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  • ISSN: 2373-9819
    Volume 2, Issue 1
    January/February 2014
    Case Report
    Sarah Doherty and Peter Ng*
    Abstract: A 47 year old man known to have been taking citalopram for several years was admitted with a mixed overdose of methadrone and the newer recreational drug (or ‘legal high’), NRG-3. He displayed signs and symptoms of serotonin syndrome which required treatment in the form of sedation and intubation and was admitted for a short stay on the Intensive Care Unit. He made a full recovery with no apparent physical or psychological sequelae and was discharged home after having a psychiatric review. The popularity and emergence of new ‘legal highs’ should alert the treating doctor to the possibility of various and largely unknown side effects. Many of the newer legal highs are molecularly related to each other and can be expected to share similar pharmacological properties, including their side effects and their propensity to precipitate a serotonin syndrome.
    Jonathan Harikrishnan, Paul, Ramnik Patel*, and Azad Najmaldin
    Abstract: The Nathanson retractor is used widely to retract the liver during laparoscopic upper abdominal surgery. Its use has been associated with a transient postoperative rise in liver enzymes which is thought to be clinically insignificant. We report two patients who underwent Nissens fundoplication in whom the Nathanson retractor was used in an uneventful fashion and were subsequently found to have an atrophied lateral segment of the left lobe of the liver. To our knowledge such a complication has not been reported previously.
    Basilios Papaziogas1, Triantafyllos Doulias2*, Panagiotis Tsiaousis1, Petros Christopoulos1, George Paraskevas1 and Ioannis Koutelidakis1
    Abstract: Osteogenesis imperfecta is a heterogeneous group of genetic disorders that affect the integrity of the connective tissue. Manifestations of the disease include bone fragility, osteoporosis, dentigenesis imperfecta, blue sclera, easy bruising, joint deformity and scoliosis. On the other hand, colonic diverticular disease is the most common acquired disease of the large bowel in the western population. More recent studies propose that that multiple factors among which also genetic influences on extracellular matrix molecules, could play a role in the genesis of colonic diverticula.
    We report the case of a 57 year old man with known Osteogenesis imperfecta type I disease who presented with acute lower left abdominal pain due to sigmoid diverticulitis. We present the hypothesis that these two entities (Osteogenesis Imperfecta and diverticulosis), as diseases attributed to weakening of the connective tissue, could have a common causative relation.
    Juan Putra, Kim Ornvold, and Arief A. Suriawinata*
    Abstract: Primary hepatic yolk sac tumor is a rare extra-gonadal germ cell tumor in children and adults. Two important differential diagnoses for hepatic tumor in a pediatric patient are hepatocellular carcinoma and hepatoblastoma. A 22-month-old boy presented to our hospital with acute respiratory distress and increased serum alpha-fetoprotein. His symptom was caused by a ruptured massive intraabdominal tumor into the pleural space, which was identified during radiological workup. Surgical resection was performed and histological examination revealed the typical endodermal sinus pattern with additional solid, microcystic, polyvesicular, and hepatoid patterns. Absence of similar lesion in the gonads and other sites established the diagnosis of primary yolk sac tumor of the liver. The patient responded well to the adjuvant chemotherapy, which consisted of cisplatin, etoposide, and bleomycin. Our case illustrates the diagnostic challenge of an extremely rare primary hepatic yolk sac tumor and the improved survival rate with multimodal therapy. Considering this rare entity as a differential diagnosis of liver tumors in children is important for timely diagnosis, appropriate management, and accurate prognostication.
    Davide Tassinari1*, Michela Maretti1, Claudia Balsamo1, Rosalba Bergamaschi1, Filomena Carfagnini2, Marianna Fabi3 and Filippo Bernardi1
    Abstract: Kawasaki disease (KD) is an acute systemic vasculitis of unknown pathogenesis that affects small and medium-size blood vessels.
    Coronary arterial lesions are the best known KD complications but many others are well known and involve various anatomical districts in the acute and sub-acute period of KD. Cerebral infarction revealed by acute neurological manifestations is extremely rare, and till now true stroke events were reported only in the acute or sub-acute stage of patients with KD.
    We describe a 31-month-old girl referred to our Paediatric Emergency Unit for the appearance of left hemiplegia and facial palsy 4-months after an acute episode of an uncomplicated KD. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) showed hyperintensity lesions due to cerebral infarction in the absence of thrombosis or aneurysms of medium and large-vessels.
    Recently, the use of MRI and/or SPECT in KD patients has outlined a great variability in cerebro-vascular involvement showing various degrees of cerebral hypoperfusion, with or without neurological symptoms. Considering the normality of MRA studies in our patient we can assume that the appearance of stroke is due to a progressive degeneration of her small vessels leading to an arteritic complication that was not completely resolved after the previous acute KD illness. In conclusion and in order to prevent long-term arteritic vascular damage, probably anti-platelet therapy should be continued for more than 6 to 8 weeks also in patients without coronary aneurismatic degeneration in the early KD stage.
    Deepti Jain*
    Abstract: A 28 year old woman was administered Mifepristone and Misoprostol combination for 5 weeks pregnancy. She kept having repeated episodes of bleeding per vaginum. She presented to us at 7 weeks of amenorhoea and was diagnosed as a case of caesarean scar pregnancy on ultrasound. Conservative Systemic Methotrexate therapy was started as the preferred modality of treatment. However after two doses of methotrexate the gestation sac increased in size and the serum human chorionic gonadotrophin level was also found to have risen. Fearing that a major episode of haemorrhage may occur an urgent laparotomy and open scar resection was performed. A highly vascular lower segment was visualized and a biconvex lens shaped area of tissue was excised. The patient recovered uneventfully. A simple algorithm for management of Caesarean Scar Pregnancy has been presented after a thorough review of literature.
    Clinical Image
    Michael Langan, Veronica Marcantoni, and Corina Ungureanu*
    Epiploic appendages are fat filled sacs extending from the serosal surface of the colon into the peritoneum. There are approximately 100 appendices along the length of the colon, with most clustering in the cecal and sigmoid region [1,2]. Epiploic appendagitis occurs when epiploic appendages undergo torsion or have spontaneous thrombosis of the draining veins and subsequently become infarcted [1,2,3]. Presentation can be seen at any age but is most common in the second to fifth decades of life [3].
    Fahd Adeeb Mohamed Ashraf*, Orla Ni Mhuircheartaigh, Shakeel Anjum, and Alexander Fraser
    A 46-year-old Caucasian lady with a background history of previous bilateral uveitis presented with progressive shortness of breath and increase exercise tolerance. She was noted to have nasal dorsal concavity, shortened vertical nasal length and bilateral auricular damage but denied any history of previous trauma. Few years before she developed symmetrical active synovitis of the small joints of her hands and feet however no diagnosis was confirmed at the time and over the space of four months the inflammation self-resolved. Physical examination revealed “saddle” deformity of her nose (Figure 1), bilateral “cauliflower” ears (Figure 2), tenderness to palpation over her anterior trachea and wheeze. Worsening of her dyspnoea and development of stridor led to tracheostomy placement.
    Case Series
    Kim Bernaerts*, Lynn Gers, Ann Verhaegen, Christophe De Block, and Luc Van Gaal
    Abstract: Insulinoma are rare pancreatic islet cell tumors with fasting hypoglycemia due to excessive insulin secretion as the main clinical expression. The treatment of choice is surgery. In the elderly, diagnosis and treatment can be challenging. The elevated perioperative risks in this population often lead to forsake the option of surgery. Nutritional approaches and medical treatment are then often preferred. However they are not always sufficient in controlling the symptoms of hypoglycemia. In these patients other treatment options such as radiofrequency ablation and embolization are considered, although only limited data are available on the use of these strategies in this specific indication and population.
    We report three cases of insulinoma in elderly patients for which different treatment options were explored.
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