Heat stroke induced cerebellar dysfunction: A “forgotten syndrome”

We report a case of heat stroke induced acute cerebellar dysfunction, a rare neurological disease characterized by gross cerebellar dysfunction with no acute radiographic changes, in a 61 years old ship captain presenting with slurred speech and gait ataxia. A systematic review of the literature on heat stroke induced cerebellar dysfunction was performed, with a focus on investigations, treatment and outcomes. After review of the literature and detailed patient investigation it was concluded that this patient suffered heat stroke at a temperature less than that quoted in the literature.

Priming the tooth surface with chlorhexidine and antibacterial activity of resin cement

AIM: To evaluate the effect of priming the tooth surface with 2% chlorhexidine gluconate on antibacterial activity of resin cement.

METHODS: Ten patients in whom a single missing tooth was present on both the right and left side in the upper or lower arch were selected. Two fixed partial dentures (FPDs) in each patient on the right and left side were planned. Each FPD was assigned either to the control or test group. In the control group, FPD was luted with resin cement and in the test group, the tooth surface was primed with 2% chlorhexidine gluconate before luting with resin cement. Bacteriological samples were collected at base line level, as the patient came to the outpatient department before the start of any treatment, 5 wk prior to cementation of FPD and at 13 wk (8 wk after final cementation). Microbiological processing of all samples was done and the results were statistically analyzed.

RESULTS: In the test group, a predominance of aerobic/facultative gram positive cocci rod was seen which indicates a healthy periodontal site, whereas in the control group, a predominance of anaerobic gram negative rods was present which indicates an unhealthy periodontal condition. This is evident by the fact that the anaerobic bacteria percentage in the control sample is 57% and 15% in the test sample after 13 wk, whereas the aerobic/facultative bacteria percentage is 43% in the control sample and 85% in the test sample after 13 wk. The percentage of gram negative bacteria in the control sample is 61% and in the test sample is 20% after 13 wk, whereas the percentage of gram positive bacteria in the control sample is 39% and in the test sample is 80% after 13 wk. The shift from anaerobic gram negative bacteria to aerobic gram positive bacteria is clearly seen from the control to test sample after 13 wk.

CONCLUSION: The present study demonstrated that priming the tooth surface with 2% chlorhexidine gluconate may enhance antibacterial activity of the resin cement.

Ingested bone fragment in the bowel: Two cases and a review of the literature

Generally, ingested foreign bodies are excreted from the digestive tract without any complications or morbidity. In adults, ingestion of foreign bodies frequently occurs in alcoholics and elderly individuals with dentures. The most commonly ingested foreign bodies are food stuffs or their parts, such as fish bones or fragments of bone and phytobezoars. Sharp foreign bodies like fish and chicken bones can lead to intestinal perforation and peritonitis. We report herein two cases, one of bowel perforation and another of anal impaction, both caused by ingested bone fragments. Complications due to ingested bone fragments are not common and preoperative diagnosis remains a challenge and therefore it must be considered in susceptible cases.

Pneumomediastinum, pneumorachis, subcutaneous emphysema: An unusual complication of leukemia in a child

Pneumorrhachis (PR), or epidural emphysema, denotes the presence of air in the spinal epidural space. It can be associated with a variety of etiologies, including trauma; recent iatrogenic manipulations during surgical, anesthesiological and diagnostic interventions; malignancy and its associated therapy. It usually represents an asymptomatic epiphenomenon but also can be symptomatic by itself, as well as by its underlying pathology, and rarely can be fatal. The pathogenesis and etiology of PR are varied and can sometimes be a diagnostic challenge. As such, there are no standard guidelines for the management of symptomatic PR and its treatment is often individualized. Here, we present a case of a 14-year-old boy treated for leukemia who developed this complication and whether chemotherapy related or not, it proved to be fatal for him. To our knowledge, this is the first case in the literature of this complication with acute lymphoblastic leukemia.

Dermatology in the military field: What physicians should know?

In the civilian dermatological setting, the top 5 skin diseases usually seen are eczema/dermatitis, acne, benign skin tumors, viral infections and pigmentary disorders. In comparison, the top 5 skin conditions encountered in the military sector are usually fungal infections, eczema/dermatitis, insect bite reactions, bacterial infections and acne. This is not surprising as military personnel, due to the special environment and vocations they are in, are prone to getting eczema as heat, sweating and wearing of the military uniform aggravate the condition. Fungal infections are common in those who wear the army boots. Insect bite reactions are not an uncommon sight among those who have to go to the jungle regularly for outfield training. Grass allergy or intolerance, contact dermatitis or acneiform eruption due to the application of military camouflage cream on the face, contact dermatitis to insect repellents, and military uniform allergy and intolerance are amongst the commonest dermatological problems encountered in the military field, and physicians should recognize them, investigate and manage these problems accordingly. Lastly, a diagnosis not to be missed in the military field is cutaneous melioidosis, especially when a military personnel presents with a non-healing ulcer.

Splenic hamartoma: A case report and review of the literature

Splenic hamartoma is a rare benign malformation, composed of an anomalous mixture of normal splenic elements, often found incidentally while working up other complaints or at autopsy. A splenic mass was incidentally found while evaluating the effects of a traffic accident in a 63-year-old woman. Abdominal computed tomography revealed a well-defined splenic mass with rim enhancement. The patient underwent splenectomy. The resected spleen contained a well-defined mass lesion measuring 3.5 cm × 3.0 cm. Microscopic examination revealed disorganized slit-like vascular channels lined by plump endothelial cells without atypia. The cells lining the vascular channels were positive for CD8, CD31, CD34 and vimentin. Endothelial cells that are positive for CD8 are a key feature that differentiates hamartoma from other vascular lesions of the spleen. Although this tumor is very rare, it must be included in the differential diagnosis of splenic mass-forming lesions.

Unusual case of insitu (intracystic) papillary carcinoma of breast

The term “intracystic papillary ductal carcinoma in situ”, has recently changed and is now more appropriately referred to as “intracystic papillary carcinoma’’ constituting only 0.5% to 1% of all breast cancers. Herein, we discuss an unusual case of intracystic insitu papillary carcinoma of breast in a postmenopausal woman, the diagnosis of which was made on histopathology and confirmed by immunohistochemistry. Patient responded well to postoperative adjuvant radiotherapy without any recurrence, thereby preventing further morbidity and mortality related to invasion or tumor progression. So careful histopathological evaluation is the mainstay to arrive at the correct diagnosis to avoid untoward complications related to under diagnosis and /over diagnosis.

Cytomegalovirus enteritis with jejunal perforation in a patient with endometrial adenocarcinoma

Cytomegalovirus (CMV) infection of the gastrointestinal tract has been reported most frequently in the setting of immunodeficiency. The whole gastrointestinal tract can be affected; however, the small bowel is rarely affected. We report a case of CMV enteritis with jejunal perforation in a 53-year-old woman with a history of chemoradiation therapy for endometrial cancer 8 years previously. At follow-up evaluation, lower abdominal pain, diarrhea and vomiting appeared. Abdominal computed tomography showed intra-abdominal free air in the subphrenic space and porta hepatis. The jejunal segment revealed serosal purulent exudates with a perforation. The resected jejunal segment showed a large geographic ulcerative mucosal lesion. The microscopic findings revealed a diffuse ulcerative mucosal change with a prominent granulation tissue formation and many large atypical vascular endothelial cells and stromal fibroblasts with intranuclear or intracytoplasmic inclusion bodies. These cells were positive for CMV antibody. The final diagnosis was CMV-associated jejunitis with a jejunal perforation.

Cystic benign teratoma of the neck in adult

Teratomas are embryonal neoplasms that arise when totipotential germ cells escape the developmental control of primary organizers and give rise to tumors containing tissue derived from all three blastodermic layers. Teratomas have been reported to occur in various sites and organs. Teratoma of the cervical neck are relatively rare in adulthood. It usually extends from the neck to the thoracic cavity causing local mass effect. In most of the cases intrauterine diagnosis is possible by ultrasound. Because of dyspnea due to mass effect, this condition is treated promptly after birth. However cases of teratoma in adulthood with supraclavicular localization have been reported rarely in the literature. The presented case is of a 25-year-old female with a cervical mass. Histological examination revealed a benign mature teratoma. The patient has been disease free for more than nine years after surgical removal of a neck teratoma.

Infliximab for the treatment of pouchitis

Pouchitis is not a rare complication that develops after an ileal-pouch anastomosis, performed after colectomy in patients refractory to treatment or with complicated ulcerative colitis. This condition may become chronic and unresponsive to medical therapies, including corticosteroids, antibiotics and probiotics. The advent of biological therapies (tumor necrosis factor-α inhibitors) has changed the course of these complications. In particular, in these cases, infliximab (IFX) may represent a safe and effective therapy in order to avoid the subsequent operation for a permanent ileostomy. This article reviews the therapeutic effects of one of the most widely used anti-tumor necrosis factor-α molecules, IFX, for the treatment of complicated pouchitis (refractory to conventional treatment and/or fistulizing).

Dynamic mechanical allodynia following finger amputation: Unexpected skin hyperinnervation

The development of chronic pain after amputations is not an uncommon event. In some cases the most disabling problem is represented by the symptom called dynamic mechanical allodynia, characterized by the painful sensation evoked by gently stroking the skin. Despite the growing interest in understanding pain mechanisms, little is known about the mechanism sustaining this peculiar type of pain. We present here the case of a 53-year-old female patient who complained of severe tactile allodynia in the hand after amputation of her left second finger, resistant to several medical and surgical treatments. In order to gain information about the pain mechanism, two neurodiagnostic skin biopsies were obtained from the area of tactile allodynia and from the contralateral, normal skin area. Skin biopsies showed an unexpected increased innervation of the allodynic skin compared to the contralateral, normal skin area (+ 80.1%). Hyperinnervation has been proposed as a mechanism of pain following nerve lesions, but the increased innervation described here could be also attributed to neuronal plasticity occurring in chronic inflammatory conditions. Independently from the uncertain cause of the epidermal hyperinnervation, in this patient we tried to reduce the elevated number of epidermal nerve fibres by treating the skin with topical capsaicin (0.075%) three times a day, and obtained a persistent pain relief. In conclusion, neurodiagnostic skin biopsy might represent an useful tool for detecting derangements of epidermal innervation in patients with dynamic mechanical allodynia and can help to select an individually tailored therapeutic strategy in such difficult clinical conditions. Further studies are needed to clarify this issue and try to gain better understanding of chronic pain mechanisms in patients who underwent finger amputation.

Recurrent epithelial ovarian cancer and hormone therapy

The role of hormone therapy in the treatment of ovarian cancer is not clear. Data on the efficacy and safety of antiestrogens and aromatase inhibitors in recurrent ovarian cancer have been accumulated through phase II clinical studies. Most of these studies were conducted in platinum-resistant recurrent ovarian cancer, and although complete response rates were not high, reported adverse events were low. If administered to patients who are positive for estrogen receptors, hormone therapy may become a viable option for the treatment of recurrent ovarian cancer.

Use of central venous saturation monitoring in a patient with pediatric cardiac beriberi

The patient was a 1-year-and-4-mo-old boy. He had drunk about 1 L of an isotonic drink for infants daily since about 10 mo after birth. He was examined by a local doctor due to anorexia and vomiting, found to have cardiomegaly, and transported to our hospital with suspected myocarditis. After admission, the patient showed polypnea, a decreased level of consciousness, and marked metabolic acidosis and lapsed into circulatory insufficiency, requiring catecholamine administration, endotracheal intubation, and extracorporeal membrane oxygenation. Initially, low-output heart failure due to acute myocarditis was suspected, but the central venous oxygen saturation was high, at 82%. Considering high-output heart failure to be more likely, we evaluated its cause and noted, by urinary organic acid analysis, increases in lactate, pyruvate, 3-OH-butyrate, acetoacetate, metabolic products of branched-chain amino acids, 2-ketoglutarate, 2-OH-glutarate, 2-keto-adipate, and 2-OH-adipate. Since the vitamin B1 level was reduced to 12 ng/mL (normally 20-50 ng/mL), a diagnosis of cardiac beriberi due to vitamin B1 deficiency was made. When unexplained heart failure is observed in children, cardiac beriberi must be excluded as a differential diagnosis of myocarditis and cardiomyopathy. The measurement of the central venous oxygen saturation may be useful for the diagnosis.

Desmopression is an effective adjunct treatment for reversing excessive hyponatremia overcorrection

We report a case of a 50-year-old malnourished African American male with hiccups, nausea and vomiting who was brought to the Emergency Department after repeated seizures at home. Laboratory evaluations revealed sodium (Na⁺) 107 mmol/L, unmeasurably low potassium, chloride < 60 mmol/L, bicarbonate of 38 mmol/L and serum osmolality 217 mOsm/kg. Seizures were controlled with 3% saline IV. Once nausea was controlled with iv antiemetics, he developed large volume free water diuresis with 6 L of dilute urine in 8 h (urine osmolality 40-60 mOsm/kg) and serum sodium rapidly rose to 126 mmol/L in 12 h. Both intravenous desmopressin and 5% dextrose in water was given to achieve a concentrated urine and to temporarily reverse the acute rise of sodium, respectively. Serum Na⁺ was gradually re-corrected in 2-3 mmol/L daily increments from 118 mmol/L until 130 mmol/L. Hypokalemia was slowly corrected with resultant auto-correction of metabolic alkalosis. The patient discharged home with no neurologic sequaele on the 11^th hospital day. In euvolemic hyponatremic patients, controlling nausea may contribute to unpredictable free water diuresis. The addition of an antidiuretic hormone analog, such as desmopressin can limit urine output and prevent an unpredictable rise of the serum sodium.

Biventricular pulsus alternans: An echocardiographic finding in patient with pulmonary embolism

Pulsus alternans is characterized by regular rhythm with beat-to-beat alternation of systolic pressures. Left ventricular alternans is usually found in severe left ventricular dysfunction due to cardiomyopathy, coronary artery disease, systemic hypertension, and aortic stenosis. Right ventricular alternans is usually associated with left ventricular alternans, right ventricular dysfunction, pulmonary embolism, and pulmonary hypertension. Biventricular alternans is rare and associated with severe left ventricular dysfunction and left anterior descending coronary artery disease. The exact mechanism of pulsus alternans has not been clearly delineated, and it has been remained a subject of investigation and conjecture since the nineteenth century. Two fundamental mechanisms have been proposed to explain ventricular alteration. The first, based on the Frank-Starling mechanism, proposes beat-to-beat alteration in end-diastolic volume accounted for the alternating contractile force. The second proposed mechanism which explains the physiology of pulsus alternans involves the abnormal calcium handling by cardiac myocytes. To the best of our knowledge, biventricular alternans in pulmonary embolism has not been previously reported in the medical literature. We present and discuss the mechanisms of pulsus alternans and its clinical implications.

Long lasting response to second-line everolimus in kidney cancer

In the case presented here, everolimus was administered after first line therapy with sunitinib in a patient with metastatic renal cell carcinoma. The safety profile was excellent. The prolonged progression-free survival (PFS) obtained with everolimus in this case is of peculiar interest, as it is a multiple of the median PFS obtained in with everolimus in the regulatory trial. Such finding suggests that a subset of patients with renal cell carcinma may particularly benefit from everolimus.

Side matters: An intriguing case of persistent left superior vena-cava

Persistent left superior vena cava, usually an incidental finding, is the most common thoracic vein anatomical variation draining into the coronary sinus. Central venous catheter procedures may be complicated secondary to the presence of a persistent left superior vena cava, leading to life-threatening complications such as arrhythmias, cardiogenic shock, and cardiac arrest. We present a case of persistent superior vena cava diagnosed on transthoracic echocardiogram (TTE) in a patient with congestive heart failure. A dilated coronary sinus was identified on TTE, followed by injection of agitated saline into the left antecubital vein resulting in filling of the coronary sinus prior to the right atrium-an indication of persistent left superior vena-cava. This also was confirmed on cardiac computed tomography. Such a diagnosis is critical in patients who may undergo central venous catheter procedures such as our patient’s potential requirement for an implantable cardiovertor defibrillator due to severe global left ventricular systolic dysfunction. The presence of a persistent left superior vena cava should always be suspected when the guidewire takes a left-sided downward course towards the right atrium at the level of the coronary sinus. Therefore, special attention should be paid to the imaging work-up prior to central venous catheter procedures.

A case of mucosa-associated lymphoid tissue lymphoma of the gastrointestinal tract showing extensive plasma cell differentiation with prominent Russell bodies

A 73-year-old Japanese woman was hospitalized for detailed examination of nausea, diarrhea and loss of appetite. Atypical erosion in the ileum was found on endoscopy. Biopsy of this erosion showed proliferation of cells containing numerous Russell bodies. Differential diagnoses considered were Russell body enteritis, crystal-storing histiocytosis, Mott cell tumor, immunoproliferative small intestinal disease (IPSID) and mucosa-associated lymphoid tissue (MALT) lymphoma. The cells containing prominent Russell bodies showed diffuse positivity for CD79a and CD138, but negative results for CD20, CD3, UCHL-1, CD38 and CD68. Russell bodies were diffusely positive for lambda light chain, but negative for kappa light chain, and immunoglobulin (Ig) G, IgA and IgM. Based on these findings, Russell body enteritis, crystal-storing histiocytosis and IPSID were ruled out. As the tumor formed no mass lesions and was restricted to the gastrointestinal tract, MALT lymphoma with extensive plasma cell differentiation was finally diagnosed. The patient showed an unexpectedly aggressive clinical course. The number of atypical lymphocytes in peripheral blood gradually increased and T-prolymphocytic leukemia (T-PLL) emerged. The patient died of T-PLL 7 mo after admission. Autopsy was not permitted.

Fine needle aspiration diagnosis of isolated pancreatic tuberculosis: A case report

Tuberculosis (TB) involving the pancreas are uncommon, especially when present in immunocompetent hosts. Pancreatic TB is more frequently associated with miliary TB or widely disseminated disease. Pancreatic TB may present as cystic or solid pancreatic masses, pancreatic abscess or acute or chronic pancreatitis. Majority of the cases are diagnosed after surgical exploration for presumed pancreatic malignancy and pre-operative diagnosis is quite difficult. However, improvement in imaging techniques and the resulting image-guided interventions gradually can obviate the need for more invasive diagnostic surgical procedures and expedite the planning of therapy. Herein, we report a rare case of isolated pancreatic TB which presented with pancreatic mass lesion in an immunocompetent host. Diagnosis was made by contrast enhanced computed tomography and guided fine needle aspiration of the pancreatic mass which revealed acid-fast bacilli on Ziehl-Neelsen stain. The case was treated successfully with antituberculous drugs. Pancreatic tuberculosis should be considered in the differential diagnosis of a pancreatic mass when the patient is young, residing in the endemic zone of tuberculosis. Every attempt should be made to diagnose the cases to prevent unnecessary operation.

Burr hole evacuation for infratentorial subdural empyema

Infratentorial empyema is a life threatening condition and constitutes a neurosurgical emergency. Purulent mastoiditis and medial otitis is the most common origin and a thorough eradication of the purulent foci is mandatory. Decompression craniectomy has been primarily advised in the literature as the gold standard of the surgical treatment but burr hole evacuation when there the lack of cerebellar edema is less invasive and deemed equally efficient in the few reported cases. This is the report of a seventeen year old female who presented in a comatose state due to infratentorial empyema with acute hydrocephalus and who improved immediately after burr hole evacuation. Details of the surgical procedures are given. Mastoidectomy was completed, with the patient under combined antibiotherapy. She leads a normal life now, more than six years after surgery.

Hypoglycemia associated with fluoxetine treatment in a patient with type 1 diabetes

We report on a patient with type 1 diabetes mellitus who presented with recurrent episodes of hypoglycemia and a marked reduction in her daily insulin requirements after introduction of fluoxetine. This 25-year-old Caucasian woman had been followed up at the outpatient clinic for type 1 diabetes mellitus and pre-pregnancy care. She used a continuous subcutaneous insulin infusion with lispro and her daily insulin dose was 0.5 IU/kg per day. She had no chronic diabetic complications or hypoglycemia unawareness. Fluoxetine at a daily dose of 20 mg had been started because of depressive symptoms and within one week, she presented recurrent hypoglycemic episodes that prompted a progressive reduction in the insulin dose down to 0.3 IU/kg per day. The reduced insulin requirements continued during the period of fluoxetine treatment while glycated hemoglobin remained stable. She had no concurrent additional cause to explain the reduced insulin requirements. After fluoxetine was stopped, insulin requirements progressively increased and returned to the patient´s usual dose.

Zinc: Role in the management of diarrhea and cholera

Diarrhea and cholera are major health problems. Vibrio cholera, the causative agent of cholera, infects the small intestine, resulting in vomiting, massive watery diarrhea and dehydration. Reduced water and electrolyte absorption is also due to zinc deficiency. Zinc has an important role in recovery from the disease. The combination of zinc with cholera vaccine and oral rehydration solutions has a positive impact on cholera and diarrhea. It has led to a decrease in the mortality and morbidity associated with diarrhea.

Vulvar granular cell tumor

Granular cell tumors are rare, usually benign, soft tissue neoplasms of neural origin. They occur more often in females than males, the peak age incidence is in the fourth through fifth decades. They can occur anywhere in the body with up to 15% situated in the vulva. The commonest presentation is as an asymptomatic mass. Microscopic findings are usually sufficient, but immunohistochemistry can also be helpful in confirming the diagnosis. The vulvar tumors are benign in 98% of cases with 2% reported as malignant. In this case report we describe a woman with a granular cell tumor confirmed by biopsy who underwent excision of the mass but with focal extension to the resection margin on microscopy. Our recommendation of re-excision was declined. Since it is not uncommon with these tumors to find groups of tumor cells extending beyond the macroscopic limits of growth, we conclude that it is advisable to have margins assessed intraoperatively by frozen section such that further excision can be performed for positive margins. Our patient has been followed for 18 mo without recurrence, should the tumor recur, re-excision, with frozen section control, is indicated. Recurrence rates are reported as 2%-8% with clear margins and 20% with positive margins.

Elastic resistance of the spine: Why does motion preservation surgery almost fail?

Single metamere motility should not be interpreted merely as a movement on the 3 planes but also, and above all, as elastic resistance to dynamic stress on these 3 planes. In the light of this consideration, the aim of motion preservation is to neutralize excessive movements while preserving the physiological biomechanical properties of the metamere involved to interrupt the progression of degenerative processes and to prevent adjacent segment disease. Despite the fact that a myriad of devices have been developed with the purpose of achieving dynamic neutralization of the spine, there are now some doubts regarding the true efficacy of these devices.

Rare case of a solitary huge hepatic cystic lymphangioma

A hepatic lymphangioma is a rare benign neoplasm and is usually associated with lymphangiomas of other viscera. A hepatic lymphangioma can be solitary, cystic or associated with multiple liver lesions and is characterized by cystic dilatation of lymphatic vessels in the hepatic parenchyma. A solitary lymphangioma is unusual. Here we report a rare case of a solitary huge primary hepatic cystic lymphangioma in a 42-year-old woman. It was discovered on routine physical examination and the patient had no obvious symptoms. Ultrasonography and computed tomography (CT) showed a giant “hepatic neoplasm” that occupied the right liver lobe. The lesion was approximately 20.0 cm × 15.0 cm × 10.0 cm in size and contained cystic and solid components. There were multiple septa inside the tumor, with some calcifications in the septa. Surgical resection was performed. Histological examination revealed multiple cystic structures lined with epithelial cells on the inner walls, accompanied by interstitial swelling and necrosis. The patient has now been followed up for nearly two years after surgery, with no recurrence to date.