Revista de informes de casos clínicos

Antecedentes: La retención prolongada de la cápsula endoscópica (CE) es una complicación poco frecuente, pero potencialmente grave. Se debe con mayor frecuencia a estenosis del intestino delgado o lesiones neoplásicas relacionadas con la enfermedad de Crohn, pero puede ser causada por estenosis posquirúrgica y enteropatía por fármacos antiinflamatorios no esteroideos (AINE). Presentamos un caso de CE retenida en el íleon distal debido a enteropatía por AINE con fotografías llamativas de la estenosis del intestino delgado y del momento de la recuperación del dispositivo laparoscópico.

Informe de caso: Una mujer de 83 años que tomaba amlodipino y esomeprazol presentó antecedentes de melena de un mes de duración y se le encontró anemia por deficiencia de hierro. Se la había examinado dos años antes por un episodio similar con gastroscopia, colonoscopia y CE sin encontrar una causa subyacente. Se repitieron la gastroscopia y la colonoscopia, que revelaron gastritis y enfermedad diverticular, pero no una fuente de sangrado. La CE mostró una estenosis ileal distal inflamada, que impedía el paso de la cápsula. La paciente estaba asintomática y la radiografía y la tomografía computarizada (TC) confirmaron la retención de la cápsula sin obstrucción intestinal. En el interrogatorio dirigido, admitió el uso poco frecuente de un inhibidor de la COX-II para la artritis durante los 3 años anteriores. Se sometió a una enteroscopia de doble balón con dilatación, que identificó la estenosis y la cápsula retenida, pero no se pudo recuperar de manera segura en ese momento ni una semana después. Presentó dolor abdominal y finalmente se procedió a la extracción laparoscópica de la cápsula y la resección de la estenosis. La histología fue compatible con una etiología por AINE.

Conclusión: La retención de CE es una complicación grave y puede ser causada por estenosis relacionadas con el uso oculto de AINE. La anamnesis dirigida y el uso de cápsulas de permeabilidad podrían reducir la incidencia de este problema.

La osteoporosis es una manifestación común del síndrome de Cushing y las fracturas, particularmente de vértebras y costillas, son complicaciones frecuentes. Las fracturas por insuficiencia de las extremidades inferiores, en ausencia de otras características cushingoides evidentes, son una característica de presentación raramente reportada del síndrome de Cushing endógeno. El síndrome de Cushing dependiente de la hormona adrenocorticotrópica (ACTH) representa la mayoría de los síndromes de Cushing endógenos e incluye adenomas hipofisarios secretores de ACTH, producción ectópica de ACTH y tumores productores de hormona liberadora de corticotropina (CRH). El muestreo bilateral del seno petroso inferior (BIPSS) es el estándar de oro para confirmar el exceso de ACTH de origen hipofisario y la lateralización dentro de la glándula. En general, se considera un procedimiento preciso y seguro, y los efectos adversos graves son raros. Informamos de un caso de enfermedad de Cushing que se presentó con una fractura metatarsiana con mínimos otros signos clínicos de hipercortisolismo y un caso nuevo de síndrome del seno cavernoso e infarto de macroadenoma hipofisario que complicó el BIPSS, con posterior mejoría temporal del hipercortisolismo.

Mycobacterium abscessus es una causa poco frecuente, pero cada vez más frecuente, de petrositis y otomastoiditis. En los últimos 40 años, el enfoque terapéutico de la petrositis ha pasado de las modalidades quirúrgicas a las médicas; sin embargo, las infecciones por M. abscessus plantean un desafío particular para el tratamiento médico de la petrositis debido a la predilección de la especie por la amplia resistencia a los fármacos. Describimos un caso en el que la petrositis debida a M. abscessus se maneja de manera eficaz en un paciente con comorbilidades significativas mediante terapia médica conservadora.

Background: Uterine leiomyomas (fibroids) are the most common neoplasm affecting women. Extrauterine leiomyomas are rare and may arise in any anatomic site; their unusual growth pattern may mimic malignancy and can result in a clinical diagnostic dilemma. Uterine fibroids are not well known to cause acute urinary retention (AUR) and subsequent urosepsis in women, and there have been few published cases of parasitic fibroids causing AUR. We present a case of a parasitic fibroid in the posterior vaginal wall occupying the rectouterine pouch (of Douglas) in a grand multiparous woman causing AUR and urosepsis requiring total abdominal hysterectomy and removal of the parasitic fibroid.

Case report: A 45-year-old business woman, P₈ ⁺⁰ who presented with abdominal swelling and pains and recurrent difficulty in passing urine with total urinary obstruction of five months duration. Abdominal examination revealed 20-weeks uterine size mass that was nodular, firm, non-tender and mobile from side to side. Pelvic examination revealed a healthy-looking cervix that was displaced anteriorly by the huge pelvic mass and occluded the pouch of Douglas. She was resuscitated and had exploratory laparotomy with removal of the mass and total abdominal hysterectomy. She had post-operation septic shock that was managed with intravenous and oral antibiotics. She had quick recovery and was discharged after four days of surgery. Histology confirmed the mass to be fibroid.

Conclusion: Parasitic fibroid can present as a case of bladder outlet obstruction and diagnosis can easily be missed. High index of suspicion, good investigation and institution of appropriate management protocol will ensure quick recovery and reduce further complications as in the case presented.

Dislocation of the knee is a serious and potentially limb threatening injury. There are 3 types of dislocation around the knee joint: patellofemoral, tibiofemoral and tibiofibular. Tibiofemoral dislocation is the variant that is deemed the most serious, with a higher risk of compromise to the popliteal artery and common peroneal nerve. Although simultaneous dislocations of two types have been described, there has been no such description of all three types occurring simultaneously. In this case we present a case of simultaneous dislocations of all 3 articulations around the knee. Diagnosis was achieved with clinical examination, plain films, CT and MRI scans. Management consisted of initial surgical debridement and reduction with stabilisation of the affected joints.

Aims: The purpose of our study was to research the clinical and pathological aspects of metaplastic breast cancer (MBC).

Material and methods: This is a retrospective study of four cases of MBC conducted at the department of pathology of Mohamed Taher Maamouri Hospital in Nabeul, between January 2016 and February 2018. Characteristics of clinical and pathological features were collected from the patient files and histopathological reports.

Results: In our study, the mean age of patients was 53 years with extremities ranging from 19 to 89 years old. The most frequent reason for consultation was a nodule with a mean size of 3.87 cm (3 - 4.5 cm) and a localization in the left breast in 75% of cases (n=3). These tumors were classified ACR 5 in 75% of cases. The diagnosis was made in 50% of cases on lumpectomy and 50% of cases on micro biopsies.

Conclusion: A metastatic lymph node location was found in only one case (25%). All patients (n=4) had squamous type of metaplastic cell differentiation and only one case was associated with a predominant NST carcinoma. In 100% of cases, it was an SBR grade III carcinoma. At immunohistochemistry, 50% of cases (n=2) had a triple-negative profile (RO, RP and Her2 negative).

Propofol Related Infusion Syndrome (PRIS) involves cardiac failure, rhabdomyolysis, metabolic acidosis, and renal failure in critically ill patients receiving long-term propofol infusions at high doses. It carries a high mortality rate of up to 81%. We present a case of a young adult who developed PRIS and survived. A 19-year-old male involved in a motor vehicle collision was intubated and sedated with Propofol. On hospital day 7, the patient suddenly became hypotensive, tachycardic, hyperkalemic, had cardiac arrhythmias, and profound metabolic acidosis. PRIS was suspected and propofol discontinued. The patient was managed expectantly and ultimately discharged on hospital day 22. PRIS is a complex syndrome and requires prompt recognition of its key features including changes in cardiac rhythm, decreased blood pressure, increased oxygenation requirements and derangements in laboratory data. A high clinical suspicion of PRIS should most readily be recognized by the critical care team.

The ureter is a common site of congenital anomalies which may be associated with a considerable morbidity particularly among young patient. The congenital anomalies of the ureter coexist with multitude of other urinary tract anomalies, but it may occur independently. It is more common in females. The complete duplication of the ureter may not produce symptoms which would suggest the presence of malformation. Therefore, such anomaly may not become apparent until later in life. Further, this anomaly might not be recognized prior to the surgery and hence, missing of the stone is highly possible. Herein we present a case of complete ureter duplicate with an obstructive stone located close to VUJ of one limb of the duplicate. A sound knowledge of the surgical anatomy and of the congenital ureter anomalies is essential for correct diagnosis and appropriate management.