repair is a feasible option with encouraging results, especially in frail patients. Due to the production lead time, Fenestrated/Branched Endovascular Aortic Repair cannot be proposed in urgent cases. In those cases, an alternate solution could be the use of "Off the shelf" (OTS) fenestrated stent grafts. Objective(s): We aimed to assess the feasibility of OTS fenestrated stent grafts in the acute treatment of a MAA. Method(s): We present the case of a frail 74-year-old woman with an acute MAA undergoing a successful treatment by Zenith t-Branch Thoracoabdominal Endovascular Graft associated with antibiotic therapy. Result(s): Thoraco-abdominal computed tomography (CT) at 1-year follow up showed good result with total exclusion of the thoracic aneurysm and size reduction. No migration of the stent was found, and all branch vessels remained patent. Conclusion(s): OTS endovascular T-branch is a feasible option to treat acute MAA and could be considered in frail patient. Further studies are required to define the place of this strategy in the management of acute MAA.Copyright © 2022

Clinical and Laboratory Evaluations of Patients Diagnosed as Having Multisystem Inflammatory Syndrome Associated with Coronavirus Disease 2019 in Children: A Single Center Experience from Konya

Objective Multisystem inflammatory syndrome in children (MIS-C), characterized by fever, inflammation, and multiorgan dysfunction, was newly defined after severe acute respiratory syndrome coronavirus 2 infection. The clinical spectrum of MIS-C can be classified as mild, moderate, and severe. We aimed to evaluate demographics, clinical presentations, laboratory findings, and treatment modalities of patients with MIS-C according to clinical severity. Methods We performed a retrospective study of patients who were diagnosed as having MIS-C between September 2020 and October 2021 in the Necmettin Erbakan University Meram Faculty of Medicine, Türkiye. Results A total of 48 patients (24 females and 24 males) with a median age at diagnosis of 10.3 years (range: 42 months-17 years) were enrolled, the most common clinical severity of MIS-C was moderate. The common presentations of patients were fever (97%), nonpurulent conjunctivitis (89.6%), rashes (81.3%), fatigue (81.3%), strawberry tongue (79.2%), and myalgia (68.8%). The most common laboratory findings were lymphopenia (81.2%), thrombocytopenia (54.1%), elevated D-dimer levels (89.5%), C-reactive protein (CRP;100%), procalcitonin (97%), erythrocyte sedimentation rate (87.5%), ferritin (95.8%), interleukin 6 (IL-6) (86.1%), and probrain natriuretic peptide (pro-BNP) (97%). High levels of CRP, procalcitonin, pro-BNP, and urea were associated with the severity of MIS-C (p < 0.05). Fifteen of the patients were found to have pulmonary involvement. Ascites were the most common finding on abdominal ultrasonography (11 patients) and were not seen in a mild form of the disease. During the study period, two patients died. Conclusion It is important to make patient-based decisions and apply a stepwise approach in treating patients with MIS-C due to the increased risk of complications and mortality. © 2022. Thieme. All rights reserved.

Pediatric ovarian torsion: A diagnostic challenge in covid-19 times

Ovarian torsion is a rare gynecological emergency in children and an early surgical intervention is needed to salvage the ovary. Herein, we present a case of eight year old girl who presented with complaints of lower abdominal pain during ongoing COVID-19 pandemic. She was diagnosed as a case of ovarian torsion on right side. She underwent exploratory laparotomy and ovarian cystectomy was performed. Delay in diagnosis and treatment of ovarian torsion may have grave consequences, resulting in functional loss of the ovary. Copyright © 2020, Kathmandu University. All rights reserved.

Emerging Catatonia and Psychosis in Resolving COVID-19 Infection in an Adolescent

Introduction: COVID-19 infection may lead to encephalopathy and various neurotrophic effects which can result in neuropsychiatric complications. Here, an asymptomatic adolescent female developed acute onset catatonia and psychosis manifesting during the resolution of Covid-19 infection. Objective(s): Discuss differential diagnosis, medical workup, and initial treatment optimization for acute stabilization. Method(s): This 15-year-old female with no previous psychiatric history nor prodromal symptomatology was hospitalized secondary to Covid -19. During the immediate three-month recovery phase following resolution of Covid-19, the patient exhibited gradually increasing anxiety, paranoia, delusions, disorganized behavior, and weight loss leading to re-hospitalization secondary to catatonia. Negative workup included rapid strep test, urinalysis, chest and abdominal x-ray, EEG, and brain MRI. Lumbar puncture revealed elevated WBC of 18 but was unremarkable for NDMA receptor antibodies, CSF HSV, and encephalitis panel. IV steroids, IVIG, and Anakinra were all given without benefit. Inadequate response to olanzapine, clonidine, and lorazepam led to an Index Series of bilateral electroconvulsive therapy (ECT). Result(s): The provisional diagnosis of psychotic disorder secondary to COVID-19 infection responded robustly regarding sleep, behavior, and affect by session #6, yet positive symptoms of psychosis persist. Ongoing ECT, psychopharmacology, and narrowing of the differential diagnosis continue. Conclusion(s): As more COVID-19 cases evolve during the pandemic, potential post-infectious neuropsychiatric complications should be considered as potentially contributory and kept in a thoughtful differential diagnosis. Regardless of ultimate causation, the acute symptom profile responded robustly to an initial Index Series of ECT.

Cerebral Venous Sinus Thrombosis in a Child With IgA Vasculitis and COVID-19 Infection

Introduction: IgA vasculitis (IgAV) is a common diagnosis in children and includes purpura, and/or petechiae (without thrombocytopenia or coagulopathy) with at least one of the following: abdominal pain, joint pain, AKI, hematuria, proteinuria, or evidence of IgA deposition. Many cases are preceded by upper respiratory tract infections, including COVID-19. The incidence of cerebral venous sinus thrombosis (CVST) in the pediatric population is low (0.6/100,000 per year). We present a case of a 5 year old boy with IgA vasculitis and COVID-19 infection found to have CVST. Case Description: A previously healthy 5 year old boy transferred to our institution with two weeks of intermittent, severe abdominal pain in the setting of COVID-19 infection with new-onset hematochezia, hypertension, and tachycardia. Abdominal ultrasound, abdominal x-ray, chest x-ray, ANA, C3, C4, ANCA, creatinine, electrolytes, and coagulation factors were normal. Urinalysis was significant for hematuria and a urine protein-to-creatinine ratio (UPC) of 2.02 mg/mg. Purpuric and petechial rash appeared the day after admission. UPC trended up to 4.82 mg/mg and a renal biopsy confirmed the diagnosis of IgA nephropathy. Patient was treated with 30mg/kg/day Solu-Medrol for three days and discharged home on 2mg/kg/day prednisolone daily. He was readmitted two days later with severe left frontal headache. UPC was worse at 5.98 mg/mg and mycophenolic mofetil (MMF) was initiated. Imaging revealed an occlusive thrombus of the left transverse sinus with nonocclusive thrombi in the distal portion of the left lateral sinus and posterior superior sagittal sinus. He started 21mg Lovenox twice daily and had minimal residual thrombosis after three months. His UPC peaked at 20.73 mg/mg and eventually normalized with high-dose steroids, Enalapril, and MMF. Discussion(s): This is the first case, to our knowledge, of CVST in a patient with IgAV associated with COVID-19 infection. Multiple case reports of IgA vasculitis associated with COVID-19 infection have been published in the past two years, and this case may support a more careful approach when it comes to screening for pro-coagulation risk factors.

To Kayexalate or Not to Kayexalate

Introduction: Although rare, it is important to consider colon necrosis, ulceration, and perforation in the management of patients with abdominal pain following kayexalate administration. We present a critically ill patient requiring partial hemicolectomy following kayexalate for hyperkalemia. Case Description: A 43-year-old male presented to the ER via EMS after being intubated emergently in the field. Was found to be COVID-19 positive and admitted to the ICU. Creatinine and potassium started trending up after day 5, requiring multiple doses of calcium gluconate, insulin, and dextrose, along with 4 doses of kayexalate 30 g over the second week. On the 10th day, he started spiking fever, having abdominal distension, and continued desaturating. Abdominal x-ray showed a large amount of free intraperitoneal air warranting emergent ex lap with partial right hemicolectomy and end ileostomy. Unfortunately, he was pronounced dead after a lengthy hospital stay of 55 days. The specimen showed perforation, mucosal necrosis, and acute serositis. It also showed Amphophilic crystals suggesting a diagnosis of kayexalate-induced colon ischemia and necrosis. Discussion(s): Kayexalate was approved by the FDA in 1958 and has been used to treat hyperkalemia. It can bind intraluminal calcium, leading to bowel obstruction or perforation, with a reported incidence of 0.14-1.8%. The identification of rhomboid or triangular, basophilic crystals with a mosaic pattern on H&E stain is pathognomonic for the presence of kayexalate. We present this case as a reminder of the rare yet devastating complications of kayexalate. For that reason, clinical suspicion should be raised in patients with abdominal pain following kayexalate. Kayexalate should only be used in patients who have life-threatening hyperkalemia where dialysis or newer cation exchangers (ie, patiromer or Lokelma) are not available, and other therapies to remove potassium have failed or are not possible. (Figure Presented).

Community-acquired Methicillin-resistant Staphylococcus aureus Pneumonia and Parapneumonic Effusion in a Male Patient with Diabetes: A Case Report

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.

Impact of imaging modality choices on emergency department length of stay for patients with renal colic

Introduction & Objectives: Renal colic is a common presentation to emergency departments. Non-contrast CT is the gold standard for diagnosing ureteric stones. Ultrasound (USS) is also commonly used, however has lower sensitivity and specificity. Uncertainty in imaging findings can delay diagnosis and thereby prolong the length of stay (LoS) in the emergency department. The aim of this study was to assess the current imaging practices for assessment renal colic in the emergency department setting and the impact of imaging modality choices on patient flow. Methods: Patient presentations were identified from Emergency Department Information System for renal colic and urinary calculus diagnosis codes from October 2019 to September 2020. This was correlated with radiology departmental records for imaging modalities used. Clinical records were reviewed for demographics, LoS, disposition, imaging findings and radiation dose. Results: 590 presentations were identified, with 431 first presentations, 86 re-presentations (within 30 days) and 73 interhospital transfers. Imaging was performed in 74.7% of presentations (n = 441). Patients had a median age of 46 years and were mostly male (69%). 73.3% of first presentations had CT as first-line imaging. Those who had USS as first-line imaging were predominantly female (59%) and younger (mean 31.1 vs 46.6 years, p<0.01). They had longer total LOS when compared to CT for first presentations (mean 604 vs 443 minutes, p < 0.01) and all presentations (mean 599 vs 440 minutes, p<0.01). Compared to CT +/- abdominal x-ray, patients having USS were more likely to be admitted to the short stay unit (71.4% vs 43.7%) for longer periods (mean 511 vs 401 minutes, p = 0.05). 17% of patients who initially had USS subsequently had a CT, with this group having the longest mean LoS (total 713 minutes, short stay 720 minutes). Conclusions: USS is more likely to be used in younger and female patients. Compared to CT, first-line USS in renal colic correlated with longer time spent in ED, more admissions to short stay and longer LoS in short stay. Given constraints on hospital resources with the Covid-19 pandemic, renal colic imaging pathways should be examined for opportunities to improve patient flow.

Neuroendocrine cancer of the prostate. Two case reports

Background: Neuroendocrine cancer of the prostate can present in diverse clinical pictures, potentially hampering the diagnosis and probably leading to underdiagnosis. Methods: Two cases are presented corresponding respectively to two forms of the disease: de novo neuroendocrine cancer and dedifferenciation of an adenocarcinoma of the prostate to neuroendocrine cancer under long term luteinising hormone releasing hormone (LHRH) agonist treatment. Results: Suspicion of neuroendocrine cancer may be raised in prostate cancer patients presenting either clinical or radiological metastatic progression without prostate specific antigen (PSA) rise, or relatively extended metastatic disease right at diagnosis associated to relatively low PSA, yet any non-pulmonary visceral metastases. Neuroendocrine cancer of the prostate can also turn out to be the origin of an adenocarcinoma of unknown primary. Conclusion: In case these considerations are respected the risk of missing the correct diagnosis of a neuroendocrine cancer of the prostate may be minimised.

Detection of Iliopsoas Hematoma by Retrospective Radiography in Veno-Venous Extracorporeal Membrane Oxygenation for a COVID-19 Patient.

In coronavirus disease 2019 (COVID-19), veno-venous extracorporeal membrane oxygenation (VV-ECMO) is used to manage respiratory distress. This study's key clinical question was whether COVID-19 could be complicated by hemorrhagic and thrombotic events, such as iliopsoas hematoma (IPH), during the management of ECMO and the method to quickly and effectively detect IPH. A 52-year-old man with fever and dyspnea was diagnosed with COVID-19 pneumonia. He warranted VV-ECMO management on day 9, which was successfully tapered off on day 18. On day 20, computed tomography revealed a unilateral iliopsoas hematoma that was successfully managed with conservative care. However, a retrospective review of abdominal radiography performed on day 14 revealed a positive left psoas sign. When managing severe COVID-19 patients with VV-ECMO, cautious anticoagulative care and abdominal X-ray findings are warranted when considering the diagnosis of iliopsoas hematoma, including circulatory instability, anemia, and pain associated with limb movement.

Platypnea-orthodeoxia syndrome years after acute pulmonary embolism: Two consecutive cases

Platypnea-Orthodeoxia syndrome (POS) is a rare condition in which dyspnoea and arterial oxygen desaturation are present in the upright position, while in the supine position, they are alleviated. It is observed in the presence of an anatomical (intra-or extracardiac) communication between the right and left heart causing a right-to-left shunt. POS is most frequently caused by a patent foramen ovale (PFO) and usually, the clinical assessment and a transthoracic echocardiograms with bubble study are enough to reach the diagnosis. The only possible treatment of POS is the percutaneous closure of the defect. We describe two cases of POS due to a PFO which manifested itself years after an episode of acute pulmonary embolism (PE), a finding never reported to date in the literature. Few cases describe the relationship between PE and POS, but these conditions may be more closely related than we currently think.

Comparison of antibiotic treatment and appendectomy for non-complicated acute appendicitis during covid-19 pandemic

Aim: To evaluate the efficacy of antibiotic treatment as the primary option for non-complicated acute appendicitis in pandemic situation. Study Design: Prospective interventional study. Setting & Duration of Study: CMH Lahore, a 700 bedded tertiary care hospital, for 4 months from 15th April 2020 to 15th august 2020. Methodology: A total of 110 cases meeting inclusion criteria, aged 13-65 years of both genders with suspicion of non-complicated appendicitis were included in the study, using probability sampling. They were divided in two groups on randomization basis. Group A for antibiotic therapy and Group B for appendectomy. Group A patients admitted in the ward 48 hours for IV antibiotics, were re-evaluated after 24 hours. If condition improves, the patient was discharged on oral antibiotics for next 10 days & if condition does not improve, antibiotics were prolonged for 48 hours. If deteriorating or patient. .chooses to change group, they underwent appendectomy. If condition improved, they were discharged on oral antibiotics for next 10 days. Group B patient were discharged after 2 post-operative doses of I/V antibiotics. Post-operative I/V antibiotics for 48 hours & 3 days oral antibiotics were given when appendix was gangrenous or perforated. Results: In a population of 110 patients, we studied the comparison of the groups having antibiotics and appendectomy as treatment for acute appendicitis. There is no significant difference in outcomes on basis of mean pain score and mean duration of hospital stay. Both ways of treatment can be adapted accordingly. Conclusion: Non-complicated acute appendicitis can be managed non-operatively in crisis situations like COVID-19 pandemic causing overburdening of hospitals.