Musculoskeletal tuberculosis with multifocal muscle abscesses in a healthy young adult.

Musculoskeletal tuberculosis represents 1% of total tuberculosis cases. It affects young adults from endemic countries or immunocompromised patients, and may lead to severe functional impairment. We report a case of a 27-year-old male from an endemic country presenting with a 4-month history of fever, a major pectoralis abscess, and low back pain. A lumbar spine MRI revealed osteolytic lesions in multiple vertebral bodies along with a large iliopsoas abscess. Both abscesses were drained and the diagnosis was established by positive polymerase chain reaction assay for tuberculosis. The patient was initiated on anti-tuberculous treatment for 9 months. Musculoskeletal tuberculosis is rarely found in Western countries. If left untreated, it can lead to severe complications which may require surgical intervention.

Rib tumors: a 15-year experience.

OBJECTIVE: A retrospective study of rib tumors was conducted to review their clinical, radiological, and pathological features, the difficulties in differentiating benign from malignant tumors, as well as the early and long-term results of surgical management. METHODS: All patients with rib lesions evaluated by the Thoracic Surgery Department from 1998 to 2012 were studied. The patient's age, sex, symptoms, radiologic evaluation, surgical procedure, pathologic diagnosis and follow-up were assessed. RESULTS: Ninety-one patients (81 male, 10 female, age range 16-80) with rib tumors underwent surgery in a period of 15 years (1998-2012). 64 patients (70.33 %) had benign lesions and 27 patients (29.67 %) had malignant tumors. In the group with malignant tumors, the main symptom was pain, and in the group with benign tumors the main symptom was swelling. Ten patients with benign rib tumor and two with malignant tumor were detected during routine chest radiograph. All patients were treated surgically with wide excision of the tumor and the diagnosis was established histologically. In the benign cohort, osteochondromas, fibrous dysplasia, enchondroma, eosinophilic granuloma and posttraumatic fibro-osseous lesion/dysplasia were among the most customary diagnoses. In the malignant cohort, 13 patients (48.15 %) had metastatic lesions, with the remaining 14 patients having primary malignant rib tumor. CONCLUSIONS: Although radiographic imaging has evolved, all rib lesions must be considered as potentially malignant until proven otherwise. Prompt intervention is necessary and surgery must consist of wide resection with tumor-free margins to provide the best chance for cure in both benign and malignant lesions.

Right heart failure post left ventricular assist device implantation.

Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation. The incidence of RHF complicates 20-50% (range, 9-44%) of cases and is a major factor of postoperative morbidity and mortality. Unfortunately, despite the fact that many risk factors contributing to the development of RHF after LVAD implantation have been identified, it seems to be extremely difficult to avoid them. Prevention of RHF consists of the management of the preload and the afterload of the right ventricle with optimum inotropic support. The administration of vasodilators designed to reduce pulmonary vascular resistance is standard practice in most centers. The surgical attempt of implantation of a right ventricular assist device does not always resolve the problem and is not available in all cardiac surgery centers.

Left atrial appendage exclusion-Where do we stand?

Atrial fibrillation (AF) is consider to be the most common cardiac arrhythmia with an increasingly prevalence. It is postulated that the source of thromboembolism in 90% of patients with non-valvular AF arises from the left atrial appendage (LAA). Stroke is the most feared and life threatening consequence of thromboembolism. Oral anticoagulation (OAC) with vitamin-K-antagonists is the standard medical therapy for stroke prevention in patients with AF. Unfortunately, chronic therapy with vitamin-K-antagonists is contraindicated in 14% to 44% of patients with AF who are at risk for stroke, and its benefits are limited by underutilization, narrow therapeutic window and increased risk for bleeding, making it often undesired. Therefore, mechanical LAA exclusion is a means of preventing thrombus formation in the appendage and subsequent thromboembolic events in these patients. The LAA can be excluded from the systemic circulation via surgical, percutaneous, or thoracoscopic approaches. Several studies of percutaneous transcatheter delivery of dedicated LAA exclusion devices, such as the percutaneous left atrial appendage transcatheter occlusion (PLAATO) device, Watchman device and the Amplatzer cardiac plug, have shown encouraging results as an alternative to vitamin-K-antagonists therapy for selected patients, good feasibility and efficacy, with a high rate of successful implantation. We discuss the current evidence for LAA exclusion in patients and review their results.

Intrapulmonary solitary fibrous tumor masquerade sigmoid adenocarcinoma metastasis.

Solitary fibrous tumor is a rare spindle cell mesenchymal tumor entity, with either benign or malignant behavior that cannot be accurately predicted by histological findings. An intrapulmonary site of origin is even rarer. We report a case of a 51-year-old woman in whom an abnormal nodule in the lower right lung was detected during staging for sigmoid adenocarcinoma. The nodule was excised and pathological examination revealed an intrapulmonary solitary fibrous tumor.

Trans-aortic excision of intraventricular lipoma with the assistance of arthroscopic camera.

Cardiac lipomas are extremely rare benign neoplasms of the heart. We report the case of a 64-year-old female complaining of rapidly worsening dyspnea and lower limb edema. Echocardiograms showed a large hyperechoic mass which occupied the left ventricle. The cardiac nuclear magnetic resonance allowed the diagnosis of the left ventricular tumor of lipoma or liposarcoma. The tumor was resected through the ascending aorta, without injuring neither the aortic valve nor the left ventricle. Histological diagnosis showed that the tumor was a lipoma. The patient had an uneventful recovery, with no recurrence two years later.

Subpleural lipoma: Management of a rare intrathoracic tumor.

INTRODUCTION: Subpleural lipomas are rare intrathoracic benign tumors. They are often discovered incidentally on plain chest radiographs and the diagnosis is usually established by computed tomography. PRESENTATION OF CASE: We report a case of subpleural lipoma, with enlargement during a period of two years. Pathology examination of the specimen confirmed the diagnosis of lipoma. DISCUSSION: For non-invasive diagnostic investigation, computed tomography enables the identification and quantification of subpleural lipoma due to their characteristic fat attenuation. Surgical resection with thoracotomy or VATS provides more accurate and firm diagnosis, and complete excision. CONCLUSION: This clinical entity needs attention due to difficult preoperative differentiation. Complete surgical excision of these lesions with the appropriate surgical approach is mandatory, for both diagnosis and treatment.

Re-expansion pulmonary edema in a patient with total pneumothorax: a hazardous outcome.

Re-expansion pulmonary edema (REPE) is a rare complication of treatment of spontaneous pneumothorax or large pleural effusions. As a complication of spontaneous pneumothorax treatment, only few cases are documented, and even fewer document the role of non-invasive continuous positive airway pressure mechanical ventilation for treatment of this rare entity. We present a case of 23-year-old man who presented with left-sided pneumothorax, developed unilateral REPE and was treated with non-invasive continuous positive airway pressure.

Pyopericardium followed by constrictive pericarditis due to Corynebacterium diphtheriae.

Pyopericardium is a rare entity associated with a high mortality. We report a case of a 44-year old man presenting with simultaneous constrictive pericarditis and pyopericardium due to Corynebacterium diphtheriae. Pericardiectomy and epicardiectomy were performed without cardiopulmonary bypass, with an excellent result.

Acute pressure overload of the right ventricle. Comparison of two models of right-left shunt. Pulmonary artery to left atrium and right atrium to left atrium: experimental study.

BACKGROUND: In right ventricular failure (RVF), an interatrial shunt can relieve symptoms of severe pulmonary hypertension by reducing right ventricular preload and increasing systemic flow. Using a pig model to determine if a pulmonary artery-left atrium shunt (PA-LA) is better than a right atrial-left atrial shunt (RA-LA), we compared the hemodynamic effects and blood gases between the two shunts. METHODS: Thirty, male Large White pigs weighting in average 21.3 kg ± 0.7 (SEM) were divided into two groups (15 pigs per group): In group 1, banding of the pulmonary artery and a pulmonary artery to left atrium shunt with an 8 mm graft (PA-LA) was performed and in group 2 banding of the pulmonary artery and right atrial to left atrial shunt (RA-LA) with a similar graft was performed. Hemodynamic parameters and blood gases were measured from all cardiac chambers in 10 and 20 minutes, half and one hour interval from the baseline (30 min from the banding). Cardiac output and flow of at the left anterior descending artery was also monitored. RESULTS: In both groups, a stable RVF was generated. The PA-LA shunt compared to the RA-LA shunt has better hemodynamic performance concerning the decreased right ventricle afterload, the 4 fold higher mean pressure of the shunt, the better flow in left anterior descending artery and the decreased systemic vascular resistance. Favorable to the PA-LA shunt is also the tendency--although not statistically significant--in relation to central venous pressure, left atrial filling and cardiac output. CONCLUSION: The PA-LA shunt can effectively reverse the catastrophic effects of acute RVF offering better hemodynamic characteristics than an interatrial shunt.

Latent congenital defect: interrupted aortic arch in an adult--case report and literature review.

Interrupted aortic arch (IAA) is rare congenital cardiac defect defined as a complete loss of luminal and anatomical continuity between ascending and descending segments of the aorta. Usually it is detected in the perinatal period or during the first hours or days of infancy. If not treated surgically, it usually is lethal. Nevertheless, diagnosis can be made in adults but is a very rare entity. Extremely few cases in adults are reported in the pertinent medical literature. We present an asymptomatic 62-year-old patient who was found to have IAA after examination for hypertension. The patient underwent a successful anatomical repair, with an uneventful postoperative course, and follow-up examinations reveal regression of hypertension and excellent health condition.

Sleeve lobectomy for patients with non-small-cell lung cancer: a simplified approach.

OBJECTIVE: Pulmonary parenchyma-saving procedures, indicated for central tumours, seem to have better results than pneumonectomy, an alternative procedure. The purpose of this study is to report our experience at our institution with sleeve lobectomy with regard to surgical technique and outcome. METHODS: We retrospectively reviewed the records of 45 patients who underwent sleeve lobectomy for non-small-cell lung cancer, with a curative intent, during the period of January 2004 and January 2008. Four of these patients underwent bronchovascular reconstructive procedures. A minor modification of the running suture technique used for bronchoplasties is described here. RESULTS: The study identified 40 men and five women with a median age of 64 years (range: 24-80 years). All 45 patients underwent oncological resections with negative results for malignancy bronchial resection margins. Neither bronchial nor vascular complications occurred. Complications were observed in 15% of our patients and included prolonged air leak in three, atelectasis needing daily bronchoscopy in three and respiratory failure due to pneumonia in one patient, who eventually died, accounting for a mortality rate of 2%. The follow-up period ranged from 1 to 52 months, with a median of 26 months, and it was complete for 43 (96%) of the patients. The overall 4-year survival was 57%. CONCLUSIONS: Sleeve lobectomy for lung cancer, although technically demanding, is associated with low morbidity and mortality and satisfactory immediate and long-term results. With increasing experience, more lung-sparing procedures should be performed in selected patients.

Bilateral sternobronchial fistula after coronary surgery--are the retained epicardial pacing wires responsible? A case report.

BACKGROUND: Temporary epicardial pacing wires are routinely used during cardiac surgery; they are dependable in controlling postoperative arrhythmias and are associated with low morbitity. CASE REPORT: We report a case of sternobronchial fistula formation induced by the existence of retained epicardial pacing wires in a patient who underwent coronary surgery ten years ago. CONCLUSION: Reported complications of retained epicardial pacing wires are unusual. We present this case in order to include it to the potential complications of the epicardial pacing wires.

Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after unsuccessful ERCP: a case report.

BACKGROUND: The presence of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously is a rare complication of upper gastrointestinal endoscopy that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space. CASE PRESENTATION: We report an unusual case of a self-limited subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an unsuccessful ERCP for removal of a common bile duct stone. CONCLUSION: There was no radiological evidence of peritoneal or retroperitoneal perforation. This complication is distinct from pneumomediastinum and pneumoperitoneum due to perforation, and must be recognized, because it is benign and needs no surgical or radiological intervention.

Schistosomal peritonitis: a rare cause of acute abdomen.

Schistosomiasis is a major parasitic infection of tropical areas. We present a 26-year-old male immigrant from Egypt with acute abdomen due to schistosomial infection, mimicking symptoms of acute appendicitis, with histopathological detection and representation of schistosomial eggs in the unusual area of the greater omentum. This is a rare case with findings of intra-peritoneal schistosoma ova. We review the pertinent literature and indicate the need for a new approach to infectious diseases with unusual clinical presentation, due to pathogens coming from distal geographical regions, in which surgeons must keep a high index of suspicion.

Gerstmann's syndrome: can cardiac myxoma be the cause?

Cardiac myxomas are primary cardiac tumours. Clinical presentations vary. Central nervous embolism has been a constant association. We describe a case of a 40-year-old female who presented with neurological signs and symptoms of Gerstmann's syndrome secondary to a left atrial myxoma.

An unusual case of a swallowed thermometer perforated in the mediastinum.

A 39-year-old woman, who was addicted to drugs, was admitted because of referred chest pain and dysphagia after deliberate ingestion of a thermometer in a suicide attempt 6 hours earlier. Rigid esophagoscopy was unrevealing. On awakening, the patient confessed that the thermometer had been swallowed more than a month be operated on and get narcotic pain medications. Her history disclosed multiple admissions and laparotomies after suicide attempts with swallowed thermometers in the last 3 years.

Undifferentiated embryonal sarcoma of the liver mimicking acute appendicitis. Case report and review of the literature.

BACKGROUND: Undifferentiated embryonal sarcoma (UES) of liver is a rare malignant neoplasm, which affects mostly the pediatric population accounting for 13% of pediatric hepatic malignancies, a few cases has been reported in adults. CASE PRESENTATION: We report a case of undifferentiated embryonal sarcoma of the liver in a 20-year-old Caucasian male. The patient was referred to us for further investigation after a laparotomy in a district hospital for spontaneous abdominal hemorrhage, which was due to a liver mass. After a through evaluation with computed tomography scan and magnetic resonance imaging of the liver and taking into consideration the previous history of the patient, it was decided to surgically explore the patient. Resection of I-IV and VIII hepatic lobe. Patient developed disseminated intravascular coagulation one day after the surgery and died the next day. CONCLUSION: It is a rare, highly malignant hepatic neoplasm, affecting almost exclusively the pediatric population. The prognosis is poor but recent evidence has shown that long-term survival is possible after complete surgical resection with or without postoperative chemotherapy.

Synchronous early primary adenocarcinoma of both rectum and gallbladder. Report of a case.

BACKGROUND: Synchronous early primary cancers are rare and in addition synchronous adenocarcinoma of both rectum and gallbladder is extremely rare. CASE REPORT: We report an unusual case of synchronous early primary adenocarcinoma of rectum and gallbladder. The patient was a 72-year-old woman with complaints of bloody stools and constipation. An endoscopy revealed adenocarcinoma of the lower rectum. A through preoperative investigation showed also cholelithiasis. The patient underwent abdominoperineal resection and cholecystectomy. The histopathological diagnosis was well to middle differentiate adenocarcinoma of the gallbladder (T2, N0, M0; stage II) and middle differentiate adenocarcinoma of the rectum (T2, N0, M0; stage II). CONCLUSION: For the cases of extracolonic primary cancer associated with colorectal primary carcinoma, Warren and Gates' diagnostic criteria are used. All patients with colorectal carcinoma, should undergo a throughout preoperative examination to exclude the possibility of synchronous early primary cancers.