Neglected volar distal radioulnar joint dislocation with an associated ulnar styloid fracture: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Volar distal radioulnar joint (DRUJ) dislocation with an isolated ulnar styloid fracture is considered as a very rare clinical entity. Due to its subtle clinical presentation, patients often presented late. Optimal management is required to prevent functional impairment and improved quality of life.

CASE PRESENTATION

A 51-year-old female presented to our outpatient clinic with neglected volar DRUJ dislocation and isolated ulnar styloid fracture, resulting from a previous injury that was initially misdiagnosed as a wrist sprain approximately four months prior. A plain wrist radiograph and computed tomography scan confirmed the volar DRUJ dislocation and ulnar styloid fracture without any other bony involvement. Surgical intervention was planned, and an open reduction technique was performed, consisting of Kirschner wire stabilization, volar radioulnar ligament plication, and volar capsular repair.

DISCUSSION

The involvement of the component of triangular fibrocartilage complex (TFCC) and joint capsule must be evaluated, as both of this structure plays an important role for long-term DRUJ stabilization. Repair or reconstruction must be attempted if an evidence of tears was observed intraoperatively. Temporary stabilization of the distal radioulnar joint while allowing the repaired tissue to heal can be achieved with radioulnar K-wire fixation.

CONCLUSION

Our report suggests that this condition can be managed with a radioulnar K-wire stabilization in combination with a soft tissue repair or reconstruction. This approach was found to resulted in satisfactory clinical outcomes.

An incarcerated paraduodenal hernia of a malrotated gut in a 26-year-old man

Introduction and importance: Paraduodenal hernias (PDHs) are congenital internal hernias. Overall, internal hernias are between 0.2 % and 0.9 %, while 53 % of these statistics are for PDH. There are left and right types of PDHs.

CASE PRESENTATION

An otherwise healthy 26-year-old man was presented with a sudden-onset epigastric and right upper quadrant abdominal pain. Abdominopelvic double contrasted CT scan revealed multiple dilated proximal-mid small bowel loops in the portal venous phase consistent with small bowel obstruction, suggesting concomitant bowel malrotation with internal paraduodenal hernia. The patient with the pre-operative diagnosis of small bowel obstruction due to volvulus was scheduled for emergency surgery. He was four weeks complication-free in his regular follow-up.

CLINICAL DISCUSSION

In 1857, Treitz first described PDH as a phenomenon when the primitive midgut in embryonic life abnormally rotates and causes mesocolic hernia. The location of the duodenal recess is the origin point for describing the hernia; thus, the jejunum is the most common herniating viscus. However, the stomach, small intestine, and sometimes the colon usually consist of the contents of the hernia.

CONCLUSION

In the absence of surgical history, abdominal wall hernia, and intra-abdominal inflammatory disease, in case of repeated abdominal pain or intestinal obstruction, and if no other causes are found, the possibility of a PDH should be kept in mind.

Two-stage surgery for large sacrococcygeal chordomas: How I do it

Sacrococcygeal chordoma is a malignant, slow-growing, and locally aggressive bone tumor. A wide surgical margin is recommended to prevent local recurrence and metastasis. This disease tends to cause massive defects when rectal resection and sacrectomy are required. Therefore, soft tissue reconstruction is required and a pedicled vertical rectus abdominis muscle flap (VRAM) is a viable option. Important anatomical landmarks, advantages and limitations are discussed and the procedure is described step by step. This case report presents a two-stage operation with an anterior rectal resection and VRAM flap harvest followed by a complementary posterior approach with sacrectomy and soft tissue reconstruction: approach and results. The wound completely healed in six weeks. Three years after surgery, no local recurrence or distal metastasis was detected. This two-stage strategy presents a viable and safe option for large sacrococcygeal chordomas.

Iatrogenic ureteral injury diagnosed after colon cancer surgery: A case report of a rare and challenging complication

INTRODUCTION

Iatrogenic ureteral injury (IUI) is an unfortunate and rare complication during colorectal surgery. While IUI remains a rare event, short and long-term complications are life-threatening ranging from intraperitoneal urinoma to septic shock and a serious risk of permanent renal failure.

CASE PRESENTATION

An 88-year-old patient was admitted with symptoms of large bowel obstruction and underwent a laparotomy with a discharge colostomy. A week later, a second laparotomy was required for a non-functional retracted stoma, revealing a perforation in a sigmoid tumor. The patient then had an oncological sigmoidectomy with Hartman's colostomy. Postoperative findings indicated a left ureteral injury. Three weeks later, a ureterostomy was performed. Unfortunately, the patient succumbed to heart failure one week after the ureterostomy.

DISCUSSION

Low anterior and abdominoperineal resection of the rectum, along with sigmoid resection are the most frequent causes of ureteral injury in digestive surgery. The primary objective of management is to establish a continuous flow of urine to avert potential complications. Preventing IUI in colorectal surgery is of paramount importance. This process initiates in the preoperative phase with a meticulous assessment of ureteral and colic anatomy through comprehensive review of preoperative imaging.

CONCLUSION

IUI remains a seldom-seen, and yet a very serious complication in colorectal surgery. It is imperative to prioritize both preoperative and intraoperative measures to prevent IUI, ensuring optimal outcomes. When the diagnosis of a IUI is established, a treatment strategy should be meticulously devised and executed by a skilled and experienced surgeon.

An unusual case of ureteric stricture post robotic partial nephrectomy of a renal mass managed by Memokath insertion

Robotic assisted partial nephrectomy is the gold standard treatment for small renal masses. Ureteric stricture is a rare but serious complication that significantly increase the morbidity and worsens the quality of life for cancer patients. Definitive treatment such as surgical reconstruction or ureteroureterostomy is not always feasible as in patients with significant morbidity or high-risk patients. Other options include ureteric double J stent or nephrostomy tube placement with regular exchange. We present a case of iatrogenic upper ureteric stricture post robotic assisted partial nephrectomy for right renal mass that was discovered on postoperative follow up imaging treated with metallic ureteral stent (Memokath) as reconstructive surgery was difficult due to proximity to the tumor bed. We found that if reconstructive surgery is not feasible, metallic ureteral stents has good durability, better quality of life than ureteric double stents for the management of ureteric stricture.

Radiological diagnosis of severe appendicitis in 4 months infant with possible microperforation: A rare case report

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention; however, it is extremely rare in infants. Its diagnosis and treatment are challenging due to nonspecific clinical signs and symptoms. As a result, delayed or missed diagnosis is common in young children and is associated with an increased risk of perforation and peritonitis. We reported a case of a 4-month-old healthy male child. The patient presented with abdominal distention and fever. After ruling out other possible causes, he was diagnosed with acute appendicitis, which was confirmed by a CT scan. A gangrenous appendix, dilated bowel loops, and free fluid in the abdomen were discovered during surgery. An appendectomy was performed. The appendix in infants has an average length of 4.5 cm compared with 9.5 cm in adults. Infantile appendicitis is considered rare but cases have been documented also in neonates, misdiagnosis rates are high due to rarity in this age group in addition to nonspecific signs and symptoms, which led to a high perforation rate. Ultrasonography can diagnose appendicitis in children with a sensitivity and specificity of 90%-95% without subjecting the child to radiation. A physician should always keep the diagnosis of appendicitis in mind in the infant age group, even though it is rare, as a delay in diagnosis and treatment has been associated with an increased risk of complications including appendicular perforation and peritonitis.

Severe pulmonary insufficiency caused by Fallot-type absent pulmonary valve syndrome: A rare reason for neonatal central cyanosis

INTRODUCTION

Absent Pulmonary Valve Syndrome (APVS) is a rare birth defect where the pulmonary valve is missing or underdeveloped. APVS often occurs alongside Tetralogy of Fallot, (TOF) another heart defect.

PRESENTATION OF CASE

A 33-year-old woman gave birth to a male infant with severe pulmonary stenosis (PS) and a large ventricular septal defect (VSD). The infant underwent surgery to close the VSD and resect the stenotic ring. Two years later, he remained asymptomatic with a closed VSD and no pulmonary valve gradient.

DISCUSSION

Despite high mortality rates, long-term survival has improved with advancements in surgical repair. This case underscores the significance of early detection and personalized surgical strategies for complex congenital heart defects.

CONCLUSION

Early identification of subtle symptoms is crucial for timely intervention, while individualized surgical strategies optimize outcomes. Further research is needed to understand the complex interplay of cardiac anomalies in APVS, particularly the absence of a patent ductus arteriosus in this case.

Coexistence of benign phyllodes tumor and invasive ductal cancer in the ipsilateral breast: A case report

INTRODUCTION AND IMPORTANCE

Phyllodes tumors (PTs) are rare breast neoplasms, with an incidence rate of <1 %. Further, the coexistence of PTs and carcinoma is also uncommon. In this report, we describe a rare case of the synchronous coexistence of a benign PT and invasive ductal carcinoma (IDC) of the ipsilateral breast.

CASE PRESENTATION

A 42-year-old woman presented with a 6-month history of a tumor in her right breast. Mammography and ultrasonography revealed a 9.0 cm breast lump, and core biopsy revealed a benign PT. A simple mastectomy of the right breast revealed IDC foci in the mammary area, close to the benign PT. Right axillary lymph node staging was performed by surgery. However, no lymph node metastasis was observed. Subsequently, appropriate adjuvant therapy was initiated. Currently, the patient is doing well.

CLINICAL DISCUSSION

Breast cancer may be located close to the PT of the ipsilateral breast and is difficult to detect preoperatively, especially in cases of large PTs. Early detection of the presence of a coexisting carcinoma is clinically important because it can alter patient management.

CONCLUSION

Careful assessment of the PT using additional breast imaging tools might help identify their coexistence with breast cancer in cases of difficult diagnosis of coexistent tumors using standard breast imaging tools such as mammography or ultrasound.

Bilothorax as a complication of endoscopic retrograde cholangiopancreatography: A rare case report and literature review

INTRODUCTION

Bilothorax is a rare and poorly documented condition in the medical literature, with following hepatobiliary procedures being the most common cause. We present a case of bilothorax following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis.

CASE PRESENTATION

A 71-year-old woman with a history of prior percutaneous biliary stone removals presented with Charcot's triad and was diagnosed with cholangitis due to a distal common bile duct stone. She underwent ERCP with successful stone extraction and stent placement. Two days later, she developed a right-sided pleural effusion diagnosed as a post-ERCP bilothorax. She was treated with thoracentesis and antibiotics, and her condition significantly improved. After 15 days, she was discharged, and a one-month follow-up showed no complications or recurrence.

CLINICAL DISCUSSION

Bile is a potent chemo irritant that can cause adhesive pleurodesis. Besides, accompanying cholangitis can lead to pleural infection and empyema. In this patient, early diagnosis leading to timely pleural drainage decisions helped avoid potential consequences.

CONCLUSION

Post-ERCP bilothorax is a rare complication but can lead to severe consequences. Nonoperative management by pleural drainage is a safe and effective strategy if diagnosis is made early, helping patients avoid more invasive interventions.

Ovarian tuberculosis mimicking ovarian malignancy in an unvaccinated patient: A case report

INTRODUCTION

Ovarian tuberculosis is a rare form of extra-pulmonary tuberculosis that usually present with atypical symptoms mimicking ovarian carcinoma.

CASE REPORT

We report a case of non-vaccinated 20-years-old women who present with non-specific symptoms and for whom imaging techniques weren't conclusive for ovarian tuberculosis. The ultrasound shows hydronephrosis secondary to the compressive pelvic mass. Regarding the compressive character of the mass and it's consequence on the urinary system as well as the suspicion of malignant origin, laparotomy was performed. Based on histopathological analysis of surgical biopsies a diagnosis of ovarian tuberculosis was made and the patient was put under anti-TB drugs. During the follow up there was a good response to treatment with improvement of health state, regression of the abdominopelvic mass as well as the hydronephrosis.

DISCUSSION

Ovarian tuberculosis can occur even in the absence of previous pulmonary TB. The major risk with female genital tuberculosis is infertility.

CONCLUSION

Ovarian tuberculosis is a rare form of extra pulmonary TB that should be always considered in differential diagnosis of ovarian TB.

Successful management of large incarcerated inguinal hernia: A case report and literature review

INTRODUCTION AND IMPORTANCE

Hernias containing organs like the cecum, appendix, sigmoid colon, ureter, and omentum are less common compared to typical inguinal hernias involving the small intestine. Patients typically present with inguinoscrotal swelling.

CASE PRESENTATION

A 53-year-old male with ischemic heart disease, diabetes, and hypertension presented with vomiting and no bowel movement for 24 h. He had a long-standing left inguinoscrotal hernia and recently underwent cardiac catheterization. Examination showed a massive hernia and an empty rectum. Imaging confirmed a small bowel obstruction. Surgery revealed an incarcerated hernia containing multiple organs, which were reduced, and hernioplasty was performed. Postoperatively, he developed abdominal compartment syndrome, necessitating decompressive laparotomy. His abdomen was closed on day 13, and he was discharged on day 30.

CLINICAL DISCUSSION

Hernias, particularly when they become incarcerated, pose significant risks to patients. If untreated, they can progress to strangulated hernias, leading to bowel ischemia and potentially fatal outcomes.

CONCLUSION

Inguinal hernias are diagnosed primarily through clinical examination. It is rare for these hernias to contain the cecum, appendix, sigmoid colon, ureter, and omentum, and such cases are typically associated with intestinal obstruction.

Isolated left foot drop post aortobifemoral bypass surgery: A case report

INTRODUCTION

Foot drop is a disorder characterized by weakness in the dorsiflexor muscles of the foot, caused by various pathologies, including neurological, muscular, spinal, and autoimmune conditions. Sometimes, it can be iatrogenic due to direct nerve compression, traction, or ischemia. The occurrence and underlying mechanism of foot drop following aortobifemoral bypass surgery are not well-documented in literature.

CASE PRESENTATION

A 40-year-old male, with short distance claudication secondary to multi-level lower limb arterial occlusions, mainly, external iliac arteries and superficial femoral arteries. The patient underwent an uneventful aortobifemoral bypass. Post-operatively, the patient developed left sided foot drop with no clear etiology. With intensive physiotherapy, the patient improved and eventually recovered.

DISCUSSION

After excluding other causes of the manifestation, this case could potentially give an insight to a rare postoperative complication following aortobifemoral bypass surgery. Despite a smooth intraoperative course, the patient developed foot drop, a rarely reported complication, suggesting a potential link between the procedure and foot drop.

CONCLUSION

This case report highlights a rare postoperative complication after aortobifemoral bypass surgery, emphasizing the need for further research to elucidate the direct mechanisms behind this rare occurrence.

Case report: Peritonitis secondary to traumatic bowel perforation during second-trimester surgical abortion

INTRODUCTION AND IMPORTANCE

Uterine perforation and bowel injury are rare but potentially life-threatening complications of surgical abortion. Early diagnosis results in easier management and better prognosis. We report here a case of a 39-year-old presented with peritonitis secondary to traumatic bowel perforation after second-trimester surgical abortion.

CASE PRESENTATION

A 39-year-old Gravida 3 Para 2 presented with acute abdominal pain two days after second trimester induced abortion. On physical examination, the patient was febrile and hypotensive with diffuse abdominal tenderness. Emergency abdomino-pelvic-CT showed generalized peritonitis with pneumoperitoneum. The patient underwent an emergency laparotomy. Per operative exploration revealed a perforation of the fundus of the uterus and the sigmoid portion of the large intestine, resulting in stercoral peritonitis. We proceeded with thorough cleansing of the abdominal cavity with physiological serum, followed by partial colectomy including the perforated sigmoid and a Hartmann's procedure. The patient was admitted to the post-operative intensive care unit for 18 days and discharged on day 27 after the surgery. Intestinal continuity restoration was performed six months after the surgery.

CLINICAL DISCUSSION

Given the severity of second trimester pregnancy termination complications, efforts should be made to promote contraception and medical first-trimester pregnancy termination. Any unusual symptom after surgical induced abortion should lead to suspect uterine perforation.

CONCLUSION

Uterine perforation during induced abortion is usually asymptomatic and can generally be managed conservatively. However, bowel injury may result in peritonitis, requiring immediate laparotomy and resection of perforated bowel. CT-scans can help diagnose this rare complication.

Synchronous metastatic prostate cancer and male breast cancer while on testosterone replacement therapy: Case report

INTRODUCTION

Testosterone replacement therapy (TRT) can improve quality of life for men with hypogonadism. However, it is generally avoided in patients with a history of prostate cancer or breast cancer as there is uncertainty about risks. This case illustrates an example of synchronous metastatic prostate cancer and male breast cancer following TRT.

PRESENTATION OF CASE

A 72-year-old man with previously treated intermediate-risk prostate adenocarcinoma experienced a gradual rise in prostate-specific antigen (PSA) while self-administering testosterone replacement. He was later found to have recurrent metastatic prostate cancer and prior to initiating androgen deprivation therapy (ADT), he was also diagnosed with male breast cancer. His treatment has consisted of continued ADT for metastatic castration-sensitive prostate cancer (mCSPC) as well as surgical resection of his breast cancer.

DISCUSSION

ADT plays a role in treatment of male breast cancer and prostate cancer. TRT remains relatively contraindicated in patients with a history of these malignancies, but the evidence supporting this recommendation is somewhat limited.

CONCLUSION

This case highlights the potential risk for synchronous recurrent prostate and new male breast cancer following TRT. Further studies are needed to better elucidate the increased risks of these malignancies with TRT.

A rare case of hibernoma in the posterior thigh of an elderly patient: A surgical case report

INTRODUCTION AND IMPORTANCE

Hibernoma is a rare benign adipose tumor that arises from brown fat. Often misdiagnosed as liposarcoma, hibernomas require biopsy and histopathological examination for accurate diagnosis. This case report presents an unusual instance of hibernoma located in the posterior thigh of an elderly patient, emphasizing the diagnostic challenges and surgical management involved.

CASE PRESENTATION

We report the case of Mrs. F.D., a 70-year-old woman with a history of ovarian cyst surgery 17 years prior, who presented with a mass in the posterior left thigh. The mass had been developing over two years and was hard, painless, and measured 7 × 12 cm. Initial imaging suggested liposarcoma; however, an MRI revealed a 9 × 19 cm mass with heterogeneous tissue characteristics. A surgical biopsy confirmed the diagnosis of hibernoma. The tumor was excised completely, and histological examination showed typical features of hibernoma.

CLINICAL DISCUSSION

Hibernomas, although rare, should be considered in the differential diagnosis of soft tissue masses. Imaging techniques such as MRI are essential, but definitive diagnosis relies on histopathology. Surgical excision is the treatment of choice, requiring meticulous technique to manage the hypervascular nature of the tumor.

CONCLUSION

This case underscores the importance of considering hibernoma in differential diagnoses and highlights the role of biopsy for accurate diagnosis. Complete surgical excision is crucial to prevent recurrence. Further research is needed to better understand the pathogenesis and optimal management of hibernomas.

Management of a small bowel hemangioma causing intussusception in an infant: A rare case report and literature review

INTRODUCTION

Hemangiomas of the small intestine are rare and usually present in young people. They are very difficult to diagnose preoperatively. We report a rare case of mixed intestinal hemangioma (IH) causing intussusception in a pediatric patient.

CASE PRESENTATION

A 3-month-old girl, with no prior medical or surgical history, was admitted with rectal bleeding and paroxysmal crying due to intermittent abdominal pain. An urgent abdominal ultrasound revealed ileo-ileal intussusception. Operative findings confirmed the intussusception, and a segmental resection of the intussuscepted jejunum was performed. Histopathological examination found a mixed hemangioma. The postoperative course was uneventful.

DISCUSSION

Clinical presentation may include intestinal bleeding leading to anemia, obstruction, intussusception and perforation. Intussusception caused by small bowel hemangioma is extremely rare. Notably, we didn't find any cases of small bowel hemangioma revealed by intussusception in children. The main treatment for hemangiomas is surgical resection of the affected segment. No evidence in the literature on postoperative recurrence of hemangiomas.

CONCLUSION

Intussusception secondary to intestinal hemangiomas is extremely rare. Preoperative diagnosis is challenging as they are often undetectable with traditional techniques. Enhanced awareness and understanding of this condition can facilitate earlier diagnosis and improve management outcomes.

Diagnosing and managing small bowel neuroendocrine tumors presenting as acute obstruction in an elderly patient: A case report and comprehensive management overview

INTRODUCTION AND IMPORTANCE

Neuroendocrine tumors (NETs) of the small bowel are rare but clinically significant due to their challenging diagnostic pathways and potential for insidious progression. Early identification is critical for effective management and improved prognosis in these cases.

CLINICAL PRESENTATION

Here, we present a case of a 75-year-old patient with no significant medical history who presented acutely with diffuse abdominal pain, vomiting, and signs of bowel obstruction. Diagnostic workup, including CT imaging, revealed a distal ileal neuroendocrine mass with mesenteric lymphadenopathy, necessitating urgent surgical intervention.

DISCUSSION

This case underscores the diagnostic complexities and therapeutic challenges associated with small bowel NETs. Surgical resection with meticulous lymph node dissection remains the cornerstone of treatment, aimed at achieving complete tumor excision and optimal disease control. The role of imaging modalities and biochemical markers in guiding clinical decisions and postoperative management strategies is discussed considering the patient's clinical course.

CONCLUSION

Timely recognition and intervention are crucial in the management of small bowel NETs, given their potential for late presentation and nonspecific symptoms. Despite diagnostic and procedural challenges highlighted in this case, early surgical intervention and comprehensive follow-up are essential for achieving favorable outcomes and minimizing recurrence risks in patients with small bowel NETs.

Impalement injury of anorectum-A rare presentation

INTRODUCTION

A rectal impalement injury is a rare type of penetrating injury that involves a solid object being forcefully inserted through anal opening. The removal of such injuries should be planned carefully with preparedness to assess and manage associated injuries in the pelvis and peri-anal region.

CASE DESCRIPTION

An elderly female, around 65 years old, had a history of accidental penetration of an iron rod into her anal orifice. The patient was hemodynamically stable, and the distal end of the penetrated rod was visible in the anal verge on arrival. On evaluation, we found that the object had perforated the posterior wall of the middle 1/3rd of the rectum and had traversed retroperitoneally, bypassing all major vessels and viscera.

DISCUSSION

We performed exploratory laparotomy, and the iron rod was extracted from the anal canal under vision, and a diversion colostomy of the sigmoid colon was performed. The patient had an uneventful recovery, and the reversal of the sigmoid colostomy was done after 3 months.

CONCLUSION

Rectal impalement injuries are rare and serious. It requires a multidisciplinary approach involving a general surgeon, a vascular surgeon, and a urologist since it is associated with a higher incidence of involving major pelvic organs and vessels. In our case, the penetrating object had bypassed all major vessels, which is a rare occurrence.

Low foetal heart rate, a potentially ominous finding: case report

Background

Congenital long QT syndrome (LQTS) type 1 is characterized by abnormally prolonged ventricular repolarization caused by inherited defects in cardiac potassium channels. Patients are predisposed to ventricular arrhythmias and even sudden cardiac death. In some cases, foetal sinus bradycardia is the only sign, making prenatal diagnosis challenging. Physicians should be aware of this subtle presentation of LQTS. Early diagnosis and proactive treatment are crucial for preventing unexpected cardiac events.

Case summary

A healthy and asymptomatic 25-year-old pregnant woman was referred to our institute for cardiac evaluation after persistent foetal sinus bradycardia was detected during repeated ultrasounds, despite the absence of any foetal morphological or functional cardiac anomalies. After a thorough assessment, the mother was diagnosed with LQTS type 1, as confirmed by molecular genetic testing. Appropriate management, including maternal medication and increased surveillance, was initiated. The infant was delivered safely, and his electrocardiogram revealed a significantly prolonged QTc interval. Genetic testing confirmed the maternally inherited variant in KCNQ1 gene, and beta-blocker therapy was started. No arrhythmic events were noted.

Discussion

Detection and careful stratification of foetal heart rate (FHR) is crucial in every pregnancy. Foetal bradycardia can be caused by both maternal and foetal factors. Persistent low FHR should raise a high suspicion for LQTS. The condition may also present with atrioventricular blocks, torsades de pointes, or sudden intrauterine foetal demise. Accurate and early diagnosis of LQTS is essential for implementing appropriate management strategies, which include vigilant monitoring, effective medical treatment, careful planning of delivery, and post-natal care.

A novel case report of isolated cardiac myxedematosus

Background

Cardiac mucinous deposits are a rare entity only previously described in the setting of scleromyxedema, a disorder characterized by cutaneous and systemic mucin deposits, fibroblastic proliferation, and monoclonal gammopathies.

Case summary

A 41-year-old woman was transferred to our hospital after a month-long hospitalization with worsening cardiogenic shock requiring ionotropic support. Cardiac magnetic resonance imaging revealed a left ventricular ejection fraction of 23%, prior right coronary artery infarct, full-thickness late gadolinium enhancement in the left ventricle basilar wall, global abnormal parametric mapping parameters of both native T1, T2, and extracellular volume, and severe biventricular dysfunction concerning for infiltrative cardiomyopathy. Endomyocardial biopsy demonstrated heavy deposits of interstitial mucin, confirmed by electron microscopy; a Congo red stain was negative for amyloid. She was treated with an aggressive decongestive strategy, oral guideline-directed medical therapy, and intravenous immunoglobulin (IVIg); she was discharged home off inotropic support. Subsequently, she had three additional hospitalizations for heart failure exacerbation in a span of 6 months, and her overall prognosis remains guarded.

Discussion

We report a first known case of isolated cardiac myxedematosus associated with a severe systolic and diastolic cardiomyopathy. Our patient did not have any clinical evidence of systemic scleromyxedema or paraproteinemia, both of which have been reported in association with cardiac mucin deposits. Mucinosus has been described in patients with systemic lupus erythematous; however, cardiac deposits have not been reported. While IVIg has been used as a treatment in previously reported cases of cardiac scleromyxedema, its clinical benefit remains unclear in isolated cardiac myxedematosus.

Severe familial dilated cardiomyopathy in a young adult due to a rare LMNA mutation: a case report

Background

Familial dilated cardiomyopathy prognosis and disease progression vary greatly depending upon the type of genetic mutation. Family history and genetic testing are paramount in developing the best treatment plan for a patient. However, with rare or novel mutations, the significance may be unknown. Regarding this, the following case report highlights the importance of vigilance and suspicion when treating a patient with a variant of unknown significance. Additionally, it shows the importance of thoroughly investigating the family history of cardiovascular disease.

Case summary

A 25-year-old Caucasian male was found to have a right bundle branch block and dilated cardiomyopathy upon presentation to the emergency department. Later testing showed that the dilated cardiomyopathy was due to an incredibly rare lamin A/C (LMNA) gene mutation, R349L. Despite treatment with a maximum-tolerable medication regimen and an automatic implantable cardioverter-defibrillator, the patient continued to decline and required a heart transplant.

Discussion

This case provides more information on the severity of this specific LMNA mutation that has only been documented once before. Of note, the time from the initial emergency department visit to the heart transplant was approximately 2 years. Given the patient's young age and rapid disease progression, in addition to a strong family history of sudden cardiac death, the significance of this mutation should not be understated. The additional knowledge gained from this case report can be used to aid in timely interventions and prognosis evaluation.

Rice body synovitis in systemic lupus erythematosus

Rice bodies (RBs) synovitis in the shoulder joints of systemic lupus erythematosus patients is a rare clinical condition that has not been previously reported. Despite the fact that the diagnosis of RBs synovitis has primarily relied on MRI imaging, ultrasound has been used less frequently. In this report, we discuss a 43-year-old female diagnosed with systemic lupus erythematosus who presented with pain and swelling in the right shoulder. The ultrasound findings were typical, and the patient was diagnosed with RBs synovitis, as she had no history of tuberculosis or rheumatoid arthritis. Subsequently, the patient underwent ultrasound-guided percutaneous biopsy and surgical excision, which led to a good postoperative outcome. Based on this case, a literature review of RBs synovitis over the past 2 decades indicates that rice bodies synovitis is rare in clinical presentation accompanied by SLE. Moreover, ultrasound has not been extensively employed for diagnosing this condition. It is important to note the pivotal role of ultrasound in detecting RBs synovitis, and it should be the preferred method for early detection. Therefore, ultrasound physicians should be well informed about this condition to enhance diagnostic precision.

Endoscopy-assisted laparoscopic wedge-resection of gastric glomus tumor: A case report

INTRODUCTION

Glomus tumor is a pericytic mesenchymal neoplasm that most commonly occurs in the extremities. The occurrence in visceral organs is rare and is a differential diagnosis with other gastric submucosal tumors.

PRESENTATION OF CASE

A woman with epigastric pain underwent esophagogastroduodenoscopy (EGD) which revealed a gastric submucosal tumor. Endoscopic ultrasound with fine-needle aspiration allowed preoperative diagnosis of gastric glomus tumor. Intraoperative EGD-assisted laparoscopic segmental gastrectomy was successfully performed. The patient was discharged in the second postoperative day. There was no evidence of recurrence at 8 months of follow-up.

DISCUSSION

The stomach is a rare location for the glomus tumor, a neoplasm of the glomus body, which is a perivascular structure with thermoregulatory function. Preoperative diagnosis is challenging, and endoscopic ultrasound (EUS) is useful for both assessing malignancy-associated features and biopsy guiding. The treatment is surgical resection with attention to adequate oncological margins while preserving healthy gastric wall.

CONCLUSION

Immunohistochemical analysis of specimen obtained by EUS fine-needle allows accurate preoperative diagnosis and laparoscopic-endoscopic combined surgery allows good oncological and functional results.

Porta hepatis lymphnode mimicking biliary atresia: A case report

INTRODUCTION

Cholestasis is the impairment of normal bile flow causing accumulation of bile salts, lipids, and bilirubin in blood which presents as Jaundice. Jaundice beyond 2 weeks of age is rare in infancy with worldwide incidence of 1 in 2500 live births. Biliary atresia is the most common extra hepatic cause of cholestasis in late neonatal and infancy period. Cholestasis and hyperbilirubinemia cause irreversible brain and liver damage if not diagnosed and treated early.

CASE PRESENTATION

A 3-week-old neonate presenting with progressive yellowish discoloration of eyes and skin. Explorative laparotomy found anatomically normal liver and biliary tree, but a lymph node obstructing the common bile duct.

DISCUSSION

This case was particularly unique as history of illness and initial investigations were suggestive of biliary atresia. However, the patient had lymph nodes with no history of any triggers to lymphadenopathy. It is a rare case of obstruction of biliary flow in this age group.

CONCLUSION

Despite biliary atresia being the commonest cause of obstructive jaundice in infancy, it is important to rule out other causes like lymph nodes obstructing the biliary tree.

Laparoscopic cholecystectomy for a gallbladder with a right sided round ligament using indocyanine green fluorescence imaging: A case report

INTRODUCTION

The gallbladder with a right sided round ligament is a rare anomaly. It is frequently associated with various biliary, vascular, and other anomalies. Herein, we present a case of a gallbladder with a right-sided round ligament treated with laparoscopic cholecystectomy using indocyanine green fluorescence imaging.

PRESENTATION OF CASE

A 50-year-old woman had right upper quadrant discomfort. Gallbladder stones, a polyp, and a right-sided round ligament were found on preoperative computed tomography. Laparoscopic cholecystectomy with indocyanine green fluorescence imaging was decided. During surgery, "fundus first technique" was performed and the biliary anatomy was confirmed with the aid of indocyanine green fluorescence guidance. The gallbladder was attached to segment 4 of the liver which was the left side of the round ligament. Cystic artery and cystic duct were ligated safely. The patient had no postoperative complication.

DISCUSSION

Although there are various anomalies in patients having a gallbladder with a rights-sided round ligament, ICG fluorescence imaging can show the anatomy of the extrahepatic biliary tree. It can enable surgeons to recognize concomitant vascular and biliary anomalies.

CONCLUSION

Laparoscopic cholecystectomy for gallbladder with a right-sided round ligament can be safely performed by identifying biliary anatomy with indocyanine green fluorescence imaging.