International Journal of Case Reports

  • Transfer Factor Revisited: Treatment of Congenital Cytomegalovirus Infection

    A 7-month-old girl with congenital cytomegalovirus (CMV) infection underwent an immune assessment in anticipation of Transfer Factor therapy. She had been symptomatic since birth, with jaundice, rhinorrhea, diarrhea, pneumonia, hepatosplenomegaly, chorioretinitis, hydrocephalus (for which she was shunted), motor retardation, and failure to thrive. Her sputum and urine cultures were positive for CMV and her IgM anti-CMV antibody titer was positive at 1:16-1:32 dilutions. Her baseline immune assessment was normal except for a failure of her peripheral blood mononuclear cells to produce migratory inhibitory factor in response to CMV antigen. Treatment with transfer factor prepared from CMV seropositive donors resulted in clinical improvement, clearance of the virus, normal migratory inhibition factor responses to CMV antigen, and subsequent development of normal growth and development parameters.

  • Subcutaneous Emphysema in Peri-Operative Period- An unusual case

    Pharyngeal perforation is a rare serious finding with fatal outcomes if not diagnosed and managed promptly(1). The main cause is an iatrogenic injury during pharyngeal instrumentation and commonly present with neck pain, swelling, and subcutaneous emphysema. Many predisposing factors played a major role like difficult instrumentation, pharyngeal infection and old age(2). In our case, we present a patient with prostate cancer who underwent radical prostatectomy and was found to have mediastinal and surgical emphysema.

  • A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent

    BACKGROUND Salmonella infection is common in tropical countries including Malaysia. It is invasive in immunocompromised and those of extreme ages. It typically presents with gastrointestinal symptoms such as diarrhea, abdominal pain or vomiting. Extra-intestinal manifestations are seen in 30% of salmonellosis cases. These atypical manifestation leads to difficulty and delay diagnosis thus poorer outcome. Pericardium involvement is estimated to be less than 2% of all cases and has mortality rate as high as 50%1. As high as 70% of pericarditis cases were identified to be immunosuppressed2; these include chronic immunosuppressant usage, autoimmune disease, end stage renal failure, malignancy and etc. Herein, we report a fatal case of pyogenic pericardial effusion by Salmonella enteritidis in an immunocompetent adolescent. CASE PRESENTATION A 16-years-old Malay boy was referred from GP to our centre in April 2015 with CXR finding suggestive of pericardial effusion. He had prolonged cough for 8 months, associated with breathlessness and failure symptoms. He had on and off fever but denied gastrointestinal symptom. He had multiple visits to private practitioners and was investigated for Tuberculosis, which yielded negative result. His condition continued to deteriorate. Of note, he had no significant medical and surgical illness. There was no history of contact with tuberculosis patients, recent travelling history or high risk behaviour. Upon admission, he was tachypnea and in shock. His blood pressure was 90/56mmHg with a pulse rate of 102bpm. His JVP was raised and heart sound was muffled. Lung examination revealed reduced breath sound bilaterally with generalized rhonchi. Initial blood investigations revealed leukocytosis with predominant neutrophils (16 x 109/L). ABG showed type 1 respiratory failure. ESR was raised, 100mm/hour. Chest X-ray showed a congested lung field consistent with pulmonary oedema. Bedside echocardiogram revealed a large pericardial effusion with diastolic right atrium and ventricle collapsed, indicating temponade effect. Emergency pericardialcentesis drained…

  • Orbital, subcutaneous, and subconjunctival emphysema following blow-out medial wall fracture

    A 40-year-old male presented to the emergency department with the complaint of a sudden, painful left eye and swelling after episodes of sneezing. A day earlier, he had sustained a blunt trauma to the left orbit as the result of a fall from motorcycle. The initial examination showed subcutaneous and subconjunctival emphysema. Visual acuity in the left eye was 20/40 (0.50), the pupils were reactive with no relative afferent pupillary defect, and there were limitations in levoduction, dextroduction, infraduction and supraduction. A slit-lamp examination revealed normal anterior and posterior segments with an intraocular pressure of 24mmHg. An orbital computed tomography scan showed orbital, subconjunctival, and subcutaneous emphysema associated with a small fracture of medial wall of the left eye. Following conservative management with broad-spectrum oral antibiotics, a topical antiglaucoma drug, low dose systemic steroid drug, and lubricating eye drops, the patient improved dramatically within one week.

  • An unusual presentation of a known condition: Q fever manifesting as an acute abdomen

    Q fever is an endemic zoonotic infection in Australia cause by Coxiella burnetii. It has been recognised in other parts of the world, especially among livestock rearing occupations, stock yard and abattoir workers. Majority (65%) of patients infected with C.burnetti are asymptomatic while symptoms similar to those of respiratory and hepatitis are the most common making diagnosis difficult in the early stages. We report a case of a young man who was exposed to and infected with Q fever as an occupational hazard. He presented in an unusual way with the predominant initial symptoms of abdominal pain, fever, hepatitis and sterile peritonitis necessitating an emergency surgical procedure to explore a suspected surgical abdomen. Respiratory involvement ensued only several days later. The diagnosis of Q fever was confirmed with positive convalescent serology phase II IgM and IgG antibodies to Coxiella burnetii. A marked clinical response to doxycycline pending serological confirmation was supportive of this highly suspected diagnosis in an at-risk patient.

  • An unusual Cause of upper airway obstruction in newborn: Congenital nasal pyriform aperture stenosis

    Congenital nasal pyriform aperture stenosis (CNAPS) is a rare cause of pediatric nasal airway obstruction that clinically mimics choanal atresia in a neonate. CNPAS is suspected clinically and confirmed with CT scanning. Early diagnosis and management is essential for this potentially life-threatening condition. Because of the association this anomaly has with other midline defects, such as holoprosencephaly, it is important to recognize it and pursue a thorough workup. Patients can be managed conservatively or surgically. Surgical treatment is usually reserved for those patients that fail conservative treatment. We present a case of CNPAS, to highlight the importance of recognizing the classic signs of CNPAS on cross-sectional imaging to prevent fatal outcome.

  • Isolated temporal bone’s Paget disease: A case report

    Paget’s bone disease (PBD) is a benign tumor of osteoclasts. We report a case of an isolated temporal bone’s Paget disease with unusual evolution to a rapidly functional degradation of vestibulocochlear system. A 60 years old female was admitted for an isolated, left sided mastoid tumefaction without any inflammatory signs. Initial temporal bone computed tomography (CT) showed a left cotton wool appearance without any ossicles lesion or vestibulocochlear extension. Anatomo pathological tests confirmed the diagnosis. The outcome was marked by the occurrence of vestibulocochlear symptoms. Treatment had consisted on subtotal surgery in combination with oral bisphosphonate with improvement of her clinical conditions. The post operative’s follow-up was simple without any abnormalities PBD of temporal bone is a benign disorder. Imaging is considered the most useful diagnosis modality for revealing the disorder that will be confirmed by histological tests. The treatment is based on medical approaches and surgery has few indications.

  • Ansa Pancreatica: An Uncommon Cause Accounting for Recurrent Pancreatitis in Children

    Acute recurrent pancreatitis is a rare entity in children. It can be caused by a number of reasons, anatomical variations being one of them. Panctreatica divisum is the most common form of ductal anomaly while ansa pancreatica is the least studied and explored. In recurrent pancreatitis, Ansa Pancreatica was recently found to be a key risk factor. It is usually found among adult alcoholics. We submit a report of a rare but important cause of acute recurrent pancreatitis; an 11-year-old child with 2 previous episodes of pancreatitis diagnosed with ansa pancreatica on magnetic resonance cholangiopancreatography (MRCP). He was advised to get stenting of Pancreatic duct. To the best of our belief, only another case has been reported in the pediatric population.

  • Non-union after correction of femoral deformity combined with total knee arthroplasty

    AnIn knee arthritis with extra-articular deformity of the femur, total knee arthroplasty becomes more challenging. Simultaneous femoral deformity correction and TKA can be a complex procedure. We present a case in which TKA and femoral osteotomy for varus femoral deformity were performed simultaneously. Non-union in the osteotomy portion occurred after the operation. Teriparatide therapy and low intensity pulsed ultrasound therapy was administered after a diagnosis of non-union. Bony union was partially obtained at 29 months after surgery.

  • Emergency presentation of a giant paraoesophageal hernia- A case report

    An emergency presentation of a paraoesophageal hernia with acute respiratory distress and an acute abdomen is a rare presentation. Hereby, we are presenting a 73year old female who presented with an acute dyspnoea and acute bowel obstruction, the imaging revealed large paraoesophageal hernia almost collapsing the right lung, she had an emergency surgery, an anterior gastropexy was performed since she was unstable. Despite subsequent surgeries e.g Collis gastroplasty and mesh cruroplasty, patient developed recurrent hiatal hernia. Unfortunately, the patient ultimately passed away from a vancomycin resistant enterococci (VRE) bacteraemia and due to overwhelming medical comorbidities. As presentation of paraoesophageal hernia with acute dyspnea and acute abdomen is a rare incidence, we discuss this and its management options through a case report.