IJCR (2020), Volume 4

  • Necrotising fasciitis of the abdominal wall

    A 53 year old gentlemen, with a history of intravenous drug use, presented to the Emergency Department in septic shock with an acute abdomen. He had been recently treated with dalteparin for a deep venous thrombosis of his left leg. He was resuscitated with fluids and antibiotics, and cross-sectional imaging suggested a diagnosis of necrotising fasciitis of the abdominal wall. He was admitted to ITU, and a laparotomy, abdominal washout, muscle debridement and laparostomy was performed overnight. No bowel perforation or contamination was identified. Over the next few weeks he underwent multiple debridements, and a negative pressure abdominal dressing was utilised. After a prolonged rehabilitation phase he was discharged home to live independently. He is currently in discussion with the plastics team regarding reconstruction of his abdominal wall. We would like to stress the importance of consideration of necrotising fasciitis as a diagnosis in the context of a critically unwell and septic patient with a history of subcutaneous/intravenous medication usage.

  • Functional Neurological Deficit: one of the most controversial diagnosis- case report of a patient with paraplegia

    Background: Conversion disorder, also called functional neurological symptom disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors.any case of FND is challenging and hard to manage due to overlapping of symptoms with other organic illnesses and also hard to be treated due to multidisciplinary approach needed. Case Report: A 34 year old patient known to have schizophrenia with previous admissions to psychiatric hospital suddenly complaining of paraplegia with no sensory deficit . these symptoms persist for 6 months. Conclusion: Long lasting symptoms is something unusually seen in conversion disorder cases where the course of illness stay for a couple of days.

  • Factor XII deficiency: A rare case report and literature review

    Background: Factor XII is part of the intrinsic pathway. the activity of this pathway is assessed by measuring the activated partial thromboplastin time (aPTT). Deficiency of Factor XII is rare, often inherited as autosomal recessive, nevertheless autosomal dominant pattern has also been reported. congenital deficiency is associated with mutations in the F12 gene on chromosome 5. Here we report a patient with factor XII deficiency which is considered as a rare inherited coagulation disorder. Case report: we report the case of a 37 years old gentleman known to have Diabetes mellitus, hypertriglyceridemia, past history of pancreatitis and an episode of gingival bleeding a year prior to this presentation which was attributed to periodontitis. He presented to the emergency room complaining of epigastric pain radiating to the back as well as non-projectile vomiting. He used to drink alcohol but stopped 6 years ago. physical examination showed epigastric tenderness, poor dental hygiene and periodontitis. investigations showed neutrophilic leucocytosis, high lipase and raised triglycerides level of 11.3 mmol/L. He was treated successfully for triglycerides induced pancreatitis with IV insulin, Dextrose 5% infusion and fenofibrates. Isolated prolonged aPTT was detected incidentally which was corrected with mixing study indicating a factor deficiency. Factor assays revealed factor XII deficiency (5.8%) with other factors being within normal ranges. Past records did not show any thrombotic event. No specific treatment was given for Factor XII deficiency. Conclusion: Factor XII deficiency is associated with an isolated prolonged aPTT without increasing risk of bleeding. patients with this condition should be offered regular follow up because of the increased rate of thromboembolic complications.

  • Combined factor V and factor VIII deficiency: A rare case report and literature review

    Background: Combined factor V and factor VIII deficiency (F5F8D) is a rare autosomal recessive inherited coagulopathy. It has a higher prevalence in the Mediterranean region (1:100,000) compare to its prevalence in the general population which is estimated to be (1:1000,000). Case report: We report a 59 years old Lebanese lady who was referred from the general surgery clinic with an asymptomatic prolongation of prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (aPTT) detected during preoperative work up for an elective umbilical hernia repair. The patient had history of bleeding following dental procedures since childhood as well as easy bruising with minimal trauma. Physical examination was unremarkable. haematological investigations were normal apart from the prolonged PT, INR and aPTT which were corrected following mixing studies. Factor assay revealed factor V level of 5.5% and factor VIII level of 11.9% with other factors within normal ranges confirming the diagnosis of combined F5F8D. Conclusion: Combined factor V and factor VIII deficiency should be suspected in patients with prolonged PT, INR and aPTT especially if they are of Mediterranean, Middle east or Arabic origin with a history of consanguineous marriages. Treatment is generally not indicated unless the patient has recurrent serious bleeding manifestations.

  • An increasing trend of iatrogenic scar endometriosis after lower segment cesarean section

    Cesarean scar endometriosis is an uncommon disorder developed due to iatrogenic implantation of endometrial tissues in the cesarean incision site. The frequency of the scar endometriosis is assumed to increase because of the increasing trend of lower segment cesarean section in modern obstetric practice. Cesarean section might be a great risk factor for the development of scar endometriosis due to higher exposure of endometrial cells to the subcutaneous tissue during the procedure. Prevention of decidual cell contamination to the superficial abdominal layers may reduce the occurrence of iatrogenic scar endometriosis. We reported a 21-year old para 2 woman with a history of cesarean section 2.5 years back who presented with a small mass at the middle of the cesarean scar which was associated with pain and blood-stained discharge during menstruation. Based on clinical and USG findings the provisional diagnosis was made scar endometriosis and subsequently we managed her by wide local excision of the lesion followed by adjuvant hormone therapy. No recurrence of scar endometriosis was observed during her follow up period.

  • Retained Penile Ring: Case Reports

    Background: Penile constriction rings have been used to prolong erection with vacuum devices in the treatment of erectile dysfunction. Some have also employed it for recreational purposes with the attendant risks of penile edema, strangulation and necrosis. We present two cases of entrapped phallus by penile rings. Case reports: 16 years old with pain and swelling of the phallus of 12 hours duration. This started after placement of a phallic ring to purportedly prolong erection which he was later unable to remove the ring despite several attempts and developed progressive swelling and pain in the phallus. He was also unable to pass urine. Examination revealed a circumcised phallus that was detumescent but grossly edematous, tender with shiny skin. Initial simple manoeuvres in the casualty proved abortive and ring had to be cut with an orthopaedic instrument. He was subsequently able to void without difficulty or any haematuria. 47 year old Asian male with a 12 hour history of penile pain and swelling following entrapment of a penile ring he had inserted for sexual gratification about 24 hours before presentation. There was a history of haematuria. The removal of the penile ring was achieved with a combination of cold compress squeeze, corporal aspiration and lubrication under general anaesthesia. Conclusion: Successful management of retained penile ring depends on early presentation by the patient to avoid adverse outcomes. It may require instruments not normally found in the urologist armamentarium.

  • Thoracic mediastinal Chordoma an atypical location – Mimicking as Adenocarcinoma

    Background: Chordoma, a rare tumor accounting for less than 4% of primary bone tumors of which incidence of thoracic chordoma is 2-5%. Describing an incidental diagnosis of chordoma in a posterior mediastinal mass. Case description: An asymptomatic 52year lady with an incidental posterior mediastinal mass was diagnosed Adenocarcinoma on endoscopic biopsy of the oesophagus. Nonresponsiveness to chemoradiotherapy warranted en-bloc resection with VATS- assisted thoracotomy which turned to be a Chordoma. Conclusion: We report this atypical presentation of chordoma mimicking as adenocarcinoma with literature review — a unique learning experience.

  • Patellar tendon rupture in a young adolescent post-Heterotopic Ossification – Uncommon presentation

    Background: Heterotropic ossification is a common entity, but in a young adolescent causing patellar tendon rupture is rare. Case description: A 13-year-old male presented to us with knee pain and inability to extend since six weeks following trivial trauma. Preliminary radiological investigations revealed a high riding patella with ossification in the patella tendon. The magnetic resonance scan confirmed the same with patellar tendon disruption and heterogenous ossification. He underwent surgery with patella tendon repair, augmentation with autograft and had complete recovery at six months follow-up. Conclusion: Heterotropic ossification caused by repetitive trauma leading to disastrous effects.

  • Idiopathic Acquired Factor VIII deficiency presenting with compartment syndrome: A case report and Literature Review

    Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital form of the disease is the most prevalent, is inherited as X-linked recessive and it causes deficiency of clotting Factor VIII or IX. clinically it presents with joint bleeding. Its counterpart, acquired haemophilia is a rare condition that usually presents with cutaneous, soft tissue or internal bleeding. The pathophysiology of the disease is centred on the formation of auto antibodies which inactivate factor VIII. Haematologically this is reflected as a prolonged aPTT with normal PT and failure of mixing studies to correct aPTT to more than 50%. To confirm the diagnosis Bethesda assay has to be performed to detect the presence of factor inhibitors. In half of the cases it is associated with an underlying condition such as autoimmune diseases, malignancy, pregnancy or infections. The mainstay treatment is to control the bleeding with bypassing agents such as recombinant factor VIIa or Factor VIII inhibitor bypassing agent as well as eradicating the inhibitor with immunosuppressive and/or cytotoxic agents. Here we report a patient with idiopathic acquired haemophilia who presented with a thigh compartment syndrome. He was successfully treated with fasciotomy, bypassing agents and immunosuppressive therapy.

  • Follicular Dendritic Cell Sarcoma of Colon Presenting as Colo-colic Intussusception: a Rare Entity in Gastrointestinal Site With Extremely Rare Presentation

    Follicular dendritic cell sarcoma is a rare mesenchymal tumor of follicular dendritic cells arising from nodal and extranodal site. FDCS generally involves the lymph nodes while many extranodal sites are also affected. We report a case of follicular dendritic cell sarcoma primarily arising in colon and presenting as colo-colic intussusception.