CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 21-2015. A 37-Year-Old American Man Living in Vietnam, with Fever and Bacteremia

Foreign Glass Bodies in Pleura and Pancreas: Systematic Review for Entry Hypotheses and Treatment Options in an Unresolved Case

BACKGROUND

Foreign bodies within the pleura and pancreas are infrequent, and the approaches to their treatment still a subject of debate. There is limited knowledge particularly regarding glass foreign bodies.

METHODS

We present a case involving large glass splinters in the pleura and pancreas, with an unknown entry point. In addition, a systematic review was conducted to explore entry hypotheses and management options.

RESULTS

In addition to our case, our review uncovered eight incidents of intrapleural glass, and another eight cases of glass in other intrathoracic areas. The fragments entered the body through impalement (81%), migrated through the diaphragm after impalement (6%), or caused transesophageal perforation (19%) following ingestion. Eight instances of glass inside the abdominal cavity were documented, with seven resulting from impalement injuries and one from transintestinal migration. There were no recorded instances of glass being discovered within the pancreas. Among the 41 nonglass intrapancreatic foreign bodies found, sewing needles (34%) and fish bones (46%) were the most common; following ingestion, they had migrated through either a transgastric or transduodenal perforation. In all these cases, how the foreign bodies were introduced was often poorly recalled by the patient. Many nonglass foreign bodies tend to become encapsulated by fibrous tissue, rendering them inert, though this is less common with glass. Glass has been reported to migrate through various tissues and cavities, sometimes with a significant delay spanning even decades. There are cases of intrapleural migration of glass causing hemothorax, pneumothorax, and heart and major blood vessels injury. For intrapleural glass fragment management, thoracoscopy proved to be effective in 5 reported cases, in addition to our patient. Most intrapancreatic nonglass foreign bodies tend to trigger pancreatitis and abscess formation, necessitating management ranging from laparoscopic procedures to subtotal pancreatectomy. There have been only four documented cases of intrapancreatic needles that remained asymptomatic with conservative management. There is no direct guidance from the existing literature regarding management of intrapancreatic glass foreign bodies. Consequently, our patient is under observation with regular follow-ups and has remained asymptomatic for the past 2 years.

CONCLUSIONS

Glass foreign bodies in the pleura are rare, and our report of an intrapancreatic glass fragment is the first of its kind. Impalement is the most likely method of introduction. As glass has significant migration and an ensuing complication potential, preventive removal of intrapleural loose glass should be considered. However, intrapancreatic glass fragment management remains uncertain.

Pancreatitis from posterior gastric wall perforation by ingested metallic wire-case report and review of literature

Gastric and duodenal perforation from ingested organic and inorganic foreign bodies, such as sewing needles, toothpick, metallic wires, fish and chicken bone, are uncommon incidents as most foreign bodies pass in the faeces. The perforated foreign body can at times migrate and either penetrate causing traumatic injury or incite inflammation with formation of abscesses or pseudo-tumours in the adjacent organs such as the liver and pancreas. We report one such case of pancreatitis in a child resulting from a metallic wire perforating the posterior gastric wall and penetrating the pancreas. The findings were detected on CT and the foreign body was extracted endoscopically. We also present review of literature on similar case reports.

Augmented reality navigation facilitates laparoscopic removal of foreign body in the pancreas that cause chronic complications

BACKGROUND

Foreign bodies that enter the pancreas and cause chronic complications cannot be removed by endoscopy. Surgical removal is necessary but also challenging. The development of augmented reality navigation has made it possible to accurate intraoperative navigation in laparoscopic surgery.

METHODS

A 37-year-old female had epigastric pain for 3 months and her abdominal CT showed a linear high-density shadow in her pancreas along with chronic pancreatitis. Three-dimensional models of the liver, pancreas, stomach, blood vessels, and foreign body were created based on CT images. Gastroptosis was found in the three-dimensional models, so surgical approach was adapted to open the hepatogastric ligament to reach the pancreas. After 2-3 s of video images were captured by 3D laparoscopy, a three-dimensional dense stereo-reconstruction method was used to obtain the surface model of pancreas, stomach, and blood vessels. The Globally Optimal Iterative Closest Point method was used to obtain a spatial transformation matrix between the preoperative CT image space and the intraoperative laparoscopic space. Under augmented reality navigation guidance, the position and location of the foreign body were displayed on the surface of the pancreas. Then intraoperative ultrasound was used for further verification and to quickly and easily confirm the surgical entrance. After minimal dissection and removal of the pancreatic parenchyma, the foreign body was removed completely.

RESULTS

The operation time was 60 min, the estimated blood loss was 10 ml. The foreign body was identified as a 3-cm-long fishbone. The patient recovered without complications and was discharged on the third postoperative day.

CONCLUSION

Because it enables direct visual navigation via simple operation, ARN facilitates the laparoscopic removal of foreign bodies in the pancreas with accurate and rapid positioning and minimal damage.

Empyema caused by Streptococcus constellatus: a case report and literature review

Background

Streptococcus constellatus is a member of Streptococcus anginosus group (SAG) that tends to cause pyogenic infections in various sites. However, Streptococcus constellatus is easily ignored by routine clinical laboratory tests for its prolonged anaerobic culture environment.

Case presentation

A 71-year-old man was admitted to our hospital due to productive cough, fever, chest pain and shortness of breath for 3 weeks. Chest computed tomography showed patchy opacities and right-sided pleural effusion, so a chest tube was inserted and purulent and hemorrhagic fluid was aspirated. The routine etiological examinations of the pleural effusion were all negative, and next-generation sequencing (NGS) detected Streptococcus constellatus. Intravenous piperacillin-tazobactam 4.5 g every 8 h was used accordingly. The patient recovered and subsequent chest computed tomography confirmed the improvement.

Conclusions

We reported a case of empyema secondary to Streptococcus constellatus infection, which was identified by NGS, instead of bacterial culture. This case highlights the utility of NGS in detecting pathogens negative in traditional bacterial tests.

Successful laparoscopic treatment for sustained abdominal pain due to fish bone migrating into the neck of the pancreas: a case report and thinking about surgical approach through the literature review

Background

The majority of ingested foreign bodies pass through the gastrointestinal tract smoothly, with less than 1% requiring surgery. Fish bone could perforate through the wall of stomach or duodenum and then migrate to other surrounding organs, like the pancreas and liver.

Case presentation

We report herein the case of a 67-year-old male who presented with sustained mild epigastric pain. Abdominal computed tomography revealed a linear, hyperdense, foreign body along the stomach wall and pancreatic neck. We made a final diagnosis of localized inflammation caused by a fish bone penetrating the posterior wall of the gastric antrum and migrating into the neck of the pancreas. Upper gastrointestinal endoscopy was performed firstly, but no foreign body was found. Hence, a laparoscopic surgery was performed. The foreign body was removed safely in one piece and was identified as a 3.2-cm-long fish bone. The patient was discharged from the hospital on the fifth day after surgery without any postoperative complications.

Conclusion

Laparoscopic surgery has proven to be a safe and effective way to remove an ingested fish bone embedded in the pancreas.

Laparoscopic removal of an ingested fish bone from the head of the pancreas: case report and review of literature

Most ingested foreign bodies pass spontaneously through the gastrointestinal tract and only 1% of them can perforate or penetrate the wall of stomach and duodenum and migrate into organs, such as the liver and pancreas. We report herein the case of a 59-year-old woman who presented to the emergency department with epigastric pain and fever. Computed tomography of the abdomen revealed a linear foreign body that perforate the posterior wall of the prepyloric region of the stomach. The foreign body was removed laparoscopically in one piece and was identified as a 3-cm-long fish bone. The patient recovered without complications and was discharged on the 4th postoperative day. Pancreatic foreign body is a rare entity and laparoscopic removal is warranted in majority of cases.

Laparoscopic removal of an ingested fish bone that penetrated the stomach and was embedded in the pancreas: a case report

Background

The gastrointestinal tract can occasionally be perforated or penetrated by an ingested foreign body, such as a fish bone. However, there are very few reported cases in which an ingested fish bone penetrated the gastrointestinal tract and was embedded in the pancreas.

Case presentation

An 80-year-old male presented with epigastric pain. Computed tomography of the abdomen showed a linear, hyperdense, foreign body that penetrated through the posterior wall of the gastric antrum. There was no evidence of free air, abscess formation, migration of the foreign body into the pancreas, or pancreatitis. As the patient had a history of fish bone ingestion, we made a diagnosis of localized peritonitis caused by fish bone penetration of the posterior wall of the gastric antrum. We first attempted to remove the foreign body endoscopically, but failed because it was not detected. Hence, an emergency laparoscopic surgery was performed. A linear, hard, foreign body penetrated through the posterior wall of the gastric antrum and was embedded in the pancreas. The foreign body was safely removed laparoscopically and was identified as a 2.5-cm-long fish bone. Intraperitoneal lavage was performed, and a drain was placed in the lesser sac. The patient recovered without complications and was discharged on the 7th postoperative day.

Conclusion

Laparoscopic surgery could be performed safely for the removal of an ingested fish bone embedded in the pancreas.

Paederus dermatitis in a seafarer diagnosed via telemedicine collaboration

Seafarers are traveling workers, subject to unique exposures and generally isolated from adequate medical care. This case report of paederus dermatitis diagnosed at sea highlights the importance of a multidisciplinary diagnostic approach and telecommunication in providing remote medical advice to isolated traveling workers such as seafarers.