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  • ISSN: 2373-9819
    Volume 1, Issue 1
    November/December 2013
    Case Report
    Thisara Weerasuriya1*, Albert Tang2, Jack Turnbull3 and Francis Chan4
    Reflex sympathetic dystrophy (RSD), also known as complex regional pain syndrome (CRPS) is a complex syndrome of pain and stiffness with vasomotor instability that can affect any part of the body but, more common in the hand and the leg [1]. It is a well-known complication to hand surgeons. The clinical features of this syndrome were described in a paper by Bruscas et al in 2010 where they prospectively followed up 171 patients diagnosed with RSD. They noted that trauma was the commonest trigger in most cases [2]. In a paper prospectively analyzing 101 carpal tunnel decompressions (CTD) de Costa, de Oliveira et al noted an incidence of 2.1% following CTD. Both our patients were following volar locking plating of distal radial fractures.
    Thisara Weerasuriya*, Albert Tang, Jack Turnbull and Francis Chan
    Abstract: A 27 year old man presented with two bony lumps in the fifth toe of the right foot. Both lumps were present from early childhood. The lump in the toe was painful while both lumps were bony and the lump in the metatarsal was diagnosed to be an exostosis of the bone while the phalangeal lump was diagnosed to be an enchondroma. It is a known association to have multiple exostosis with diaphyseal bony deformities and this syndrome is called diaphyseal aclasis. However, the association of exostosis with enchondroma has been reported before but not in the same digit. This case is unique as there were no other exostoses or enchondromata detectable in this patient. No diaphyseal bony abnormalities were detected. This is a case of an unusual association of two conditions.
    Bradley W. Anderson1*, Jackson J. Liang1 and Vuyisile T. Nkomo2
    Abstract: A 76-year-old male presented in new-onset atrial flutter with rapid ventricular response. Pharmacologic and electric attempts at rate control with intravenous diltiazem, esmolol, digoxin, amiodarone and transesophageal echocardiogram-guided cardioversion were unsuccessful. While hospitalized, thyroid function studies detailed a low thyroid stimulating hormone level (TSH) and elevated free thyroxine accompanied by the findings two thyroid nodules on ultrasound, suggesting the diagnosis of toxic multinodular goiter. The patient’s methimazole dosage was titrated upwards which led to prompt conversion to normal sinus rhythm. This case demonstrates a distinct temporal correlation between the administration of methimazole and successful rate control and conversion to normal sinus rhythm in a gentleman who had failed typical pharmacologic and electric therapies.
    Fahd Adeeb Mohamed Ashraf1*, Leong Sum2 and Sinead Harney1
    A 29-year-old healthy gentleman was diagnosed with ankylosing spondylitis (AS) and was treated with etanercept 50 mg subcutaneously weekly, after failing conservative treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and exercise. Twenty months after initiation of etanercept, over the course of two weeks, he developed bilateral lower limb pain, numbness and weakness with bilateral upper limb paraesthesia. In the ensuing week, he developed night sweats, back pain and urinary retention. Magnetic resonance imaging (MRI) of the whole spine showed diffuse intramedullary central cervical and thoracic cord T2 hyperintense lesions with relative sparing of the periphery. These areas also showed patchy enhancement post gadolinium administration (Figure 1, 2 and 3). There was no significant expansion of the spinal cord and MRI of the brain did not demonstrate any abnormality. Lumbar puncture and blood serology ruled out infection, malignancy and other metabolic causes. His blood cultures were sterile, and his skin testing for tuberculosis (TB) with a subsequent interferon-gamma release assay (IGRA) test were both negative. Overall clinical presentation and imaging features were compatible with transverse myelitis (TM).
    Hassan A. Al-Jafar1*, Salem Al-Shemmari2, Leena Ayt Oglu3, Fisal AlSayegh4, Abdulla Al-Aqeel5 and Ebrahim Al-Zayer6
    Objective: In this study we found in our small group of patients in this rare disease that pegylated interferon a-2a (Peg-IFN-2a), which is approved for treating hepatitis C virus infection, is associated with relatively milder and less frequent adverse effects and better treatment compliance than conventional treatments, including hydroxyurea or anagrelide, in polycythemia vera (PV) and essential thrombocythemia (ET) patients. To our knowledge, we assessed the off label use effects of Peg-IFN-2a on ET and PV patients in Kuwait for the first time;
    Methods: we administered the off label drug use Peg-IFN-2a to 5 patients (1, PV; 4, ET) who could not tolerate hydroxyurea or anagrelide. Most patients showed an acceptable hematological response. One patient relapsed during Peg-IFN-2a treatment, while another one preferred to resume oral treatment with a lower dose of anagrelide to avoid Peg-IFN-2a injections. All patients were positive for the JAK2 gene mutation.
    Results: Cellular overproduction of PV and ET was controlled in most cases on the follow up of >3 years. Overproduction of blood cells increased quickly when Peg-IFN-2a was discontinued for 2–3 weeks to evaluate patient response.
    Conclusion: This study shows that toxicities of Peg-IFN-2a treatment were lower than with conventional treatments and with good compliance.
    Ishaq Mohammed1*, Nurulizzah Ibrahim2 and Mahrous Alsoud2
    NSAIDs do cause weight gain by mechanisms of fluid and water retention. Can chronic high dose NSAID therapy cause massive weight gain? We describe a case of a 69 year old Caucasian lady who was known to have Dercums Syndrome (A rare disorder of painful lipomas). She presented to cardiology out patients via her primary care physician with a history of palpitations and breathlessness over the last few years with no history of syncope, chest pain or dizziness.
    She was being treated with high dose Ibuprofen 600mg three times a day for the last 6years!In this duration she gradually gained lot of weight and started developing cardiovascular symptoms. Her symptoms resolved completely following discontinuation of Ibuprofen. In the process of gradually withdrawing her from high dose NSAIDS over weeks she lost nearly 9.2 kg body weight.
    Learning objectives: Drugs should be prescribed to patients with lot of care and full understanding of potential side effects and interactions of side effects with patient characteristics.
    Full drug history is pertinent in approaching any case as it is often overlooked. In this case, it shows how important drug history is to manage this patient’s symptoms. This could in fact save a lot of resources from doing unnecessary investigations trying to look for causes of her symptoms.
    Medication review should be done at every earliest opportunity to avoid adverse effects. This patient was on high dose of Ibuprofen for the last 6years and she could be at risk of other serious side effects involving kidneys, liver, gastrointestinal tract.
    Chronic high dose NSAID therapy could lead to alarming weight gain with fluid and salt retention causing cardiovascular side effects.
    John Schembri1*, Lara Sammut2 and Pierre Ellul1
    Abstract: Vasoactive intestinal peptide tumours (VIPomas) are rare pancreatic neuroendocrine tumours with an estimated incidence of between 0.2 to 0.5 per million per year that usually present with a conglomerate of findings related to the excessive secretion of vasoactive intestinal peptide (VIP) including profuse watery diarrhoea, dehydration, hypokalemia and hypoclorhydria occasionally referred to as VIPoma syndrome. VIPomas are usually considered as a cause of chronic diarrhoea and the onset of symptoms is often described as insidious.
    Here we present a patient who developed acute diarrhoea with typical symptoms and laboratory findings of a VIPoma, later radiologically and histologically confirmed. Despite demonstrating the typical features of severe watery diarrhoea, dehydration and hypokalemia our case was atypical in its rapidity of onset and progression of the clinical syndrome. In view of the acuteness in onset and severity of her biochemical derangements the patient ended up developing an unfavourable outcome despite the absence of metastasis and a relatively young age which are usually regarded as good prognosticators.
    Marcelo Rodrigues Bacci1*, Janaina Aparecida Bode Santos2, Flavia Baldini Russo1, Patrícia Zilda de Souza1, Bruna Maria Grosso Mascarenhas1, Leonardo Fernando Ferrari Nogueira2 and Fernando Luiz Affonso Fonseca3
    Introduction: Thyroid dysfunctions are highly prevalent diseases. Despite of its high prevalence the presentation is unusual nowadays because of oral hormone therapy widely used in insufficiency of the gland however hyperfunction states are common also. About 12% of the US population will develop some alteration of thryroid function in their lifetime. Among these diseases we highlight the presence of myxedema coma in a female patient.
    Case presentation: A 58-year-old female patient with symptoms of drowsiness and loss of motor coordination. At admission in the emergency department, ventilatory assistance was required, and the patient presented progressive improvement after oral levothyroxine reposition. Differential diagnosis of the reduction of consciousness highlighted the presence of infection and stroke. They were not detected. The ultrasonographic analysis showed a diffuse and heterogeneous enlargement of thyroid.
    Conclusion: Despite the possibility of adrenal insufficiency, pan hypopituitarism, infection and even a tumour, the thyroid stimulating hormone and free thyroxin levels were determinant to make the diagnosis of myxedematous coma according the signs and symptoms of the patient´s entrance presentation. Myxedema coma is a syndrome that results from the intense reduction of the thyroid hormone synthesis.
    Mourad H. Senussi*, Nizar H. Senussi, Anirban Bhattacharyya, and William Sanders
    Chilaiditi’s sign is an incidental radiological finding that may be mistaken for pneumoperitoneum and in the presence of symptoms (known as Chilaiditi’s syndrome), may potentially lead to unwarranted surgical intervention. We report a case of Chilaiditi’s syndrome in a 55-year-old woman presenting with vague epigastric pain who was ultimately found to have evidence of coronary ischemia with subsequent revascularization leading to complete symptom resolution. A 55-year-old woman presented with a 1-day history of fatigue and vague abdominal discomfort. She reported the insidious onset of mild to moderate, non-radiating, throbbing, epigastric pain that began 3-days prior to admission. She denied any similar symptoms in the past. The pain was associated with several bouts of non-bloody emesis. She denied any abdominal distention. She also denied any recent consumption of alcohol or use of NSAIDs. Past medical history included methadone use and chronic constipation. Her medications included methadone 5 mg once daily. No previous surgical history. She is a former intravenous heroin drug abuser.
    Papa Dasari1*, Manikandan K2, Haritha Sagili3, Arpitha Anantha Raju4 and Verma SK5
    Background: Adenosarcoma of endometriosis presenting with neurological paraneoplastic manifestations is rare case 30 year old multiparous woman presented to neurologist with stroke. Subsequent evaluation revealed haemorrhagic ascites with adnexal masses and pulmonary thrombosis. Her CA 125 level was very high and ascetic fluid cytology showed adenocarcinoma deposits and she was treated as advanced ovarian malignancy. The plan was to give neoadjuvant chemotherapy and do interval debulking after treating pulmonary thrombosis with anticoagulants. She developed haemorrhagic ascites and pleural effusion and desaturation while on anticoagulants immediately after first cycle of chemotherapy and was managed for the same. Laparotomy after stabilisation revealed large multiple friable tumor masses in the peritoneal cavity, Omentum and rectovaginal septum. Uterus and adnexa appeared normal. Evacuation of freely floating tumor masses, resection of rectovaginal and omental masses and TAH with BSO with infracolic omentectomy was carried out. Histopathological examination showed transition of benign endometriotic elements and malignant stromal component with sarcomatous changes in tumor masses fulfilling the Sampson’s and Scott’s criteria for malignant transformation of extrauterine endometriosis. Chemotherapy was restarted (paclitaxel and carboplatin) after surgery and was given for 3 cycles. But she developed recurrence in pelvic lymphnodes and parametrium after 3 cycles. She was later treated with Ifosphamide for which she reponded with disappearence of recurrence. Literature search did not reveal a similar case presentation and this may be the first case of adenosarcoma of omental endometriosis presenting with neurological manifestations.
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