Look, but to the left: A rare case of gallbladder sinistroposition and comprehensive literature review

Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is of significant intraoperative importance. Due to its association with other anatomic anomalies involving key structures in the hepatobiliary system, discovering it intraoperatively as opposed to preoperatively suddenly increases the difficulty of a gallbladder procedure.

1)

Left-sided gallbladder (LSGB) is a rare anatomic variation that, while benign in the context of its transposition, is of significant intraoperative importance.

2)

Although laparoscopic cholecystectomy of a LSGB is safe, it is associated with higher risk of complications such as common bile duct injury.

3)

Most cases of a LSGB are diagnosed intraoperatively, and this sudden discovery during the procedure can increase the difficulty, duration, and stress of the procedure due to the other potential anatomic anomalies that LSGB is associated with in the hepatobiliary system.

Fungal burn wound infection caused by Fusarium dimerum: A case series on a rare etiology

Introduction

Fusarium dimerum is a filamentous mold associated with poor outcomes in immunocompromised hosts and burn victims. It can be acquired via inhalation or through skin dehiscence.

Methods

Our work presents a Case series of 8 patients from ages 3–57 years who were admitted with multiple burn wounds over the past 6 months. After initial stabilization measures, they all underwent debridement for the lesions after negative initial fungal cultures. The 44-year-old male was the first patient to develop punched-out eruptions on burn areas 7 days after admission; all the other patients experienced similar lesions during the next 6 days. Tissue cultures of the lesions exhibited Fusarium dimerum growth. The patients were managed accordingly with amphotericin B or voriconazoles. All the patients recovered except the 11-year-old boy, who expired on day 9 due to ARDS and sepsis complications.

Outcomes

Infection with Fusarium dimerum carries a high risk of dissemination in burn infections. Hence, appropriate screening should be carried out via histologic and mycologic diagnostics early in the disease course.

Conclusion

Considering the sparse literature that is available regarding Fusarium infection in burn victims, this study aims to improve the knowledge surrounding different facets of this disease including its epidemiology, diagnosis, management, and the need to maintain high suspicion of this fungal disease in burn patients.

•

Fusarium dimerum is a filamentous mold associated with poor outcomes in immunocompromised hosts and burn victims. It can be acquired via inhalation or through skin dehiscence.

•

Our work presents a Case series of 8 patients from ages 3–57 years who were admitted with multiple burn wounds over the past 6 months. After initial stabilization measures, they all underwent debridement for the lesions after negative initial fungal cultures.

•

Infection with Fusarium dimerum carries a high risk of dissemination in burn infections. Hence, appropriate screening should be carried out via histologic and mycologic diagnostics early in the disease course.

A case of isolated sinus bradycardia as an unusual presentation of adrenal insufficiency

Introduction

Sinus bradycardia is a common entity encountered in clinical practice. The differential diagnosis is quite broad; it can be an incidental finding in otherwise healthy adults or the first clue to a lethal pathology.

Case presentation

This case highlights a patient who presented with symptomatic sinus bradycardia, which resulted in syncope requiring admission for permanent pacemaker implantation and later found to have an underlying adrenal insufficiency (AI). Patient's underlying hyponatremia was corrected but bradycardia persisted and after the initiation of steroids, bradycardia resolved. Therefore, the likely culprit for bradycardia was AI.

Discussion

Multiple disease processes that manifest with sinus bradycardia are commonly due to the increased vagal tone or the presence of intrinsic conduction disorders. Sinus bradycardia is a common clinical finding with a broad differential including intrinsic and extrinsic causes of sinus node dysfunction or AV block.

Conclusion

It is imperative for clinicians to be aware of rare etiologies for underlying symptomatic bradycardia. While extremely effective at preventing symptomatic bradycardia, avoiding a pacemaker by correcting the underlying etiology of symptomatic bradycardia may improve quality of life and avoid an unnecessary procedure.

Chilaiditi syndrome: A structural displacement in a heart failure patient

Background

Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea.

Case presentation

In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging.

Conclusion

Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution.

Learning objective

Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.

•

Chilaiditi's sign in an incidental finding on chest or abdominal radiograph associated with gastrointestinal symptoms and less commonly associated with dyspnea.

•

Chilaiditi's sign with underlying heart failure is not well understood.

•

Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.

COVID-19 and mucormycosis superinfection: Exploring the missing pathophysiological links

The coronavirus disease 2019 continues to unearth new facets that portend grave clinical implications. In recent times, there has been mounting fervor regarding coronavirus disease 2019 and mucormycosis superinfection. While the correlation between the two is conspicuous, the underlying pathophysiological mechanisms that render a patient with coronavirus disease 2019 susceptible to mucormycosis, or vice versa, are still elusive.

Surgical Versus Medical Management of Necrotizing Enterocolitis With and Without Intestinal Perforation: A Retrospective Chart Review

Background

Necrotizing enterocolitis (NEC) is a debilitating disease that predominantly afflicts premature neonates, although it can also affect term neonates. The clinical features of the ailment vary widely and range from transient feed intolerance to life-threatening complications such as septicemia and disseminated intravascular coagulation. While surgery is usually only reserved for severe cases, such as those presenting with intestinal perforation, the role of surgical management in cases of NEC without perforation remains elusive.

Methods

A retrospective chart review of patients, three years in duration, was conducted and studied confirmed cases of NEC. The clinical presentations studied included cases of NEC with pneumatosis intestinalis, fixed bowel loop, pneumoperitoneum, and abdominal wall erythema. The patients were divided with regards to their intestinal perforation status and with pertinence to the treatment modality employed (medical or surgical). The results in either group were eventually analyzed in terms of the overall survival rate.

Results

A total of 48 patients were included in the study, of which 79.16% presented without perforation and 20.83% with perforation. Of the study participants included, 26 were females and 22 were males. Pertinently, no gender predominance was appreciated. In patients without perforation, medical management was noted to boast a lower mortality rate when compared with surgical intervention (15.6% vs 50.0%, respectively). In patients with perforation, the overall mortality was noted to hover at 50.0%, which was higher than that encountered in the non-perforation group.

Conclusion

In patients with NEC without perforation, surgical treatment confers no comparative therapeutic advantage when compared with medical management alone. Conservative management with broad-spectrum antibiotics including metronidazole yields equally favorable outcomes in such cases.

Five-year comparison of diabetic control between community diabetic center and primary health-care centers

Context:

Hyperglycemia is the most important factor for development of complications. A high level of hemoglobin A1c (HbA1c) is linked with such complications of diabetes.

Aims:

The aim of this study was to compare diabetic care between community diabetic center (CDC) and primary health centers.

Settings and Design:

This was a retrospective cohort study conducted at King Abdulaziz Medical City for National Guard Health Affairs at Riyadh, Saudi Arabia.

Subjects and Methods:

Data were retrieved from electronic medical records for diabetes mellitus Type 2 patients who were treated at two settings: CDCs and primary healthcare.

Statistical Analysis Used:

SPSS (V21) was used to analyze the univariate and bivariate analysis, Student's t-test for continuous variables and Chi-square test for binary variables were used. P value was set as statistically significant if it is <0.05.

Results:

The mean difference for HbA1c from first to last visits increased significantly +0.2 ± 1.67 with P = 0.002 while the low-density lipoprotein (LDL) on the other way around improved by decrease of −0.159 ± 0.74 and P < 0.000. Body mass index (BMI) among the sample increased by +0.134 ± 1.57 with no significant, P = 0.078. Among the sample, 39.5% improved their HbA1c while 56.8% deteriorated and 3.6% of the samples’ readings remain the same. 55.3% of the sample improved in LDL and 52.4% in the high-density lipoprotein while 53.7% improved in triglycerides. The BMI was improved among 43.4% of diabetic patients.

Conclusions:

The 5-year management of diabetic patients failed to improve the A1c or BMI, at both CDC and primary health-care centers.