International Journal of Case Reports

Introduction: In England 12,000 children are diagnosed with appendicitis each year. The diagnosis of appendicitis is difficult especially in children. There are many other diagnoses which mimic appendicitis including Meckel’s diverticulum, intussusception, gastroenteritis and mesenteric adenitis. Unfortunately there is no gold standard in the diagnosis of appendicitis and often clinicians are hesitant to submit a child to radiological investigations. Presentation of the case: An eleven year old boy, of Bangladeshi origin, presented to the Royal Gwent Hospital, South Wales, with an acute onset of centralised abdominal pain and vomiting. Following a period of observation and re-examination his pain had localised to the right iliac fossa and it was decided on clinical grounds to perform a laparoscopy for suspected appendicitis. Intra-operative findings showed an intussusception of the small bowel secondary to a mucosal lesion. Histology showed high grade non-Hodgkin’s lymphoma with a pattern suggestive of Burkitt’s lymphoma. Conclusion: The case highlights the importance of accurate diagnosis of appendicitis and the difficulties of managing abdominal pain in children. More needs to be done to develop a better criterion and judicial use of imaging to guide surgical intervention.

Broncho-oesophageal fistula refers to an abnormal communication between a bronchus and the oesophagus. Broncho-oesophageal fistula is rare and can be either congenital or acquired. Congenital fistulas are usually diagnosed in the neonatal period as they present with respiratory distress and cyanosis during feeding. Whereas developmental anomaly is the commonest cause in infancy and childhood, the aetiology in adults is most frequently secondary to an oesophageal malignancy1. Non-malignant causes of fistulae are rare. Diagnosis of a broncho-oesophageal fistula may sometimes be difficult because of an insidious and non-specific clinical course2. A rare case of broncho-oesophageal fistula due to carcinoma of the oesophagus, which was discovered incidentally during a barium swallow study is presented. SUMMARY A 68-year-old man with dysphagia who was diagnosed to have carcinoma of the oesophagus, which was complicated by broncho-oesophageal fistula is presented. The role of radiology in the management of this condition is discussed.

Background: Strangulated hernia is one of the most emergency cases that require surgery under general anaesthesia. Here, we present a rare case of strangulated PUH repair done under rectus sheath block (RSB). Case Presentation: We report here a case of a 74-year-old male with diabetes mellitus, hypertension, ischemic heart disease with ejection fraction 20% who presented to our ER with peri-umbilical hernia (PUH) swelling and constipation. On examination, incarcerated PUH was found with massive ascites. Under local anaesthesia, rectus sheet block was performed. During midline laparotomy, there was a supra-umbilical hernia defect of about 3 cm narrow neck containing bowel loop about 5-7cm in length, initially appeared ischemic then regain Its normal colour, primary repair done for the defect. No complication was observed in the post-operative period. Discussion: Strangulated hernia is an emergency case that requires surgical intervention, hernia reduction and resection of necrotic tissue if needed. PUH repair as a day case by using local anaesthesia is a good option as it has advantages of low recurrence and infection rate. For patients with 3 to 4 ASA class, general or spinal anaesthesia is risky, and RSB is the best alternative option in such high-risk patients. Conclusion: Rectus sheath block is a good option for strangulated PUH patients.

Posterior perforation of gastric and duodenal ulcers is uncommon and frequently misdiagnosed due to nonspecific clinical exam findings. The need for surgical treatment has recently been questioned in patients with contained perforations due to the success of nonoperative management and the morbidity and mortality associated with surgical intervention. We present a clinically stable 65-year-old morbidly obese female transferred to our institution with radiographic evidence of posterior perforation of a duodenal ulcer with a large associated abscess cavity. A fenestrated 9.5 French nasal feeding tube was directed over a guide-wire into the abscess cavity under endoscopic/fluoroscopic guidance and used for decompression. The patient was managed conservatively and repeat computed tomography (CT) demonstrated resolution of the cavity. She was discharged to home after an uncomplicated 10-day hospital course. Contained posterior peptic/duodenal ulcer perforations associated with an abscess cavity can be successfully managed conservatively in patients that are hemodynamically stable and without overt signs of peritonitis. Natural orifice drainage of the cavity, gastric decompression, antibiotics, PPI administration, and nutritional support can avoid the morbidity and mortality associated with traditional surgical management.

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiographic syndrome characterized clinically by new onset neurological manifestations as well as neuroimaging findings of reversible cerebral edema. We report a case of PRES in the setting of systemic lupus erythematosus (SLE) with new-onset Class IV Nephritis treated with pulse corticosteroids, plasma exchange, intravenous immunoglobulin (IVIG) and cyclophosphamide. We also present a brief review of the associations between PRES and SLE.

Background: Immunotherapy has revolutionised the management of metastatic melanoma, however, immune-related adverse events remain an important complication of therapy. We hypothesise pyrexia is a rare presentation that may herald the development immune-related toxicities and identify a potential role for fluorodeoxyglucose-positron emission tomography (FDG -PET) in the earlier diagnosis of these toxicities. Case Presentation: We report a case of a 54-year-old man with metastatic melanoma, on combination immunotherapy with ipilumimab and nivolumab, where several days of fever heralded the development of clinical enterocolitis. He ultimately required treatment with infliximab with quick resolution of his symptoms. FDG- PET imaging performed as a work up for his pyrexia demonstrated extensive entero-proctocolitis and a follow up FDG-PET 3 months post infliximab demonstrated complete resolution of the entero-proctocolitis and ongoing complete extracranial response of the melanoma. Conclusion: Early FDG-PET in patients with unexplained pyrexia on immunotherapy may help in an earlier diagnosis of immune-related toxicities allowing prompt initiation of therapy and a reduction in morbidity and mortality associated with these treatments.

Herpes simplex virus type-1 (HSV-1) causes a wide variety of clinical disorders of major public health concern. HSV-1 infections are common in oral and perioral area. We report the short-term efficacy of topical application of etamsylate in herpes simplex labialis lesion. Mucosal lesion resolved after 4 days of treatment leaving behind no apparent signs of cosmetic disturbance.

There is a wide variety of treatment options available for patellar tendinopathy, the majority of which are non-surgical, and no consensus exists on the optimal method of treatment. We report that peritendinous injection of dobesilate in patients with chronic patellar tendinopathy, resulted in significant long-term improvement in knee function and reduced pain.

Overdose by calcium channel blocker (CCB) antihypertensive agents has been shown to be a cause of significant morbidity and can often be fatal. (1) Although overdoses of calcium-channel blockers and beta blockers are uncommon, they have a high mortality rate, and management may be complicated. (2) Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. (3) We report a case of severe Amlodipine/Atenolol overdose that was refractory to multiple therapeutic approaches but rapidly responded to plasmapheresis. We describe the case of a previously healthy 25-year-old lady presented after ingesting 30 tablets of Amlodipine 5 mg/Atenolol 50 mg in a suicide attempt. The patient was initially managed with fluid resuscitation, calcium boluses, glucagon bolus, methylene blue boluses and multiple vasoactive agents. Hyperinsulinemic euglycemic therapy was initiated when hypotension persisted despite conventional treatments but was stopped later due to life threatening hypoglycemia and hypokalemia. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels as knowing that amlodipine is highly protein bound. Plasmapheresis is a procedure used to remove pathologic substances from a patient’s blood that has proven useful in some cases of drug overdose. (1) A dramatic improvement of cardiovascular stability was already observed during plasmapheresis. The primary outcomes were to reduce mortality and improve hemodynamic parameters. The secondary outcomes included reduce length of stay in intensive care unit, duration of vasopressor use and functional outcomes. (4) Conclusion: This case demonstrates that a Plasmapheresis can be effective in restoring hemodynamic stability in severe calcium channel blocker toxicity and recommend its use in patients with calcium channel blocker toxicity that is not responsive to traditional therapies.

Systemic lupus erythematosus (SLE) is often associated with various systemic manifestations, from peripheral cytopenias to renal involvement or neuropsychiatric symptoms. Here, we present a patient in whom the cause of fever and altered mental status was unknown despite repeated lumbar punctures, but later became elucidated following the development of rash and lymphadenopathy with subsequent biopsies. This case demonstrates a unique presentation of Kakuchi-Fujimoto Disease, a necrotizing lymphadenitis manifesting in association with SLE and autoimmune hepatitis. Further, this case illustrates the proclivity of autoimmune disorders to occur concurrently.