Articles of International Journal of Case Reports

A rare case of adult ileo-colic intussusception: Hamartomatous polyp as a lead point with concurrent appendiceal neurofibroma in Neurofibromatosis Type 1

Intussusception is a rare cause of adult intestinal obstruction and unlike in children, adult intussusception is commonly caused by a lead point, requiring surgical intervention in most cases. Hamartomatous polyp is a non-neoplastic growth of tissue containing mature cells, distributed in an abnormal manner. It is often associated with intestinal polyposis syndromes such as Peutz-Jeghers syndrome and Juvenile polyposis. In the current case, we report an extremely rare case of ileo-colic intussusception secondary to a lead point of an isolated ileal hamartomatous polyp in an elderly gentleman with Neurofibromatosis type-1. Patient was successfully treated with ileo-colic resection involving the intussuscepted segment of bowel. There was an incidental finding of a nodule in the appendix and the histology confirmed this as a neurofibroma. Post-operative recovery of the patient was unremarkable.

Intramucosal esophageal dissection after esophagogastroduodenoscopy: two case reports

Introduction: Intramucosal esophageal dissection (IED) is an uncommon disorder, described as the separation of the mucosa and/or submucosa from deeper muscular layers due to abrupt increase in intraesophageal pressure. Case presentation: The first case il that of a 52 – years old female patient who underwent an esophagogastroduodenoscopy for control. After the procedure an extensive subcutaneous emphysema of the neck and a massive pneumomediastinum occurred. The patient was successfully treated with a conservative approach. The second case is that of a 43-years old male patient affected by Down’s Syndrome, who underwent an esopagogastroduodenoscopy because of persisting dysphagia. The endoscopic showed the presence of a serrated stricture at 20 centimeters from dental arcade. After the procedure he fell dysphagia. A neck-chest TC-SCAN showed superior and posterior pneumomediastinum and subcutaneous emphysema, without signs of mediastinitis. The patient was successfully treated with conservative approach. After a few days, a new chest CT-SCAN showed the presence of an anomalous right subclavian artery arising from the descending part of the aortic arch, causing dysphagia lusoria. Discussion: The causes of IED include iatrogenic instrumentation, hemostatic applications, mucosal injuries from ingestion of sharp foreign body, or spontaneous. A fluoroscopic upper gastrointestinal series or upper gastrointestinal endoscopy has been widely used to diagnose IED. CT and magnetic resonance are useful for differential diagnosis. In the absence of signs of mediastinitis management is conservative. Conclusion: CT SCAN should be the first exam to perform in the suspicion of IED. The first line treatment should be conservative. In case of the onset of complications and in patients who are refractory to conservative management, endoscopic or surgical treatment are indicated.

Paget´s disease of bone in a patient on peritoneal dialysis

Paget´s disease of bone is a disorder characterized by disorganized bone remodeling. It´s occurrence in patients with end-stage kidney disease on renal replacement therapy is rare. Here we report a case of Paget´s disease of bone in an 80-year-old male on peritoneal dialysis that presented a high level of alkaline-phosphatase with a mildly elevated parathyroid hormone level and typical imaging findings localized to the pelvis. This is the fourth reported case of Paget´s disease in a patient on peritoneal dialysis and the first treated with denosumab.

A Case of Upper Limb Deep Vein Thrombosis in a Known HIV Patient With Non Hodgkins Lymphoma

This is a case of upper limb deep vein thrombosis in a HIV positive patient who had also been diagnosed of Non-Hodgkins Lymphoma. This case highlights the importance of thromboprophylaxis and thrombotic risk assessment in all HIV positive as well as cancer patients particularly in low resource setting which are at risk of increased morbidity and mortality.

Clinical and biochemical manifestations of undiagnosed Hashimoto’s thyroiditis

We report the case of a 69 year old female who presented with mild cognitive impairment and difficulty mobilising in the setting of profound hypothyroidism secondary to Hashimoto’s thyroiditis with associated elevated creatine kinase (CK), hyponatraemia, anaemia, renal impairment, hypercholesterolaemia and hypertryglyceridaemia. On initial investigations the patient had a thyroid stimulating hormone (TSH) of 49 mU/L, free T4 <5.4 pmol/L, thyroid peroxidase (TPO) antibody positive, CK 1628 units/L, sodium 120 mmol/L, haemoglobin 87 g/L, creatinine 109 mcmol/L, total cholesterol 8.1 mmol/L and tryglycerides 4.7 mmol/L. On examination the patient had no features of myxoedema coma but was found to have delayed relaxation of tendon reflexes, puffy facies with loss of outer one third of eyebrows, coarse hair, brittle nails and slowing of speech and movement with obvious cold intolerance. There was no muscle weakness on examination to suggest myositis although the patient complained of generalised aches and lethargy. The patient was initially treated with 100mcg oral thyroxine daily however this was increased and oral liothyronine introduced following an inadequate improvement. Eleven days post admission the TSH was 6.26 mU/L and the free T4 was 12.4pmol/L following a total of 1500mcg oral thyroxine replacement and 60mcg oral liothyronine replacement. The hyponatraemia improved with a strict fluid restriction of 500 millilitres daily to sodium 133 mmol/L and the renal function improved to a creatinine of 70 mcmol/L on discharge. Atorvastatin was withheld due to the elevated CK which improved to 370 units/L and the anaemia remained stable throughout the admission. Although the patient refused formal cognitive assessments her functional abilities improved with treatment. This case highlights the clinical and biochemical features of severe hypothyroidism in the setting of undiagnosed Hashimoto’s thyroiditis.

Isolated Aortitis with multiple Aortic aneurysms and widespread venous, arterial and intracardiac thrombosis: A challenging Vascular Behcet’s Disease case management

In 1937, Hulusi Behcet’s brought to our attention the existence of a disease characterized by recurrent oral aphthae and any of several systemic manifestations including genital aphthae, ocular disease, skin lesions, gastrointestinal involvement, neurologic disease, vascular disease, or arthritis [1-3]. He became the first physician to describe this and the disease was henceforth named after his name. The aetiology of this disease remains unclear however it has been noticed that Behcet’s syndrome is remarkable for its systemic vasculitides which include its ability to involve blood vessels of all sizes (small, medium, and large) on both the arterial and venous sides of the circulation with occlusive nature [4]. This makes Vasculitis the major cause of the clinical manifestations of the disease with the involvement of almost any organ. We herein report an unusual case of a thirty-year-old Syrian man with no past medical illnesses. On presentation, he suffered from a sudden onset of shortness of breath and a history of hoarseness of voice for less than a week, and drastic weight loss of about thirty kgs within a month. Imaging confirmed the presence of pulmonary embolism, bilateral deep venous thrombosis, intracardiac thrombosis, popliteal artery thrombosis with thoracic, and abdominal aortic aneurysms. This case highlights the importance of having a high suspicion of the possibility of Behcet’s disease when multiple thrombi and aneurysms manifest in a patient on the silk root country. Thereby, stressing the importance of familiarizing ourselves with such unusual presentations of Behcet’s disease and the course of this unusual presentation with some learning points with a good literature review included below.

Autologous Tenocyte Implantation (ATI) and the Use of Collagen Scaffolds: a Case Report of a Novel Surgical Treatment for Gluteal Tendon Repair

Background: Ortho-biological therapies such as platelet-rich plasma and autologous tenocyte implantation injections are hypothesized to introduce cellular mediators such as growth factors into tendons, promoting natural healing. Methods: This case introduces a 63-year-old female with an extensive history of lateral hip pain and treatment refractory tendinopathy with tearing. She underwent open surgery to repair the gluteus medius tendon, using supplementary autologous tenocyte implantation (ATI) in conjunction with a Celgro (Orthocell, Perth, Australia) collagen scaffold. Level of evidence: 4 Results: She had normal function in the hip at 12 months. MRI scans post-operatively at 12 months showed a marked reduction in inflammation, an intact tendon and a reduction in atrophic changes in the muscle belly. Conclusion: Surgical repair of a large degenerate tear of the gluteus medius tendon, augmented with autologous tenocyte implantation in a collagen scaffold led to an excellent patient outcome and MRI findings demonstrated tendon healing with improved tendon structure and reduced inflammation.