Anti-glomerular basement membrane disease with IgA nephropathy: A case report

BACKGROUND

Anti-glomerular basement membrane (GBM) disease is a rare autoimmune disease manifesting as acute progressive nephritis syndrome with or without varying degrees of pulmonary hemorrhage. Anti-GBM disease coexisting with Immunoglobulin A (IgA) nephropathy is rarer and has different clinical manifestations and prognoses than simple anti-GBM disease. We describe a case of coexistence of these two diseases.

CASE SUMMARY

A 49-year-old man with hematuria and proteinuria accompanied by a slight elevation of serum creatinine was admitted to our hospital. The pathological results of renal biopsy and the elevated serum anti-GBM antibody titer supported a diagnosis of anti-GBM disease combined with IgA nephropathy. After treatment with corticosteroids and cyclophosphamide, the patient's serum creatinine was relatively stable, and the hematuria and proteinuria moderately improved in the subsequent six months.

CONCLUSION

Anti-GBM disease coexisting with IgA nephropathy is rare. The clinical manifestations and prognosis are better than those of simple anti-GBM disease. In this case, the patient's condition was improved and his renal function remained relatively stable with corticosteroid and cyclophosphamide treatment. New detection methods to identify whether the crescents in this case were derived from anti-GBM disease or IgA nephropathy are worthy of further exploration.

Kimura's disease in soft palate with clinical and histopathological presentation: A case report

BACKGROUND

Kimura’s disease is an inflammatory disease that is usually found in the deep lymph nodes of the head and neck. While rare, It is most frequently seen in young men. The oral cavity and salivary glands may also be involved. There are no reports on tumor occurring in soft palate. We have encountered a case of Kimura’s disease in the soft palate of an elderly woman.

CASE SUMMARY

A 63-year-old elderly Chinese woman with a slowly growing mass in the upper jaw was referred to our service. A biopsy to the mass was taken after the patient was referred to our service. The tumor was diagnosed as benign. We performed cervical lymph node puncture and partial surgical excision of the lesion. The tumor, which showed signs of marked follicular hyperplasia with follicles surrounded by eosinophils and lymphocytes, was located within the soft palate. Kimura’s disease was diagnosed after histopathologic examination of the resected tissue. The etiology of Kimura’s disease is not fully understood. One current model includes T-cells involvement with cytokines also playing a role. The patient was without evidence for recurrence of partially resected area 6 mo later. This report shows that Kimura’s disease is not limited to the head, neck, and salivary gland lymph nodes. We present a case of a tumor in soft palate. This location adds another possible site for consideration during the differential diagnoses of a slowly growing mass.

CONCLUSION

The present case illustrates a characteristic description of Kimura’s disease. This case highlights the main differences between Kimura’s disease and angiolymphoid hyperplasia with eosinophilia.

Uncommon post-infarction pseudoaneurysms: A case report

BACKGROUND

Mechanical complications are a rare presentation in chronic coronary syndromes, which have significantly decreased in the primary coronary intervention era. Incomplete rupture may occur, resulting in pseudoaneurysms (PANs). Early reperfusion decreases the risk of this complication. Echocardiography is the method of choice for diagnosis.

CASE SUMMARY

A 54-year-old female hypertensive patient, with a history of non-revascularized inferior and anterior ST-segment elevation myocardial infarction (MI) 4 years prior, was admitted to the cardiac unit of the hospital with complaints of abdominal pain and dyspnea lasting 2 mo. The patient was hemodynamically stable, and 12-lead electrocardiogram showed persistent ST elevation and Q wave in the inferior and apical regions. Transthoracic echocardiogram in the two-chamber view showed a narrow neck of a wide PAN in the distal apical left ventricular inferior wall. In addition, the apical four-chamber and subcostal views revealed a second bulky PAN of the apical wall separated from the first by a common organizing thrombus. Cardiac magnetic resonance imaging confirmed the coexistence of more than one PAN. The patient received conservative medical treatment, and surgery was scheduled for outside the country. The patient had worsening multiple organ failure and died 4 wk after presentation.

CONCLUSION

Multifocal PANs rarely occur in chronic MI. Attention should be paid to patients with pain and cardiovascular risk factors.

Evaluation of intracoronary function after reduction of ventricular rate by esmolol in severe stenotic myocardial bridge: A case report

BACKGROUND

Severe stenotic myocardial bridges (MBs) have been reported to lead to intracoronary ischaemia, but the physiological evaluation of MBs using intracoronary function evaluation indicators after intraoperative drug treatment has not been fully established.

CASE SUMMARY

We performed through snuff fossa for coronary angiography in a patient with chest tightness after repeated exercise, and the results showed that the middle part of the anterior descending branch was a MB with 100% systolic compression. The intracoronary function evaluation (defined as the ratio of distal coronary pressure to aortic pressure with zero microcirculation resistance) was instantaneous wave-free ratio (IFR) without drug and fractional flow reserve (FFR) with adenosine. The IFR was 0.73, and the FFR was 0.66. Then esmolol 0.02 µg/kg/min was intravenously injected. The IFR and FFR were measured again when the heart rate dropped to 60 beats/min. The IFR was 0.83, and the FFR 0.65.

CONCLUSION

This case report is a case of isolated MB with severe stenosis. After intraoperative drug treatment decreased the ventricular rate, an increase in the coronary function evaluation index was immediately observed to confirm the effective improvement of coronary blood flow.

Anti-programmed death 1 antibody in the treatment of coexistent Mycobacterium fortuitum and lung cancer: A case report

BACKGROUND

Nontuberculous mycobacterium (NTM) refers to all mycobacteria except Mycobacterium tuberculosis and Mycobacterium leprae, also known as environmental Mycobacterium. The patients with lung cancer and NTM are somewhat special; the two diseases are inevitably influenced by each other. It brings difficulties and challenges to the choice of treatment. Recently, cancer immunotherapy has been considered one of the pillars for the treatment of lung cancer. However, the clinical experience in the application of immune checkpoint inhibitors is scarce for lung cancer patients with pulmonary tuberculosis, and lung cancer with NTM is even more rare. Although it ameliorates lung cancer, immunotherapy with immune checkpoint inhibitors presents complications of infectious diseases, including tuberculosis and NTM.

CASE SUMMARY

A 61-year-old male patient visited a doctor in May 2019. His admitting diagnoses were: (1) Cancer of the left lung with a pathological diagnosis of poorly differentiated non-small cell carcinoma, likely poorly differentiated adenocarcinoma, clinical stage IIIb (T3N3M0); and (2) Mycobacterium fortuitum (M. fortuitum) infection. We chose to proceed with pembrolizumab treatment. After two treatment cycles, a chest computed tomography scan showed a new irregular subpleural mass in the anterior segment of the left upper lobe of the lung, a reduction in the mediastinal enlarged lymph node, and no other obvious changes. Next, an ultrasound-guided biopsy of the new tumor was performed. Pathological examination showed that a large number of carbon particles were deposited in the alveolar tissue with histiocyte reaction and multinucleated giant cell formation. The tuberculosis (TB) specialist suggested that anti-TB therapy be combined with continued antitumor treatment. The patient continued to be treated with pembrolizumab. After 14 cycles, the lesion shrunk by 79%, there was no recurrence of M. fortuitum infection, and there were no intolerable adverse reactions.

CONCLUSION

We have observed that in cases of lung cancer complicated with M. fortuitum infection, opportunistic pathogen infection recurrence can be overcome, and immunotherapy is most beneficial when TB doctors and oncologists cooperate to closely observe dynamic changes in M. fortuitum and lung cancer. Treatment should be maintained with low dosage anti-TB drugs after general anti-TB chemotherapy for 1 year; this may prevent opportunistic pathogen infection recurrence during immunotherapy.

Steriod for Autoimmune pancreatitis complicating by gastric varices: A case report

BACKGROUND

Both autoimmune pancreatitis (AIP) and gastric varices are related to various diseases. However, AIP complicated by gastric varices is extremely rare, and has only been reported in a few studies. Here, we report a case of AIP complicated by gastric varices in a female Chinese patient.

CASE SUMMARY

A 59-year-old Chinese woman was admitted to our hospital with mild abdominal pain. Computed tomography and magnetic resonance cholangiopancreatography revealed a diffusely enlarged pancreas, an obstructed splenic vein and slight splenomegaly. Esophagogastroduodenoscopy showed gastric varices in the partial gastric fundus and the red-color sign was positive. Blood chemistry showed that IgG4 was notablely elevated. The patient was diagnosed with AIP complicated by gastric varices. Steroid therapy was administered to this patient with the risk of gastrointestinal bleeding. After one year of therapy, the pancreas, spleen and splenic vein recovered to the normal states, and the gastric varices had disappeared.

CONCLUSION

We present this case together with evidence from the literature to demonstrate the effectiveness of steroid therapy in the treatment of AIP complicated by gastric varices.

Late ischemic stroke and brachiocephalic thrombus in a 65-year-old patient six months after COVID-19 infection: A case report

BACKGROUND

Although it is well established that coronavirus disease 2019 (COVID-19) is associated with inflammation and a prothrombotic state leading to stroke and venous thromboembolism (VTE), the nuances of this association are yet to be uncovered[1]. Many studies link elevations in inflammatory markers to cases of thromboembolism. Most reports of thromboembolism associated with COVID-19 occur in the venous circulation during or just after the initial hospitalization due to COVID-19[2]. It is unclear how long the hypercoagulable effect of COVID-19 lasts.

CASE SUMMARY

We present a unique case of a 65-year-old-female who presented to her primary care doctor with a sore throat, cough, fatigue, congestion, diarrhea, headache, and anosmia. She tested positive for severe acute respiratory syndrome coronavirus 2 and received a bamlanivimab infusion 9 days later. After recovering from the acute illness, she received the Pfizer-BioNTech COVID-19 vaccine. Months later, she presented to the Emergency Department (ED) complaining of right sided shoulder pain and motor weakness in her left hand while trying to type on a keyboard. On presentation to the ED, her calculated Padua prediction score for risk of VTE was two and inflammatory markers were not elevated. She was found to have a brachiocephalic artery occlusion as well as an ischemic stroke which was treated with heparin.

CONCLUSION

This case suggests hypercoagulability due to COVID-19 may extend further than current literature suggests, to at least six months.

Paraplegia secondary to disseminated mucormycosis: case report and literature review

BACKGROUND

We report a case of spine infection with mucormycosis that manifested signs of paraplegia in a patient suffering from disseminated mucormycosis. Timely and effective surgery was performed. A review of the literature is included.

CASE PRESENTATION

A patient with diabetic ketoacidosis complained of back pain and fatigue for one month, and his right lower extremity activity had been limited for 10 days. T4-T6 vertebral and paravertebral soft tissue-involved infections were identified by MRI, which were derived from right lung pneumonia. He underwent abscess debridement, spinal canal decompression, pedicle screw fixation and amphotericin B liposome injection. Histopathological examination revealed broad aseptate hyphae suggestive of invasive mucormycosis. There was improvement in neurological function after surgical and medical treatment. Three months after the surgery, the patient died of uncontrollable massive bleeding of the urinary system. Mucormycosis is characterized by rapid development and a high mortality rate. This case shows the significance of a multidisciplinary team in the diagnosis and treatment of patients with mucormycosis. In addition, orthopedic surgeons should design appropriate surgery plans for spine-involved mucormycosis patients.

CONCLUSION

This case present a patient with paraplegia caused by the spread of pulmonary mucormycosis to the vertebral and paravertebral soft tissue of levels T4-T6. After medical treatment, surgical debridement and internal fixation, the patient recovered well but later patient died of possible disease dissemination to the renal or urinary tract which resulted in massive haemorrhage.

Mesentery solitary fibrous tumor with postoperative recurrence and sarcomatosis: A case report and review of literature

BACKGROUND

Solitary fibrous tumors are rare neoplasms of mesenchymal origin. They are often of low malignant potential and rarely metastasize. They frequently arise from the pleura and can occur at any soft tissue site in the body. However, these tumors rarely develop in the mesentery, peritoneal cavity or peritoneum.

CASE SUMMARY

We report on a scarce case of solitary fibrous tumor of the rectal mesentery showing sarcomatosis about 4 years after previous tumor resection. This 69-year-old male had no clinical symptoms but was transferred to our hospital because of a suspected tumor recurrence from follow-up abdominal computed tomography. Tumor markers (CEA, CA 19-9 and CA 125) were within the normal range. Open laparotomy showed sarcomatosis, and pathology confirmed its mesenchymal origin and diagnosis as the solitary fibrous tumor. Our case may be the second recurrent mesentery solitary fibrous tumor reported to date, and the only one with progression to sarcomatosis. There has been no evidence of recurrence in follow-up at the 28^th mo after extensive intra-operative peritoneal lavage and cytoreductive surgery.

CONCLUSION

Although there are few risk factors of cancer recurrence in this patient, careful long-term follow-up after cytoreductive surgery is necessary.

Ruptured endometrioma in a nonpregnant patient: a case report

Background

Endometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.

Case presentation

A 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.

Conclusions

Ruptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma.

Ten-year follow-up of renal adenomatosis with magnetic resonance imaging: a case report

Background

Renal adenomatosis is a rare disease that presents as multiple papillary adenomas in the bilateral kidneys. Moreover, papillary adenoma is considered a precursor to papillary renal cell carcinoma. Therefore, patients with renal adenomatosis may have higher risk of developing malignancy than patients without this benign condition.

Case presentation

We present the case of a 62-year-old Asian woman with past history of papillary thyroid cancer. She underwent contrast-enhanced magnetic resonance imaging of the abdomen to screen for metastasis in 2010 and was followed up with computed tomography or magnetic resonance imaging annually. She was found to have a right renal tumor on computed tomography and underwent partial nephrectomy. The pathological diagnosis of the right renal tumor was angiomyolipoma. Renal adenomatosis was also histologically confirmed in the renal parenchyma adjacent to the angiomyolipoma. In this case report, we demonstrate the natural course of renal adenomatosis over 10 years using imaging studies. The benign tumors gradually progressed during the follow-up period. Larger tumor sizes and more hypoenhanced nodules in the bilateral kidneys were observed on follow-up computed tomography and magnetic resonance imaging.

Conclusions

Due to its malignant potential, the clinical course of renal adenomatosis must be monitored. We present the natural course of renal adenomatosis with magnetic resonance imaging during a 10-year follow-up period.

Coronavirus disease 2019 presenting as psychosis: a case report

Background

The coronavirus disease 2019 syndrome typically consists of respiratory symptoms and other general nonspecific symptoms. Psychotic manifestations of coronavirus disease 2019 attributable to severe acute respiratory syndrome coronavirus 2 infection are seldom reported. We report a case of coronavirus disease 2019 in a young West African male who had no known risk factors of psychiatric illness or past history of psychiatric disease presenting with acute psychosis.

Case presentation

Our patient, who was a young West African male, presented without the typical respiratory symptoms of coronavirus disease 2019 and also without a background history of psychiatric illness or any other significant stressors in his past or present social history. He had acute onset of psychotic symptoms consisting of visual and auditory hallucinations, delusions of persecution, and lack of insight. He was admitted and managed with antipsychotic medication and mood stabilizer. His laboratory workup was normal except for positive coronavirus disease 2019 polymerase chain reaction and his liver enzymes, which showed elevated gamma glutamyl transferase, a finding consistent with coronavirus disease 2019. His head computed tomography scan was also normal. The patient made a gradual recovery from his psychotic symptoms, with gain of insight 7 weeks after onset of symptoms, at which time his coronavirus disease 2019 test came back negative along with other laboratory parameters. He returned to work 12 weeks after his presentation and has been performing well.

Conclusion

Psychosis can be a primary presenting symptom in patients with coronavirus disease 2019, including those without respiratory symptoms.

Central nervous system infection with Seoul Orthohantavirus in a child after hematopoietic stem cell transplantation: a case report

Background

Patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT) are prone to complicate viral infection. Central nervous system (CNS) involvement caused by the viruses is rare but with poor prognosis. Hantavirus, which usually cause hemorrhagic fever with renal syndrome (HFRS), and none case has been reported about these infection in allo-HSCT patients.

Case presentation

In August 2021, a 13-year-old male child developed intermittent fever and refractory hypotension after allo-HSCT. Magnetic resonance imaging of the head revealed abnormal signal foci in the left midbrain cerebral peduncle and bilateral thalamus. His family reported traces of mouse activity in the patient’s home kitchen. HFRS was suspected, but with no significant kidney damage. The specific immunoglobulin (Ig) G and M of hantavirus were negative. The metagenomic next-generation sequencing (mNGS) detected Seoul Orthohantavirus (SEOV) sequences directly in cerebrospinal fluid and blood.

Conclusions

Allo-HSCT patients are a high-risk group for infection. Usually the causative agent of infection is difficult to determine, and sometimes the site of infection is concealed. This report highlights the importance of suspecting hantavirus infection in allo-HSCT patients with CNS symptoms despite the absence of renal syndromes. The mNGS is a powerful tool for detecting pathogens. CNS infection with Seoul orthohantavirus in transplant patients is rare but possible as demonstrated in this case. To the best of our knowledge, this is the first reported case employing mNGS to diagnose SEOV caused CNS infection in an allo-HSCT patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-022-01766-6.

Sporadic adult-onset neuronal intranuclear inclusion disease without high-intensity signal on DWI and T2WI: a case report

Background

Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative disease characterized by eosinophilic hyaline intranuclear inclusions in cells in the central and peripheral nervous system. High-intensity signal in the corticomedullary junction on diffusion-weighted imaging (DWI) is supportive to the diagnosis of NIID. We describe a patient with sporadic adult-onset NIID but without any high-intensity signal on DWI and T2-weighted imaging (T2WI).

Case presentation

A 58-year-old woman without special family history developed mild persistent tremor in the right hand and deteriorated 2 years later. At 60 years of age, the patient began to conceive the bank, police and internet being deceptive, further presented apathy and confusion after two and a half years, as well as fabrication of non-existent things. Despite the treatment of antipsychotic drugs due to a diagnosis of mental disorder, the patient appeared weakness in the right limbs. Neurological examination revealed mutism, resting tremor, cogwheel-like rigidity in upper limbs, and weakness in all limbs. Brain magnetic resonance imaging displayed no cerebral atrophy initially but atrophy of frontal, temporal and parietal lobes 5 years later. No any high-intensity signal on DWI and T2WI was revealed. However, hypometabolism in the cortexes with atrophy and the right putamen nucleus were showed on ¹⁸F-fluoro-deoxy-glucose positron emission tomography/magnetic resonance. On the basis of 107 GGC repeats (normal number <40) in NOTCH2NLC gene and intranuclear inclusions with p62 immunoreactivity in the adipocyte of cutaneous sweat duct by skin biopsy, NIID was finally diagnosed. The symptomatic treatment was given but the patient had no evident improvement.

Conclusions

Our case highlights that despite the lack of high-intensity signal on DWI and T2WI, NIID is still considered for patients with parkinsonism and mental impairment.

Severe thyrotoxicosis as initial presentation of gastric choriocarcinoma: a case report

Background

Extragonadal choriocarcinoma is rare and can be associated with hyperthyroidism when producing very high levels of human chorionic gonadotropin.

Case presentation

A 62-year-old Hispanic female presented with a 3-week history of shortness of breath, palpitations, extreme weakness, new-onset hot flashes, and right flank pain. Her physical examination was remarkable for tachycardia, hepatomegaly, hyperreflexia, and tremor; goiter was absent. Laboratory studies revealed increased lactate dehydrogenase, alkaline phosphatase, suppressed thyroid stimulating hormone, very elevated T4, and absent thyroid stimulating immunoglobulin. ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography exhibited hepatomegaly with multiple large fluorodeoxyglucose-avid liver masses and a focus of fluorodeoxyglucose avidity in the stomach with no structural correlate. A thyroid scan (^99mTcO₄⁻) showed diffusely increased tracer uptake. She was started on propranolol and methimazole. Upon stabilization of severe thyrotoxicosis, upper endoscopy was performed, showing a ~ 5 cm bleeding lesion in the greater stomach curvature body; biopsy was consistent with choriocarcinoma; beta-human chorionic gonadotropin hormone was 2,408,171 mIU/mL. The patient received methotrexate followed by etoposide and cisplatin. Methimazole was titrated down, and upon liver failure the medication was stopped. The thyrotoxicosis was effectively controlled with antithyroid drug and concurrent chemotherapy. At ~ 1.5 months after initial diagnosis, the patient died due to bleeding/acute liver failure with coagulation defects followed by multiple organ failure.

Conclusions

Severe thyrotoxicosis can represent an unusual initial presentation of metastatic choriocarcinoma in the setting of extreme elevation of beta-human chorionic gonadotropin. Primary gastric choriocarcinoma is an aggressive malignancy with very poor outcomes. The co-occurrence of severe thyrotoxicosis with advanced primary gastric choriocarcinoma and imminent liver failure complicates management options.

Occult clavicle osteomyelitis caused by Cutibacterium acnes (C. acnes) after coracoclavicular ligament reconstruction: A case report and review of the literature

INTRODUCTION

Clavicle osteomyelitis is a rare, but serious complication following operative repair of acromioclavicular (AC) joint separations. Cutibacterium Acnes (C. acnes) is rarely a causative pathogen in clavicle osteomyelitis and diagnosis can be challenging due to the indolent nature of this organism.

CASE PRESENTATION

A 45-50 year old female with a chronic AC joint separation underwent an open coracoclavicular reconstruction using semitendinosus allograft and FiberTape (Arthrex, Naples, FL). At the six month follow up, the patient complained of mild persistent pain. Imaging demonstrated widening of the medial suture tunnel with distal clavicle osteolysis, which was concerning for osteomyelitis. This was successfully treated with implant removal revision surgery and additional intravenous antibiotics. Cultures of the graft material were positive for C. acnes. The patient continued to have osteolysis of the distal left clavicle for a period of time despite resolution of osteomyelitis.

DISCUSSION

C. acnes osteomyelitis of the clavicle is difficult to diagnose because of its vague associated symptoms when implicated in infections. There are no known obvious predisposing factors for C. acnes clavicle osteomyelitis. Literature suggests management should include aggressive irrigation and debridement, removal of any hardware, and extended intravenous antibiotic administration.

CONCLUSION

C. acnes clavicular osteomyelitis is uncommon, thus established treatment guidelines have not yet been formed. Revision surgery to remove graft material, irrigate, and debride in addition to antibiotic treatment was successful for our patient. Additional pathologic manifestations of C. acnes infections could include continued clavicular erosion post-clearance of infection, although further investigation is necessary.

Anti-LGI1 encephalitis recurring 3 years after the first episode: a case report

Background

Patients with antibodies against leucine-rich glioma-inactivated 1 (LGI1) present with limbic encephalitis, which is clinically characterized by a subacute disturbance of memory and behavior, often experience seizures. Most patients have a monophasic course, often with hyponatremia.

Case presentation

Herein, we report a 67-year-old Japanese male presenting with involuntary neck movement, abnormal behavior and apraxia. He was disoriented to time and place and occasionally unable to follow directions. Laboratory tests revealed the patient had hyponatremia (131 mEq/L). Cerebrospinal fluid (CSF) analysis showed that the cell count (1/μL) and protein content (33 mg/dL) were in the normal ranges. Electroencephalography showed transient theta bursts in the right frontal lobe. Magnetic resonance imaging (MRI) of the brain demonstrated hyperintensities in the medial temporal lobe and basal forebrain on fluid-attenuated inversion recovery (FLAIR) without gadolinium enhancement. Anti-voltage-gated potassium channel (Anti-VGKC) complex antibodies were below the reference level for limbic encephalitis. Although the diagnosis was unknown, intravenous methylprednisolone therapy was effective. Three years later, the patient began to speak incoherently and became disoriented to time. FLAIR MRI of the brain revealed recurrence in the left medial temporal lobe. The patient’s serum sodium level was 131 mEq/L. After intravenous methylprednisolone therapy, he regained alertness. A CSF sample stored at the time of the first attack was assayed and the patient was found to be LGI1-positive and CASPR-2-negative, and the diagnosis of anti-LGI1 encephalitis was made.

Conclusions

Monitoring serum sodium levels and the preserved samples from the first episode were useful for diagnosis.

Long delay in diagnosis of a case with MEN1 due to concomitant presence of AIMAH with insulinoma: a case report and literature review

BACKGROUND

ACTH-independent macronodular hyperplasia (AIMAH) is an uncommon disorder characterized by massive enlargement of both adrenal glands and hypersecretion of cortisol. Concomitant AIMAH and multiple endocrine neoplasia type1 (MEN1) is rare to our knowledge.

CASE PRESENTATION

Herein, we describe a 32 year old woman with long history of prolactinoma and secondary ammonhrea presented with not-severe manifestation of hypoglycemia due to concomitant presence of insulinoma with AIMAH leading to 12 years delay of MEN1 diagnosis. Laboratory tests showed severe hypoglycemia associated with hyper insulinemia (non-fasting blood sugar = 43 mg/dl, insulin = 80.6 μIU /ml, C-peptide = 9.3 ng/ml) hyperparathyroidism (calcium = 10.3 mg/dl, phosphor = 3.1 mg/dl, PTH = 280 pg/ml) and chemical evidence of an ACTH-independent hypercortisolism (serum cortisol value of 3.5, after 1 mg dexamethasone suppression test serum ACTH value of 17 pg/ml, and high urinary cortisol level). Abdominal CT scan demonstrated two enhancing well-defined masses 27*20 mm and 37*30 mm in the tail and body of the pancreas, respectively, and a 36*15 mm mass in left adrenal gland (seven Hounsfield units). Dynamic pituitary MRI revealed a partial empty sella. The physical examination of the patient was unremarkable. Distal pancreatectomy and a left adrenalectomy were performed. After the surgery, we observed clinical and biochemical remission of hyper insulinemia and gradual decrease in urinary cortisol. The histological features of the removed left adrenal gland were consistent with AIMAH. Histological examination of the pancreatic lesions revealed well differentiated neuroendocrine tumors. Genetic abnormalities in the MEN1, heterozygote for pathogenic variant chr11; 645,773,330-64577333AGAC, c.249-252delGTCT, p. (11e85Serfs Ter33) in exon 2 were found. It was recommended the patient undergoes parathyroidectomy as soon as possible.

CONCLUSION

Given the history and presentation of our case, we recommend that the clinicians consider the possibility of autonomous cortisol production in MEN1 patients who do not show severe symptoms of hypoglycemia in the presence of insulinoma.

FDFT1/FGFR2 rearrangement: A newly identified anlotinib-sensitive FGFR2 variant in cholangiocarcinoma

According to previous reports,10-16% of patients with clinically advanced cholangiocarcinoma develop FGFR2 fusions or rearrangements. Treatment with FGFR2-specific inhibitors (tyrosine kinase inhibitors, TKIs) has proven effective for patients with cholangiocarcinoma. In this study, we report a case of advanced cholangiocarcinoma, in which the patient was unable to tolerate the adverse effects of standard first-line chemotherapy. Genetic testing suggested the presence of a novel variant resulting from FDFT1/FGFR2 rearrangement. Owing to poor accessibility and high price, only a limited number of patients with advanced cholangiocarcinoma have access to TKIs and precision targeted therapy in China. Anlotinib is a novel small-molecule multi-target TKI developed independently in China. It has a broad target spectrum, including FGFR, and can effectively inhibit tumor angiogenesis and tumor cell proliferation, thereby achieving an anti-tumor effect. Here, the patient was prescribed anlotinib. After treatment, the tumor size continued to shrink, and no significant adverse effects were reported. The finding suggested that anlotinib may be effective in patients with FDFT1/FGFR2 rearrangement and could serve as a novel treatment option for affected patients in future.

Hem-o-Lok clip migration into renal pelvis and stone formation as a long-term complication following laparoscopic pyelolithotomy: a case report and literature review

BACKGROUND

Hem-o-Lok clips (HOLCs) are widely used in minimal access urological operations due to the advantage of vascular control and suture stabilization. In rare cases, however, they can develop problems themselves. Migration of HOLCs into the collecting system is a fairly rare complication after laparoscopic pyelolithotomy. To date, only two cases were reported in the literature.

CASE PRESENTATION

This article describes a case of 51-year-old man with a complaint of left flank pain. He had a medical history of ipsilateral retroperitoneal laparoscopic pyelolithotomy at another hospital 8 years ago. Non-contrast CT scan demonstrated a renal stone in the left ureteropelvic junction complicated by mild hydronephrosis. A straight foreign body was found near the renal pelvis, with part of it wedging into renal pelvic wall. A percutaneous nephrolithotomy (PNL) was performed for this patient. After some fragmentation, a HOLC was found in the kernel of the stone. With an alligator plier, the clip was totally removed out of the collecting system. The postoperative period and follow-up were uneventful.

CONCLUSIONS

HOLC migration into renal pelvis is a rare complication following laparoscopic pyelolithotomy. It could act as nidus for stone formation under extended exposure to urine. Using HOLCs to stabilize the anastomotic suture near renal pelvis should be avoided to prevent this complication. Instead, knotting is a better choice under such condition. The secondary calculi and dislodged HOLCs can be removed through PNL by an alligator plier after laser lithotripsy.

Use of dental drill handpiece to remove steel nut causing penile strangulation: a case report and review of the literature

BACKGROUND

Penile strangulation is an uncommon urological emergency that requires prompt intervention to avoid potentially serious sequelae including loss of the distal penis secondary to ischemia and subsequent gangrene. We present a case report of a patient who presented to the hospital with penile strangulation injury of 10-hour duration secondary to the presence of a thick hexagonal steel nut. This case is presented in accordance with Consensus Surgical Case Report guidelines.

CASE PRESENTATION

A 24-year-old Vietnamese man presented to the emergency room with urinary retention and decreased penile sensation following a 10-hour history of penile strangulation due to the presence of a thick hexagonal steel nut that he had placed around the shaft of the penis for the purpose of sexual enhancement during masturbation. The hexagonal nut was tightly entrapping the penile shaft, resulting in edema, congestion, and swelling of the distal 5 cm of the phallus. Given the thickness of the foreign body as well as the degree of penile swelling, we were unable to remove the hexagonal nut using traditional methods of alleviating penile strangulation injuries. Following consultation with a dental colleague, a dental diamond drill handpiece was utilized to cut the foreign body without injury to the underlying penile skin. Subsequent follow-up in clinic demonstrated no significant urinary or sexual sequalae from this episode.

CONCLUSION

We report a case of penile strangulation requiring novel instrumentation and collaboration for successful treatment.

Complex gastroschisis with apple peel jejunoileal atresia, primary closure, and Santulli procedure as a surgical alternative. Case report

BACKGROUND

Gastroschisis is a closure defect of the abdominal wall classified as complex when it presents with necrosis, volvulus, or atresia of the gastrointestinal tract. Jejunoileal atresia is caused by abnormal closure, discontinuity, or narrowing of the intestine. Apple Peel or type IIIb is the rarest presentation, with an incidence of 1.3 per 10,000 live births. In addition to presenting a high mortality rate.

PRESENTATION OF CASE

We present a preterm newborn patient of 30 weeks with a diagnosis of gastroschisis and jejunoileal atresia type IIIB. The congenital wall defect was closed in the first surgical stage, and he was then taken at four weeks to correct the atresia. In the second surgery, we found a difference in intestinal calibers of 8:1, and the surgical team decides to perform remodeling of the proximal sac with a mechanical stapler and perform anastomosis using the Santulli technique. On day 6 of life, enteral feeding began through a nutrition tube localized under intestinal anastomosis with progressive nutritional increase. Subsequently, intermittent and progressive occlusion of the stoma was performed, leading the patient to a definitive surgical closure one month later.

CONCLUSIONS

The mortality rate for gastroschisis and complex intestinal atresia is high. Advances in prenatal diagnosis, neonatal intensive care, and proper surgical correction are crucial to improving survival rates. The Santulli procedure is a surgical alternative for intestinal atresias with a caliber discrepancy greater than 4 to 1 or when the characteristics of the distal part do not allow a primary anastomosis to be performed.

Curative remnant total pancreatectomy for recurrent pancreatic acinar cell carcinoma: A case report

Introduction and importance

Acinar cell carcinoma (ACC) of the pancreas is a rare pancreatic cancer subtype (incidence, 0.5–2%) with unclear epidemiology and prognosis. Sometimes, repeat resection including total pancreatectomy is required for recurrence. We report a case of ACC recurring in the remnant pancreatic head after distal pancreatectomy that was successfully cured by remnant pancreatic resection following combination therapy with nab-paclitaxel (nab-PTX) and gemcitabine (GEM).

Case presentation

A 64-year-old woman was referred for pancreatic tumour treatment. CT revealed a 46-mm tumour in the pancreatic body, and endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) indicated ACC. Distal pancreatectomy was performed, and the final diagnosis was ACC. CT 18 months later showed a 34-mm tumour in the remnant pancreatic head revealed as ACC by EUS-FNA. Portal vein invasion was apparent, so neoadjuvant chemotherapy with nab-PTX and GEM was administered, and remnant pancreatic resection (total pancreatectomy) was performed. No recurrence or distant metastasis was present more than 6 months later.

Clinical discussion

Mean survival time for ACC is 18–47 months, and prognosis is good compared with pancreatic ductal adenocarcinoma (PDAC). ACC tends to extend and grow along the main pancreatic duct, which increases the recurrence rate to 50–60%. EUS and EUS-FNA were useful for evaluating tumour extension and diagnosis. Repeat pancreatic resection that included total pancreatectomy was feasible and could be performed safely.

Conclusion

ACC has a better prognosis than PDAC but with a higher recurrence rate. Aggressive surgical resection that included remnant total pancreatotomy with chemotherapy was useful in treating ACC.

•

Acinar cell carcinoma (ACC) of the pancreas is a rare type of pancreatic tumour.

•

ACC has good prognosis compared with pancreatic ductal adenocarcinoma, but the recurrence rate is high.

•

Surgical resection that includes remnant pancreatic resection is useful for pancreatic tumours.

•

Neoadjuvant and adjuvant chemotherapy are useful in treating ACC.

Renal transplantation in gigantism: A case report

BACKGROUND

Gigantism, characterized by excessive growth and height is due to increased secretion of growth hormone, most commonly from a pituitary adenoma. In addition to the surgical and anesthetic complexity, the extreme stature of these patients presents a unique challenge for kidney transplantation in deciding whether to proceed with a single or dual kidney transplantation. The lack of relevant literature further adds to the dilemma.

CASE SUMMARY

A 45-year-old patient with untreated gigantism and end stage renal failure on renal replacement therapy was waitlisted for a deceased donor dual kidney transplantation due to the extreme physical stature (Height-247 cm and weight-200 kg). He was offered 2 kidneys from a 1-0-1 HLA mismatched 24-year-old DCD donor (Height-179 cm and weight-75 kg), and was planned for a bilateral retroperitoneal implantation into the recipient external iliac vessels. The immunosuppression consisted of alemtuzumab induction (50 mg) and steroid-free maintenance with tacrolimus. The donor’s right kidney was uneventfully implanted extra-peritoneally into the right external iliac vessels. On contralateral exposure, the left common and external iliac arteries were ectatic and frail. A complex vascular reconstruction was not preferred in order to preserve the arterial supply to the left lower limb, to minimise the cold ischemia time and prevent additional warm ischemic insult to the second kidney. Hence, it was decided not to proceed with dual transplantation. Amidst concerns of nephron mass insufficiency, the graft function was remarkable with a serum creatinine of 120 µmol/L within a month from transplantation and 94 µmol/L at 1-year post transplantation, and without proteinuria.

CONCLUSION

To our knowledge, this is the first case report on kidney transplantation in gigantism. Although it is believed that dual kidney transplantation is ideal, a single kidney transplantation from an appropriately selected donor can provide sufficient functioning nephron mass in patients with gigantism.