A Case Report of Brucellosis-Associated Infective Endocarditis.

Brucellosis is a prevalent zoonotic infection that can be relatively well managed and tolerated if appropriate treatment is initiated. Unfortunately, likely secondary to decreased awareness and vague symptoms, the diagnosis can be easily missed leading to worsening complications that severely increase the mortality rate. We present a case of a 25-year-old female who presented from a rural setting with a diagnosis of brucellosis, which was delayed. She ultimately developed infective endocarditis with cardiac vegetations on imaging. Despite improvement on antibiotics and reduction in size of cardiac vegetation, she suffered a fatal cardiac arrest before undergoing surgical intervention. Better awareness regarding hygiene and sanitary food handling should be encouraged, especially in underdeveloped rural areas, to help prevent infection. More studies need to be performed to help better identify symptoms coupled with maintaining a high index of suspicion so as to expedite diagnosis, treatment, management and hopefully prevent the progression of disease and worsening complications.

Surgical Infection Society-Chest Wall Injury Society Recommendations for Management of Surgical Site or Implant-Related Infections After Surgical Stabilization of Traumatic Rib or Sternal Fractures.

Background: Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. Conclusions: Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.

Brain Abscess as a Complication of Hereditary Hemorrhagic Telangiectasia: A Case Report.

An 18-year-old male, previously diagnosed with hereditary hemorrhagic telangiectasia (HHT), presented to the outpatient department with a complaint of generalized seizures and fever for the past five days. He had a history of recurrent epistaxis, progressive shortness of breath, and cyanosis. Magnetic resonance imaging (MRI) of the brain revealed an abscess in the temporoparietal region. A computed angiogram of the pulmonary vasculature showed the presence of arteriovenous malformation (AVM). A four-weekly antibiotic regimen was initiated, which resulted in a profound improvement in symptoms. A brain abscess can arise as a complication of vascular malformation in a patient with HHT, providing a nidus for bacteria to migrate toward the brain. Early recognition of HHT is essential in these patients and their affected family members, as screening can help us prevent complications at an earlier stage.

Moebius Syndrome: What We Know So Far.

Moebius syndrome (MBS) is a rare congenital cranial nerve disorder characterized by unilateral, bilateral symmetrical, or asymmetrical facial (VII) and abducens (VI) nerve palsies. Genetics and rhombencephalon vascular disturbances from intrauterine environmental exposures have been attributed to its development. It can present with various orofacial abnormalities. Although the diagnosis is purely clinical, certain characteristic features are present in the brain's images. With no cure, it is essential to devise management on a personalized basis. We discuss etiology, presentation, diagnostic approaches, and effective management in the existing literature. This comprehensive review examines the clinic-pathological aspects of Moebius syndrome. The authors employed the PUBMED base index to identify pertinent literature and reference it according to research keywords. Findings suggest the most popular etiology is the theory of intrauterine vascular disruption to the brainstem during embryogenesis, followed by the genetic hypothesis. Intrauterine environmental exposures have been implicated as potential risk factors. Facial and abducens nerve palsies are the most common presenting features. However, clinical manifestations of lower cranial nerves (IX, X, XI, XII) may be present with orthopedic anomalies and intellectual deficiencies. The diagnosis is clinical with minimal defined diagnostic criteria. Characteristic radiological manifestations involving the brainstem and cerebellum can be observed in imaging studies. With no definitive treatment options, a multidisciplinary approach is employed to provide supportive care. Despite radiological manifestations, Moebius syndrome is diagnosed clinically. Although incurable, a multidisciplinary approach, with personalized rehabilitative measures, can manage physical and psychological deficits; however, standard guidelines need to be established.

Tumor location and concurrent liver resection, impact survival in T2 gallbladder cancer: a meta-analysis of the literature.

Aim of doing this review was to give a uniform consensus on prognostic impact of tumor location (hepatic vs peritoneal), liver resection and adjuvant chemotherapy in gall bladder cancer and, to compare them with previous well-studied factors of survival. We systematically review PubMed, Scopus and Cochrane for relevant articles with no date restrictions, language was restricted to English. Those articles were included that had provided Hazard ratio (HR) of survival for T2 gall bladder cancer. We identified nine retrospective studies published between 2014 and 2020 with 2345 patients. Meta-analysis showed that T2b (hepatic) cancers had higher odds of mortality (HR 3.16 [2.11, 4.74], I2 = 0%). Liver resection was associated with significantly higher odds of 5-year overall survival only in T2b (2.20 [1.33, 3.63], I2 = 67%), adjuvant chemotherapy was not associated with any significant decrease in mortality risk (0.98 [0.83-1.16]. I2 = 20%). Hepatic sided gall bladder tumors carry higher odds for mortality and recurrence. T2a tumors can be managed without hepatic resection. To risk stratify patients we also formulated a scoring system for mortality risk.

Vasitis Nodosa: A Rare Diagnosis for Inguinal Swelling.

Vasitis nodosa involves benign, reactive spindle-shaped nodular thickening of the ductal epithelium of vas deferens. We report the case of a 21-year-old male with a history of bilateral undescended testes and left orchidopexy. The patient presented with the complaint of a non-tender left inguinal swelling. The definitive diagnosis of vasitis nodosa was made based on clinical evaluation and imaging findings. We suggest that this rare entity should be considered as a differential diagnosis of inguinal swelling during the assessment of the male urogenital system.

Spontaneous pneumomediastinum and subcutaneous emphysema in a non-intubated COVID-19 patient: a case report.

The development of spontaneous pneumomediastinum and subcutaneous emphysema are few of the rare clinical manifestations observed in coronavirus disease-19 (COVID-19) patients which are yet to be fully understood. Most cases of spontaneous pneumomediastinum arise due to factors causing high intra-alveolar pressure. Herein, we report a case of a COVID-19 positive elderly male, who presented with spontaneous pneumomediastinum and subcutaneous emphysema unrelated to high-pressure ventilatory measures, detected on chest computed tomography (CT). Despite acute medical care, the patient progressed towards a more serious clinical course. Male gender and diffuse alveolar damage caused by COVID-19 seems to be the most relevant association in this case. However, we have enlightened other possible pathological mechanisms and their association with severity index of COVID-19.

Combined Diagnostic Accuracy of Total Leukocyte Count, Neutrophil Count, and Ultrasonography for the Diagnosis of Acute Appendicitis.

Acute appendicitis is a common surgical emergency that classically presents with right lower abdominal pain and tenderness on palpation. The diagnosis is often based on clinical examination in order to avoid the complications of surgery delay, yielding a high rate of negative appendectomies. Ultrasonography is a regularly used modality for establishing the diagnosis, whereas abdominal computed tomography (CT) is often used in sonologically equivocal cases. Other parameters include total leukocyte count, granulocytes, C-reactive protein (CRP), leukocyte elastase activity, D-lactate, phospholipase A2, and interleukin-6 (IL-6). We conducted a prospective study to assess the combined accuracy of total leukocyte count, neutrophil count, and ultrasound as an integrated diagnostic tool. The results of these investigations were tabulated and compared to histopathological evidence of acute appendicitis on biopsy (taken as the gold standard) to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Combined sensitivity and specificity were calculated using cross-tabulation, whereas diagnostic accuracy was estimated from the receiver operating curve (ROC) at the optimal cut-off point. The results showed that the absence of inflammatory findings on ultrasound and normal blood parameters (total leukocyte count and neutrophil count) have a high combined diagnostic accuracy and appendicitis may be ruled out.

Rare Association of Budd-Chiari Syndrome With Celiac Disease: A Case Report.

Budd-Chiari associated with celiac disease is a rare phenomenon in the medical literature with annual incidence of less than five per million. The majority of the cases are reported from the North African region. Our patient presented in the out-patient department with symptoms of progressive abdominal distension, diffuse abdominal pain and shortness of breath for one year. She was a known case of celiac disease for the last three years. The clinical examination revealed ascites, jaundice, decreased air entry in basal segments bilaterally, and multiple hemangiomas all over the body. Haematological and biochemical investigations, including levels of pro-thrombotic factors and homocysteine level, turned out to be normal. However, computed tomography (CT) revealed hepatic vein obstruction. Hence, a diagnosis of Budd-Chiari syndrome was confirmed. The patient was managed with anticoagulants, diuretics and gluten-free diet. Within a month, the patient showed marked improvement with a significant reduction in ascites. To the best of our knowledge, this rare association is the first case to be reported from Pakistan and third from the region of South Asia.

Right Scapular Swelling Revealed to Be a Spontaneous Lateral Chest Wall Hematoma: An Intriguing Case Report.

Chest wall hematoma commonly occurs as a result of blunt thoracic trauma. We report an intriguing case of spontaneous lateral chest wall hematoma that presented with right scapular swelling and tenderness on palpation having hemodynamic instability without any prior history of recent trauma or surgery. Chest x-ray and ultrasound were carried out at the time of admission to evaluate the swelling, followed by contrast-enhanced CT (CECT) of the chest to identify and localize the bleeder. Transcatheter arterial embolization (TAE) of the intercostal artery was performed to treat the condition successfully. CECT is found to be vitally important in localizing bleeders. Other possible options include exploratory thoracotomy, video-assisted thoracic surgery (VATS) exploration, and angiography.