Polyvinyl chloride solvent cement poisoning: a case report.

BACKGROUND: S-lon® (S) is a locally produced polyvinyl chloride-based solvent cement. It is a clear, slightly viscous liquid. Other constituents include 1-cyclohexanone, 3-butanone, and 1-acetone. It is used ubiquitously for building construction in Sri Lanka. Although the clinical effects of the compound have not yet been ascertained, the constituents have been implicated in neurotoxicity, respiratory tract, eye and skin irritation, and delayed liver and renal injury. CASE DESCRIPTION: A 42-year-old South Asian male presented following self-ingestion of S. His vital parameters were stable and initially managed symptomatically. A few hours later, he developed central nervous system depression and stridor requiring elective intubation. Examination of the upper airway revealed inflammation and edema. He was sedated and ventilated, and intravenous dexamethasone was administered. Attempts at removal of the nasogastric tube after extubation on day 3 failed. The patient had to be reintubated and sedated owing to extreme agitation not responding to routine doses of sedatives. The nasogastric tube had been amalgamated after reacting with S, forming a solid clump, later found after removal. The posterior pharynx and nasopharynx were packed and later removed before extubation. The patient made a full recovery and was transferred to the ward on day 5. CONCLUSION: Ingestion of a sufficient quantity of S could result in gut absorption with central nervous system depression, coma, and even death. No antidote is available for toxicity, and management is largely supportive. As witnessed in our patient, chemical laryngitis and upper airway inflammation may lead to upper airway obstruction. Chemical reactions with medical equipment may lead to unforeseen outcomes.

Primary thyroid MALT lymphoma with a probable brain secondary in a male patient: A case report.

INTRODUCTION AND IMPORTANCE: Primary Mucosa-associated lymphoid tissue (MALT) lymphoma of the thyroid is a rare tumor. PRESENTATION OF CASE: A previously well male in his 50s presented to our institution with difficulty in breathing and sleep apnea. He was diagnosed with a large retrosternal multinodular goiter with level 2 unilateral cervical lymphadenopathy. Fine needle aspiration cytology of the thyroid revealed chronic thyroiditis and the enlarged lymph node cytology was inconclusive. He underwent total thyroidectomy and level VI bilateral cervical lymph node clearance. The histology revealed an extra-nodal marginal zone lymphoma of MALT. A whole-body CT scan did not demonstrate any other primary site. The patient received 4 cycles of local radiotherapy. Subsequently, he was diagnosed with a brain tumor not amenable to surgical interventions following persistent headaches. He died shortly after due to complications of probable cerebral metastasis. CASE DISCUSSION: MALT lymphomas of the thyroid carry a good prognosis; however, no universal guidance exists regarding the optimal therapy and follow-up. CONCLUSION: This case report highlights the importance of early diagnosis, identification of poor prognostic factors, and patient-tailored therapy and follow-up.

Psychological Autopsy in Small Penis Syndrome: Determining the Manner and Circumstance of Death Following a Vehicular Accident.

Road traffic accidents and related deaths are on the rise, especially in developing countries. Even though uncommon and probably under-recognized, predisposing psychiatric states may be contributory, posing the question of whether these could be avoided. Psychological autopsy, despite not being performed routinely, might play a pivotal role in such instances, in reconstructing events leading to the catastrophe and determining the role played by the parties involved. The legal implications, such as the exoneration of the wrongly accused, might be substantial. This case report presents a death of a middle-aged South Asian male with strong history and evidence of small penis anxiety following a direct collision in a road traffic accident. It highlights the careful evaluation of the clinical history of the deceased by a psychological autopsy and reiterates the importance of the former in suspected cases.

A fatal aorto-oesophageal fistula due to a mutton bone: A case report.

INTRODUCTION AND IMPORTANCE OF THE CASE: Aorto-oesophageal fistula (AEF) following foreign body ingestion is rare and conservative management is always fatal. The delayed presentation further confounds poor outcomes. PRESENTATION OF CASE: A 46-year-old South-Asian woman presented with pain and difficulty in swallowing following ingestion of a mutton-containing meal. The patient refused urgent upper GI endoscopy and was initially managed conservatively on the basis of the resolution of symptoms and hemodynamic stability and was discharged home. On review a week later, the patient did not consent to a UGIE. She presented the next day with a severe upper GI bleed. Due to profuse haemorrhage, a bleeding point could not be identified, and she suffered a cardiac arrest. Attempts at resuscitation were unsuccessful. The autopsy revealed an AEF caused by a sharp mutton bone lodged in the lower oesophagus. CLINICAL DISCUSSION: High-risk food bolus impactions such as the ones caused by sharp objects need urgent endoscopy to confirm the position and extraction if safe. AEF occurs with time and could result in massive haemorrhage and mediastinitis. Endoscopic stenting, thoracoscopic surgery, and open repair are methods of emergent and definite management that still carry significant mortality. CONCLUSION: Management of AEF requires early diagnosis with a high index of suspicion, endoscopic and CT-based angiography studies, and surgical interventions tailored to patients based on the available expertise. High-risk patients should be similarly educated on the probable complications and the symptomatology.

Bone pathology mimicking non-accidental injury in a child - Bewildered by bones, case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Physical abuse of children is criminal conduct in the purview of medico-legal sciences and the confirmative diagnosis of 'child abuse' is imperative for further legal proceedings. Clinicians play a pivotal role in the protection of children by recognizing and reporting such cases and treating the victims of abuse. PRESENTATION OF CASE: To the best of our knowledge, we present the first case report in literature where osteofibrous dysplasia resulted in a pathological fracture in a 10-month-old South-Asian child which resembled the picture of child abuse. CLINICAL DISCUSSION: The challenges faced by clinicians in the process of analysis of presumed child abuse are numerous and careful formulation and elimination of medical conditions which may mimic non-accidental injury (NAI) is a must, prior to making an incontrovertible diagnosis. CONCLUSION: The telltale signs of NAI such as soft tissue injuries and fractures in a victimized child should always be evaluated cautiously with the intent of excluding pathologies that may mimic them and the evidence in this regard is seldom in literature.

Fatality in the perioperative period: A case report on refractory hypoxemia in an infant following open inguinal herniotomy.

INTRODUCTION AND IMPORTANCE OF THE CASE: Post-operative adverse respiratory events are not uncommon among infants. PRESENTATION OF CASE: A 2-month-old male infant with an acyanotic heart disease underwent an elective open inguinal herniotomy under general anaesthesia. The intraoperative period was uneventful. The infant developed intermittent respiratory apnea and low oxygen saturation, followed by bradycardia in the post-anaesthesia care unit. Despite continued resuscitative efforts, the baby succumbed. The autopsy did not reveal new pathology. A period of interrupted monitoring during the recovery was noted. This could have led to undetected apnoea following an obstructed airway and resultant prolonged hypoxemia, further complicated by underlying structural heart disease. CLINICAL DISCUSSION: Hypoxemia in the postoperative period in infants could be multifactorial. Airway obstruction due to secretions, airway spasms, and apnoea are common causes. CONCLUSION: Prolonged hypoxia among paediatric patients could rapidly progress to cardiovascular collapse, hypoxic brain injury, and even death. This warrants close monitoring and active management during impaired oxygenation and ventilation during perioperative LMA use.

Management of an intraoperative tracheal injury during a Mckeown oesophagectomy: A case report.

INTRODUCTION AND IMPORTANCE: Tracheobronchial injuries are uncommon complications during oesophagectomies adopting blind dissection or thoracoscopy. Neoadjuvant chemo-radiotherapy is considered a risk factor while double-lumen endotracheal tube insertion and direct surgical damage are other related causalities. PRESENTATION OF CASE: A 65-year-old male underwent a Mckeown oesophagectomy with a right thoracotomy for a mid-oesophageal carcinoma. During the latter stages of cervical dissection and oesophageal mobilization, a 2-cm tracheal injury was noted in the posterior membranous trachea. It was repaired with 2.0 prolene with interrupted sutures and local transposition muscle flap using prevertebral muscles. Post-operatively, he was ventilated in view of prolonged surgery and the probability of airway oedema with the double-lumen ET tube. A transient bubbling of the intercostal drain was managed conservatively and attributed to a secondary pneumothorax. He was extubated and made an uncomplicated recovery. At 2 years, he did not have any tracheal stenosis. CLINICAL DISCUSSION: If diagnosed intraoperatively and for sizes >2 cm, tracheobronchial injuries should be repaired. Various techniques exist with differing evidence. Repair with non-absorbable sutures, use of synthetic grafts, innate tissue such as intercostal and pectoral muscle flaps, and pericardial and pleural flaps are all being used. Early extubation might be useful provided other criteria for extubation are met. CONCLUSION: Tracheobronchial injuries during oesophagectomies present a surplus challenge to both the anaesthetist and the surgeon. Collective decision-making tailored to the patient and close monitoring during the postoperative phase would result in good outcomes.

Vaginal prolapse of a large uterine cervical leiomyoma complicated with cervical inversion: A case report of an extremely rare entity with review of the literature.

Cervical leiomyoma is a relatively uncommon type of uterine leiomyoma. Prolapse of a cervical leiomyoma with inversion of the cervix is an extremely rare phenomenon, especially in a non-puerperal woman. Only a handful of cases are reported in the English literature. The case discussed here is of a vaginal prolapse of a submucous cervical fibroid complicated by cervical inversion in a South Asian perimenopausal woman with multiple comorbidities who had defaulted medical follow-up during the second wave of the COVID-19 pandemic. Being one of the largest reported cervical fibroids to date is another particularity of this case. Emphasis is given to the clinical diagnostic, anaesthetic, and surgical challenges encountered with a brief note on the impact of COVID-19 on outpatient clinic follow-up.

An unusual case of a traumatic splenic rupture masquerading as myocardial ischemia: a case report.

BACKGROUND: The spleen is one of the most frequently injured abdominal organs during trauma, which can result in intraperitoneal bleeding of life-threatening magnitude. Although splenic injury secondary to trivial trauma comprises a minor fraction of abdominal injuries, undiagnosed or delayed diagnosis may result in a complicated clinical course. CASE PRESENTATION: One such event is presented here, wherein a late diagnosis of an advanced grade splenic injury following a trivial trauma initially presented in disguise as acute myocardial ischaemia in a previously healthy South Asian woman in her late 30s. Emergency laparotomy and splenectomy were performed with simultaneous massive transfusion for a 3.5-L blood loss. She subsequently had an uncomplicated clinical course with regular surgical follow-up. CONCLUSION: Splenic injuries might present with ambiguous symptoms such as atypical chest pain and shoulder pain, necessitating attending clinicians to have a high degree of suspicion, especially in busy units such as the emergency department (ED).

Systemic lupus erythematosus mimicking idiopathic multicentric Castleman disease: A diagnostic dilemma.

Castleman disease is a heterogeneous group of disorders of lymphoid tissue. It can often mimic other autoimmune diseases or malignancies, presenting a diagnostic dilemma to attending clinicians. Systemic lupus erythematosus and Castleman disease share many clinical and biochemical features rendering a special diagnostic challenge. Herein, we report a case of a young female who initially presented with features of idiopathic multicentric Castleman disease, subsequently developed antinuclear antibody positivity, and fulfilled the criteria for the diagnosis of systemic lupus erythematosus. Following the commencement of treatment for systemic lupus erythematosus, she had a marked response with resolution of altered clinical and biochemical profile.

Investing in the Academic Writing: Training Future Reviewers and Sustaining Efficient and Quality Peer Review.

Peer reviewers are considered gatekeepers in academic writing who play a pivotal and essential role during the publication process. Excellent manuscripts invariably need excellent reviewers. Producing peer reviewers with such caliber is time-consuming albeit necessary for the progress and continuity of academia. Despite the popular belief that an experienced author invariably makes a good reviewer, the reality is far-fetched. This suggests the need for peer reviewer training, which should be effective, logistically affordable, and demonstrate long-lasting positive impacts. Open review, co-review, and several reviewer training programs are already in place for this purpose with varying efficiencies. This narrative review discusses the current modalities available to a junior reviewer to improve his/her review skills and proposes a reviewer residency concept that could be adopted as a part of peer reviewer training.

A peculiar appendix: A case report.

INTRODUCTION AND IMPORTANCE: Acute appendicitis is a clinical diagnosis with marked variations in the clinical presentation, the latter resultant of varied anatomical positions of the appendix. PRESENTATION OF CASE: Here we present the first documented case of the vermiform appendix located in the ascending colon of a young South Asian male who presented with right upper abdominal pain. The ultrasound scan of the abdomen failed to visualise the appendix in the right iliac fossa. Persistent symptoms despite conservative therapy and elevated inflammatory markers warranted an open laparotomy. The histology further confirmed acute appendicitis. CLINICAL DISCUSSION: Atypical locations and congenital anomalies of the appendix are relatively rare entities. Appendicular duplication and hypoplasia are the predominant varieties of congenital anomalies. Caecal diverticula might mimic acute appendicitis despite the relative rarity and absence of all three layers of intestinal wall, which could be of use in distinguishing an abnormally located appendix. CONCLUSION: Such deviations from the norm lead to atypical clinical and imaging findings where operative interventions might be required in place of non-operative care, especially in instances of persistent symptomatology.

Acute abdomen following axial torsion of a Giant Meckel's diverticulum in a young male: A case report.

INTRODUCTION AND IMPORTANCE: Among Meckel's diverticulum (MD), the 'Giant' category is relatively rare. Most Giant MDs lead to complications such as torsion and diverticulitis. PRESENTATION OF CASE: A 20-year-old South Asian male presented with a three-day history of vomiting and left-sided abdominal pain. X-ray and ultrasound scan of the abdomen illustrated features of small bowel obstruction. He underwent laparotomy under general anaesthesia. A gangrenous, axially torsed 25-cm Giant MD with concurrent ileal compression by a mesodiverticular band was detected and diverticulectomy and segmental resection with end-to-end anastomosis of the ileum was performed. Histology revealed ectopic gastric and pancreatic tissue. He had an uneventful postoperative stay and was devoid of any surgery-related complications at one-year follow-up. CLINICAL DISCUSSION: Adults mainly present with bowel obstruction following complicated MDs. Multiple mechanisms have been elaborated as causalities of bowel obstruction where the presence of bands of congenital or inflammatory origin, intussusception, and enteroliths are relatively common. The presence of ectopic tissue in MDs is associated with increased complications. Symptomatic MDs need resection to abate future complications such as haemorrhage and obstruction. CONCLUSION: Despite the low diagnostic potential of clinical examination and radiological studies, a high degree of suspicion is warranted in cases of probable MD-resultant complications, where more common aetiologies have been ruled out, as delay in diagnosis and definitive surgical therapy are invariably associated with worsened morbidity and mortality. It is high time to elucidate related demographics and clinical data on Giant MDs to identify high-risk categories and develop safer follow-up protocols.

A fatal perforation of the distal ileum from an ingested fish bone: A case report.

INTRODUCTION AND IMPORTANCE: Foreign body-induced perforations of the ileum are rare consequences among adults. PRESENTATION OF CASE: This is a case report of a delayed presentation of an ileal perforation and concurrent faecal peritonitis presented as an acute abdomen, resultant from an ingested fishbone, which led to fatality despite urgent laparotomy. CLINICAL DISCUSSION: Perforations following ingested foreign bodies are frequently unanticipated clinically, and diagnosed during advanced imaging studies or surgical interventions. Endoscopy, laparoscopy, and laparotomy have been used during surgical management in reported cases; however, prior early identification is pivotal for good outcomes as delayed presentations and delayed diagnosis carry a poorer prognosis. CONCLUSION: Despite fish bones being frequent foreign bodies in the gastrointestinal tract and the majority causing no life-threatening adverse effects, they are the leading foreign bodies instigating gastrointestinal perforations. A high degree of suspicion is required when attending to patients with suspected gastrointestinal perforations and absent typical findings in routine imaging, where fish bones could be the aetiology.

Reactivation of varicella-zoster virus following mRNA COVID-19 vaccination in a patient with moderately differentiated adenocarcinoma of rectum: A case report.

Herpes zoster which is the reactivation of varicella-zoster virus, a pathogenic human alpha-herpes virus, following primary infection or chicken pox, is known to occur especially in advanced age and in the immunocompromised among other predisposing factors. COVID-19 vaccination-induced immunomodulation is a novel scenario, hypothesized to be a result of shifting of T-lymphocyte population towards vaccine-induced naïve CD8+ subset, offsetting the balance of varicella-zoster virus responsive T-helper cells, thereby defecting the cell-mediated immunity which suppresses the latent varicella-zoster virus. The exact mechanism, however, is still elusive. Herein, we discuss a case of reactivation of varicella-zoster virus following BNT162b2 mRNA COVID-19 vaccine in an elderly female on oral medication for long-term diabetes and hypertension with good control who has undergone local radiotherapy for an underlying adenocarcinoma of rectum awaiting surgical resection, highlighting the key features of pathogenesis of the disease in relation to COVID-19 vaccination with a pertinent survey of the literature. This case report highlights the importance of differentiating vaccine-related cutaneous reactions with clinically more significant adverse events, early specific therapy thus preventing poorer acute and chronic outcomes.

Two lives at stake: Obstetric anaphylactic shock resulting in acute respiratory distress syndrome - A case report.

Maternal anaphylaxis is rare albeit life-threatening critical incident dreaded by many due to negative effects on not only the mother but the foetus as well. Antibiotics and anaesthetic agents still contribute to majority of the episodes. Consequences of anaphylaxis such as placental insufficiency and subsequent foetal neurocognitive deficits are devastating outcomes. Acute respiratory distress syndrome following anaphylaxis is even rarer among the normal population. The management of maternal anaphylaxis does not differ from routine recommendations even though close monitoring and preparedness for early delivery should be embedded in the protocols. This is a rare case report of a primi mother who developed anaphylactic shock following intravenous penicillin in the background of negative allergic history, resultant foetal distress requiring emergency lower segment caesarian section and delayed onset acute respiratory distress syndrome which was later attributed to anaphylaxis. Pertinent identification and management which included a multidisciplinary team culminated in favourable outcomes.

A Rare Case of Bilateral Achilles Tendon Xanthomas in a Teenager, Successfully Treated with Tendon Sparing Technique.

BACKGROUND: Xanthoma of the Achilles tendon, even though being benign, is a surgically challenging orthopaedic condition. Causality is believed to be due to a pathological error in the metabolism of low-density lipoprotein and their resultant accumulation, as foam cells within the tendon. Tendon xanthomas are often found to accompany heterozygous familial hypercholesterolemia. Case Presentation. A 19-year-old girl presented to our institution (a District General Hospital), with soft tissue lumps over posterior aspect of the ankle on both sides for several years. She had noticed a rapid increase in size in recent 3 months and sought medical advice. During investigation, she was diagnosed having bilateral Achilles tendon xanthomas clinically, confirmed by ultrasound scan and magnetic resonance imaging, and familial hypercholesterolemia concomitantly. The former was managed with intralesion subtotal resection where the histology further confirmed the diagnosis. The patient was commenced on statins and followed up while assessing the functional outcome and recurrences up to 2 years, with favourable results. CONCLUSION: Subtotal resection of Achilles tendon xanthoma (tendon sparingly) offers cosmetically and functionally acceptable outcomes, with faster recovery and no recurrences over 2 years.

Haemophagocytic Lymphohistiocytosis with Leptospirosis: A Rare but Devastating Complication.

INTRODUCTION: Secondary haemophagocytic lymphohistiocytosis (sHLH), often associated with an array of infections, malignancies, and autoimmune diseases, is rarely seen with leptospirosis, which carries a relatively poor prognosis even with modern state-of-the-art medical care. We describe a patient with leptospirosis complicated by sHLH who succumbed to illness following multiorgan dysfunction. Case Description. A 74-year-old farmer presented with high-grade, unsettling fever for a week. Muddy water exposure and suggestive symptoms prompted investigation and management in the line of leptospirosis (IV ceftriaxone was instituted, and later, MAT (microscopic agglutination test) became positive). Subsequently, he developed severe acute hypoxemia requiring mechanical ventilation and acute renal failure requiring renal replacement therapy. Bone marrow biopsy and markedly elevated serum ferritin and triglyceride levels done on day 10 (with unresolving fever, hepatosplenomegaly, and pancytopaenia) confirmed the diagnosis of HLH. The routine cultures, retroviral studies, CMV, dengue, hanta and mycoplasma antibodies, tuberculosis and COVID-19 PCR, and malaria screening were all normal. There was no improvement of hypoxemia following intravenous methylprednisolone. He died on day 15 despite escalating organ support. CONCLUSION: Leptospirosis is a common zoonotic disease in the tropics with significant morbidity and mortality. In the case of severe leptospirosis, overlapping clinical features with sHLH make the diagnosis of the latter challenging. No assessment tools are available to date to predict the risk of developing sHLH in a patient having leptospirosis. Outcome following sHLH due to leptospirosis still remains majorly ominous. A high index of suspicion and low threshold for specific investigations could possibly alter the outcome following such an occurrence.

Corrigendum to "Pus in Spinal Needle: Diagnosis and Management of a Long-Segment Spinal Epidural Abscess".

[This corrects the article DOI: 10.1155/2021/9989847.].

Cerebral cavernous malformation in a child leading to a fatal subarachnoid hemorrhage - "silent but sinister:" A case report and literature review.

BACKGROUND: Cerebral cavernous malformations (CCMs), otherwise known as cavernous hemangiomas/ cavernomas, are a type of vascular malformation. It is the third most common cerebral vascular malformation, histologically characterized by ectatic, fibrous, blood filled "caverns" with thin-walled vasculature without intervening normal brain parenchyma. CASE DESCRIPTION: Herein, we present a case of an original, spontaneous hemorrhage from a sporadic form of CCM without associated gross developmental venous anomaly in an 11-year-old child, which is an extremely rare occurrence, with the special emphasis on the demographic data of the affected population, risk factors associated with hemorrhage, and correlation of histopathological and radiological findings with an in-depth literature review. CONCLUSION: The significant majority of the CCM are clinically occult. Hence, the development of risk assessment tools and guidelines for timely neurosurgical intervention poses a greater clinical challenge for medical experts rendering the management of the affected individuals with CCM in an anecdotal situation. Presentation of life-threatening rebleeds and neurological deficits in the diagnosed population albeit uncommon is possibly preventable outcomes.