Revista de informes de casos clínicos

Clinical guidelines, defined as ‘systematically developed statements to assist both practitioner and patient decisions in specific circumstances, have become an increasingly familiar part of clinical care. A central challenge in Primary Care is the question of how do we act in the field of atypical courses of diseases or clinical symptoms beside the spectrum of EBM and how could this gap be measured in scientific literature. Main purpose of this paper is a brief analysis of the actual role and evidence of clinical case reports and case series in primary care as a basis for a scientific discussion. According to the scientific-accepted Oxford levels of evidence case reports and case series belong to the level 4 of evidence. At present a significant majority of published case reports deal with descriptions of physician’s care following their clinical intuition beside the pathways of randomized controlled trials (RCT) or guidelines. Clinical symptoms of many cases will add up to what we would recognize as a ‘medical’ condition, but in up to 19% they are vague, non-specific and/or contradictory and the management of patients with such undefined symptoms can pose a daunting challenge. Even randomized controlled trials are the gold standard in clinical research and systematic reviews and meta-analysis have the highest level of evidence, there is still a need for well-prepared case reports; for instance to describe rare adverse drug effects.

In many cases it is possible to increase the vertical dimension of occlusion if two foundational principles are maintained. The starting point for reconstruction of the vertical dimension of occlusion must be with the mandibular condyles in centric relation. Reconstruction must be within range of neuromuscular adaptation for each individual patient.

Introduction: Unicornuate uterus accounts for 5 percent of all Mullerian anomalies.Rarely it could be a site for ectopic pregnancy, where natural course is rupture during second trimester, with a potentially life-threatening heavy bleeding. However, in about 10 percent of cases horn pregnancy will go to term or form a lithopedion. We describe an unexpected horn pregnancy reaching near term with live term intrauterine pregnancy, an unusual presentation. Case presentation: 25 years old Gravida III, Para II woman presented to our hospital with complaint of right upper quadrant swelling of 5 months duration. Thirteen months back, she was diagnosed to have IUFD with femoral length of 34 weeks and misoprostol used for induction of labor but failed. Patient went home and she came again with the above complaint. On examination, uterus was 26 weeks sized, positive fetal heartbeat. She has 20 cm × 20 cm firm, non-tender right upper quadrant mass. Ultrasound showed singleton intrauterine alive pregnancy of 26 weeks + 5 days and dead fetus of 34 weeks by femur length in the right abdominal cavity. Transverse lower uterine segment cesarean was done to effect 3800 gm male alive neonate. Resection of rudimentary horn and right salpingectomy was done. The horn was connected to the isthmic right wall of the uterus by a thin fibromuscular tissue and contained 2200 gm macerated fetus and placenta. No right ovary seen. The patient and neonate progressed well and were discharged. Conclusion: An ectopic pregnancy in a rudimentary horn is rare and carries severe maternal and fetal consequences; antenatal diagnosis is challenging. Therefore, high index of suspicion is recommended to prevent morbidity and mortality after failed induction. The life-threatening complication is rupture of the horn.

Serious exposure to paraquat (more than 10 ml 20% paraquat) usually results in death due to progressive pulmonary fibrosis. We report successful treatment of an 83-year old male who ingested 50 ml 20% paraquat and the follow-up result after 19 months. Our successful treatment might due to early and enough gastric lavage, superhigh dose of steroids and ambroxol, and early and long process of blood purification. At follow-up, the patient’s general condition, laboratory reports, pulmonary function, and chest radiography remains relatively normal. This successful case suggested that paraquat caused pulmonary fibrosis was reversible, and that paraquat had no long-time side effect to lung, liver, kidney, heart, and marrow if the patient received enough and perfect therapy in time.

Purposes: Congenital uterine anomalies (CUA) are benign conditions associated with relatively serious complications affecting the reproductive life. Due to their infrequency CUA are often misdiagnosed, exposing the patient to possible future complications. Case description: We report the cases of three women affected by an unknown CUA, which underwent three different diagnostic and surgical approaches. Conclusions: A correct and early diagnosis of CUA is mandatory to allow a correct clinical and therapeutic management. In our opinion we might avoid the use of MRI considered as the second line technique after 2D-US, keeping in mind that in CUA the diagnostic value of 3D-US has the same accuracy as MRI.

Heart failure usually occurs in the setting of a low cardiac output, however in rare cases it may be associated with a high cardiac output. We present a rare and intriguing case of a patient with end-stage renal disease (ESRD) on hemodialysis that developed high output heart failure from his arteriovenous fistula (AVF). A 36 year old African American male with ESRD secondary to hypertension, on hemodialysis for six years, presented to emergency room with a history of chest pain and shortness of breath. He was diagnosed with congestive heart failure secondary to coronary artery disease. His transthoracic echo showed an ejection fraction of 65% and both the stress test and cardiac enzymes were negative for ischemia. Further workup revealed a cardiac output of 10.6 L/min and access flow of 2.37 L/min. We made a diagnosis of high output heart failure secondary to the AVF. He was taken to surgery for a minimally invasive limited ligation endoluminal-assisted revision (MILLER) procedure after which his symptoms resolved. High output heart failure, though a rare complication of AVF placement is an important differential in hemodialysis patients who present with symptoms of congestive heart failure. An accurate diagnosis will prevent morbidity and unnecessary hospital admissions.

Griscelli syndrome (GS) is a rare autosomal recessive disorder characterized by partial albinism. GSis a rare condition; its prevalence is unknown. Type 2 appears to be the most common of the three known types. The three different types of GS are caused by mutations in three different genes. Patients with GS type 1 have primary central nervous system dysfunction, resulting from mutations in the MYO5A gene. Type 2 patients commonly develop hemophagocytic. Lymphohistiocytosis, caused by mutations in the RAB27A gene, and type 3 have only partial albinism resulting from mutations in the MLPH. While hematopoietic stem cell transplantation is lifesaving in type 2, no specific therapy is required for types 1 and 3. Patients with GS types 1 and 3 are very rare. To date, 12 patients with similar presentation of GS-3 as our case have been reported. About 20 GS type 1 patients, including the patients described as Elejalde syndrome, have been reported. We report a 11 years old child with type 3 GS, referred to our clinic for partial albinism, healthy otherwise, having only pigmentary dilution; silvery gray hair, eye brows, and eyelashes. Though GS type1 and 2 have been reported in the literature; however reports on GS type 3 from Saudi Arabia are very scanty. In communities with high incidence of consanguinity possibility of GS should be kept in mind.

Background: Osmophobia is defined as intolerance to odors and it is associated to primary headaches, particularly to migraine with or without aura. It occurs during headache attacks and/or in the period between headache attacks. It is not yet known specific treatment for osmophobia. Case: We describe a case of a 38-year-old woman diagnosed with migraine without aura according to ICHD- 3 criteria. She complained of severe osmophobia both during and between headache attacks. In the pain-free period, she had extreme intolerance to any odors. Physical examination and imaging were unremarkable. Several prophylactic treatments of migraine were administered the past two years. There was a marked improvement in the frequency and intensity of headache attacks, but osmophobia remained unchanged. She would like to treat only her osmophobia. A prophylactic treatment with phenytoin was started to osmophobia, with disappearance of this symptom within 90 days. Conclusion: From our experience in this case, phenytoin should be considered as possible prophylactic treatment for osmophobia between headache attacks in migraine patients.

Behcet disease (BD) is a chronic multisystem disorder characterized predominantly by recurrent episodes of occlusive vasculitis. According to the accumulated data, it is seen that intracranial hypertension generally develops secondary to the cerebral venous sinus thrombosis in BD. In the study, it was aimed in light of literature to discuss a case where intracranial hypertension occurred without venous sinus thrombosis. A 36-year-old female was evaluated for the symptoms of blurred vision in her left eye for the last 3 months and transient visual obscurations in her right eye beginning 3 days ago. It was found out that the patient had been diagnosed with BD one and a half months ago. Fundus examination revealed bilateral swollen optic discs. Lumbar puncture revealed an opening pressure of 360 mm H2O, with normal composition. The patient was diagnosed with intracranial hypertension developing secondary to BD according to modified Dandy criteria. Methylprednisolone 1000 mg intravenously (IV) for 5 days, followed by prednisolone 60 mg po, was administered. A significant improvement was observed in the complaints and papilledema of the patient. Inflammation could play a significant role in the intracranial hypertension developing without venous sinus thrombosis in BD. As a result, BD should be considered in the differential diagnosis in patients with intracranial hypertension especially in areas where the disease prevalence is high.

Catatonia occurs in a range of psychiatric, neurologic, medical, and toxic conditions. Several neurobiological abnormalities predispose individuals to catatonia. Here we present a case of a 57-year-old man with a major depressive disorder with psychotic features and catatonia, whose evaluation was notable for positive serum antibodies against N-type calcium channel, without evidence for malignancy.

Mitochondrial neuro-gastrointestinal encephalomyopathy (MNGIE), is an autosomal recessive disease, is one of the mitochondrial disorders, and is a multisystem disease clinically defined by progressive ophthalmoplegia, peripheral neuropathy, leukoencephalopathy, mitochondrial abnormalities and severe gastrointestinal involvement. Mitochondrial disorders have clinical manifestations reflecting the fact that nearly all organ systems utilize oxidative metabolism. Clinical features often involve tissues with high energy requirements such as central and peripheral nervous systems, and eye, muscle, kidney and endocrine organs.. To the best of our knowledge there is no case report of this syndrome from Middle East and since this presents with diagnostic difficulties so is being reported.

Navicular bone fractures of the foot are rare , but can have serious consequences because of the essential role of the talonavicular joint. A classification system was devised on the basis of the direction of the fracture line, the pattern of disruption of the surrounding joints, and the direction of displacement of the foot.

Physicians frequently see patients suffering from muscular cramps. Diagnosis of muscular cramps in general is not complex and can mostly be based on history and physical examination only. However, there is no clear evidence for the efficacy of pharmacological or other treatments for muscular cramps, apart from magnesium salts in pregnancy-associated cramps. New therapies are therefore urgently needed. We present three patients with treatment-refractory muscular cramps who responded favorably to treatment with the supplement and endogenous lipid messenger, the autacoid palmitoylethanolamide (PEA).

A six-year-old, in good physical shape with medium length curly hair, Libyan white boy has presented with one single lesion which was itchy, painless with some scaly hair loss in the right parietal region on the scalp, since few weeks.

Extremely rare (1% of the cases), cutaneous endometriosis can be located in the umbilical region. Its principal differential diagnoses are keloid scar, sebaceous cyst and melanoma which must first be discounted. Most often in a secondary location and accompanied by concomitant menstrual pain and bleeding following abdominal surgery, Villar’s nodule can also be totally asymptomatic, isolated and without a known cause. This was the distinctive feature of our 33-year-old patient whose nodule had appeared 5 years beforehand. Only histological examination could confirm a diagnosis of endometriosis - even if the bluish multinodular aspect had strongly suggested it. Extended excision is the treatment of choice.

Objective: The primary purpose of this study is to compare appearance of granulation tissue, rate of wound infection, period of hospital stay and duration for complete wound healing using two different methods of wound dressing at secondary healthcare centres. Material and Methods: 127 patients between the age group 14-68 years with an average age of 42 years were included in this study. Out of these 127 cases, 1 died due to urosepsis with severe lung infection and 6 cases did not turn up for follow up treatment. The remaining 120 cases were divided into two groups i.e. A and B. Group A was subjected to modified negative pressure wound therapy (NPWT) using sterilized polyvinyl alcohol sponge as an alternative to standard Granu Foam. A Ryle’s tube with additional pores were created and interposed between the PVA sponges. The Ryle’s tube was attached to the suction drain and another end of the suction drain connected directly to wall suction which is programmed to produce a pressure of 125 mmHg. At the end of 72 hours, a new cycle was repeated. Group B was subjected to daily dressing with advanced wound dressings (dermacyn and solcoseryl gel). Results: Statistically better result was obtained in favour of NPWT for wound dressing. The appearance of granulation tissue was more rapid in group A patients. The infection rate of group A patients was very low when compared to group B patients. The mean time (duration) to complete healing was faster in Group A, however the mean length of hospital stay was longer as compared to group B patients. Conclusion: Healing is more rapid with less infection rate in NPWT group compared to advanced wound dressing group. NPWT using wall suction and PVA sponge can be performed in secondary healthcare centres with low resources as well as for patients who could not have afforded charges of commercially available standard VAC device or advance wound dressings.

Given over 2.64 million total percutaneous coronary interventions performed in the United States, and that acute cardiac tamponade is one of the most common complications of such percutaneous coronary interventions, clinicians should be familiar with diagnosing impending pericardial tamponade, and a simple and safe bedside technique for drainage. We describe a technique for echocardiographically guided rescue pericardiocentesis in the setting of acute tamponade to demonstrate the efficacy and safety of this technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach. A case of a 52-year-old male was brought to the Emergency Department after a witnessed cardiac arrest. He underwent cardiac catheterization and percutaneous coronary stent implantation. Thirty minutes after stenting, the patient developed signs of cardiac tamponade, and point-of-care echocardiogram confirmed a pericardial effusion. An in-plane ultrasound-guided pericardiocentesis was successfully performed by the junior house-staff under direct attending supervision. Serial echocardiograms demonstrated preserved left ventricular systolic function without new effusion. The patient remained hemodynamically stable for 48 hrs following the procedure at which time the pericardial catheter was removed. Ultrasound image guided pericardiocentesis is a rapid and safe technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach.

A case of a 62-year-old woman with breast cancer who developed an atypical femoral fracture during denosumab therapy for bone metastasis is reported. About 8.5 years before the fracture, she was diagnosed with breast cancer with liver and bone metastases and started receiving chemotherapy. Three and a half years later, zoledronic acid (40 mg every 4 weeks) was added, which was continued for 2 years and 4 months. At around 1.5 years after discontinuation of zoledronic acid, bone metastasis recurred and she began treatment with denosumab at 120 mg every 4 weeks. Fifteen months after starting denosumab, she sustained a left subtrochanteric fracture. Faint hot spots in the bilateral subtrochanteric regions were found on bone scintigraphy 2 months after the start of denosumab, and the tracer accumulation was slightly increased on bone scintigraphy 1 year later. Prior to the fracture, she had been experiencing a dull ache in her left thigh for a few months. Our case suggests that denosumab treatment for bone metastasis is a risk factor for atypical femoral fractures, and that thigh pain and subtrochanteric hot spots on bone scintigraphy could be signs of an impending fracture.

Here, we report a case of fulminant amebic colitis diagnosed after colonic resection in a 66-year-old male who visited our hospital complaining of prolonged fever and consistent pain in the right abdomen. The patient had neither watery nor bloody stool. Laboratory data revealed increased white blood cell counts (15,900 cells/μl) and high levels of C-reactive protein (10.3 mg/dl). Contrast enhanced computed tomography revealed remarkably hypertrophic and edematous lesions in the right-sided colon. Stool culture revealed no pathogens. The patient was suspected to have infectious colitis; thereafter, the antibiotic flomoxef sodium (3 g/day) was administered. Colonoscopy revealed a circumferential white coat and stripped mucosal lesions in the right-sided colon; thereafter, ischemic colitis or enterohemorrhagic Escherichia coli colitis was the differential diagnosis. When the general condition of the patient and their inflammatory response deteriorated, surgical treatment was adopted. Surgical findings revealed a rightsided necrotizing colon and yellowish ascites, which was later found to contain Enterococcus faecalis and grampositive bacillus. Pathological findings revealed the presence of trophozoites of Entamoeba histolytica. Consequently, fulminant amebic colitis was diagnosed. The postoperative course was uneventful, and the patient was discharged on postoperative day 18.

A gastrobronchial fistula (GBF) is a rare and life-threatening disease. The prognosis in patients with GBF is related to early diagnosis and urgent surgical intervention. We report a rare case of fistulous communication between the stomach and the residual pleural space, presenting with a 1-month history of coughing. The patient was initially misdiagnosed as having bronchitis. When patients present with a persistent long-term dry cough, we suggest that GBF should be included when making a differential diagnosis. We provide a review of the literature by discussing possible causes such as erosion into a bronchus after a perigastric abscess secondary to gastric ulcer perforation.

Loxoscelism is a rare but often underestimated cause of dermonecrosis in emergency departments. Different kinds of treatment are proposed in literature, but a shared management protocol is not yet available. We propose a therapeutic protocol considering a case which occurred in our emergency department, managed with the support of the Poison Control Center (PCC) and the Hyperbaric Unit. In particular, focusing on the risk of bacterial superinfection and necrotizing fasciitis, we suggest to consider the use of hyperbaric therapy.

According to World Health Organization (WHO), ischemic heart disease is the highest cause of death in the world. As current guidelines recommend, Dual-Antiplatelet Therapy (DAPT) of aspirin and P2Y12 receptor inhibitor should be used at least 1 year in Acute Coronary Syndrome (ACS) patients with or without Percutaneous Coronary Intervention (PCI). We here present a complex PCI case who had complicated with atrial fibrillation (AF) after more than 1 year’s DAPT. Then, he took new oral anticoagulants (NOAC) only. Unfortunately, we found total thrombotic occlusion in his right coronary artery (RCA) stents. Finally, he was accepted coronary artery bypass grafting surgery (CABG).

We reported a 54-year-old patient with a complete hydatidiform mole invasive in myometrium. This diagnostic was suggested by irregular vaginal haemorrhage, amenorrhea and reduced nausea. Our paraclinical investigation was: pelvic ultrasound and level of serum beta-human chorionic gonadotropin (β-hCG). Endovaginal ultrasound reveal enlarged uterus volume, with dimensions 12/15/8 cm, with the presence of multiple nodular formations located intramural and subserosal and a mass with Doppler rich blood supply through myometrium and endometrium. The level of β-hCG was 28099.00 mIU/L. Therapeutic method applied was abdominal hysterectomy and bilateral salpingo-oophorectomy. Anatomopathological report revealed a complete invasive mole and endometrial polyp. After the surgical intervention the patient was treated with Methotrexate as prophylactic chemotherapy recommended by oncologists because of the invasive character of mole and age of patient. The complete invasive mole is a benign tumor that is characterized by abnormal proliferation of trophoblast and is locally invasive and possible metastatic. Developing pregnancy rate in perimenopause period is very rare and most of the pregnancies that occur at this age are abnormal, spontaneous abortion occurring most often. We choose to report this case to emphasize that this condition can occur in a relatively advanced age, especially during perimenopause period.

We report nine cases of Lichen Planus Pigmentosus (LPP) inversus in Caucasian patients. They were 5 women and 4 men aged from 29 to 77 years with violaceous hyper pigmented ovalar or annular macules and patches mostly located at axillary folds but also groin, submammary folds, popliteal and genital regions. Histological examinations showed a band-like lymphocytic infiltrate in the upper dermis and melanophages in the papillary dermis. LPP inversus is a rare variant of LPP appearing in non-sun exposed areas. In contrast to LPP which occurs almost exclusively in dark skinned individuals, a comprehensive review of the literature revealed that about half of the cases reported of LPP inversus affects fair skinned individuals including Caucasian patients.

A 25-year-old man suffered from repeated attacks of orthodromic atrioventricular reciprocating tachycardia utilizing a left lateral accessory pathway (AP) for retrograde conduction. The catheter was approached through the aorta to map the AP and was entrapped in the mitral valve apparatus, and it had a broken internal wire. A snareassisted technique was successfully utilized to retrieve the catheter.

The current study presents a mammary carcinoma characterized with both micro papillae and mucinous feature in a 43-year-old female. The patient presented with a six-month history of growing painless mass in the right breast. The patient underwent mastectomy with the ipsilateral axillary dissection and was followed-up for 10 months without any evidence of metastasis and recurrence. Except for the abundance of extracellular mucin, the current example shows a diffuse architectural pattern equivalent to the pattern seen in invasive micro papillary carcinoma. Up to now, the essence of the special subtype and the classification of the rare breast carcinoma are still controversial.