Ischemic Colitis in a Patient with Severe COVID-19 Pneumonia

At the time of the current COVID-19 pandemic, on a daily basis, we encountered patients suffering from various manifestations of this infection. The most common are respiratory symptoms. Many of the patients require acute hospital care, and a smaller group of them are hospitalized in intensive care units. A subset of these critically ill patients demonstrates clinically remarkable hypercoagulability and thus a predisposition to venous and arterial thromboembolism, manifested by thrombotic events ranging from acute pulmonary embolism and splanchnic vascular ischemia to extremity ischemia. The article describes a case of a patient with COVID-19 pneumonia complicated by massive bleeding into the gastrointestinal tract due to ischemic enterocolitis in connection with COVID-19 infection.

A rare case of urothelial carcinoma metastasizing to the gallbladder wall with manifestations as acute cholecystitis

BACKGROUND

Metastasis to the gallbladder is very rare. This case report highlights a rare cause of acute cholecystitis, which should be considered by the surgeon and other treating physicians in the differential diagnosis of patients with urothelial carcinoma.

CASE

We report the case of a 73 year-old man with follow-up oncology care. He was diagnosed with infiltrating urothelial carcinoma in 2019, received neoadjuvant chemotherapy, and subsequently underwent radical cystectomy with ureteroileostomy in April 2020. Histology confirmed complete regression of bladder cancer, the lymphonodes were also free of tumour infiltration. In July 2021, the patient was examined for intermittent abdominal pain, predominantly of the right upper quadrant. On clinical examination, the gallbladder hydrops was palpable and a positive Murphy's sign was present. Due to the signs of acute cholecystitis, the patient was indicated for acute cholecystectomy. Gallbladder histology revealed metastatic involvement of the gallbladder wall by urothelial carcinoma.

CONCLUSION

If patients with bladder cancer present with intermittent right subcostal pain or signs of acute cholecystitis and diagnostic imaging shows a thickened gallbladder wall, clinicians and radiologists should consider the possibility of metastatic origin of lesion.

Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature

Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.

Cerebral air embolism: neurologic manifestations, prognosis, and outcome

Background

Cerebral air embolism (CAE) is an uncommon medical emergency with a potentially fatal course. We have retrospectively analyzed a set of patients treated with CAE at our comprehensive stroke center and a hyperbaric medicine center. An overview of the pathophysiology, causes, diagnosis, and treatment of CAE is provided.

Results

We retrospectively identified 11 patients with cerebral venous and arterial air emboli that highlight the diversity in etiologies, manifestations, and disease courses encountered clinically. Acute-onset stroke syndrome and a progressive impairment of consciousness were the two most common presentations in four patients each (36%). Two patients (18%) suffered from an acute-onset coma, and one (9%) was asymptomatic. Four patients (36%) were treated with hyperbaric oxygen therapy (HBTO), high-flow oxygen therapy without HBOT was started in two patients (18%), two patients (18%) were in critical care at the time of diagnosis and three (27%) received no additional treatment. CAE was fatal in five cases (46%), caused severe disability in two (18%), mild disability in three (27%), and a single patient had no lasting deficit (9%).

Conclusion

Cerebral air embolism is a dangerous condition that necessitates high clinical vigilance. Due to its diverse presentation, the diagnosis can be missed or delayed in critically ill patients and result in long-lasting or fatal neurological complications. Preventative measures and a proper diagnostic and treatment approach reduce CAE's incidence and impact.

Subpleural pulmonary nodule marking with patent blue V dye prior to surgical resection

Background and objective

Subpleural located pulmonary nodules are perioperatively invisible to the surgeon. Their precise identification is conventionally possible by palpation, but often at the cost of performing a thoracotomy. The aim of the study was to evaluate the success rate and feasibility of the pre-operative CT-guided marking subpleural localized nodule using a mixture of Patent Blue V and an iodine contrast agent prior to the extra-anatomical video-assisted thoracoscopic surgery (VATS) resection in patients for whom the primary anatomical resection in terms of segmentectomy or lobectomy was not indicated.

Methods

The data of consecutive patients with pulmonary nodules located ≤ 30 mm from the parietal pleura, who were indicated for VATS extra-anatomical resection between 2017 to 2023, were retrospectively reviewed and analyzed. All patients indicated for VATS resection underwent color marking of the area with the pulmonary lesion under CT-guided control immediately before the surgery. The primary outcome was the marking success. Morphological lesion characteristics, time from marking to the surgery, procedure related complications, final histology findings and 30day mortality were analyzed. Additionally, we assessed the association of the successful marking and the patient's smoking history.

Results

A total of 62 lesions were marked. The successful marking was observed in 56/62 (90.3%) patients. The median time from the lesion marking to the beginning of surgery was 75.0 (IQR 65.0-85.0) minutes. The procedure related pneumothorax was observed in 6 (9.7%) patients, intraparenchymal hematoma in 1 (1.6%) patient. No statistically significant association of the depth of the subpleural lesion's location, occurrence of complications or time from the marking to surgery and the successful marking was observed. The 30day mortality was zero. No association of smoking and successful marking was observed.

Conclusions

The method of marking the subpleural pulmonary lesions under CT-guided control with a mixture of Patent Blue V and iodine contrast agent is a safe and effective method with minimal complications. It provides surgeons the precise visualization of the affected pulmonary parenchyma before the planned extra-anatomical VATS resection.

Precise Localization of the Subsolid Lesion by Colour Marking under CT-Guided Control before Video-Assisted Surgery Resection: A Case Report

Introduction

Lung cancer is one of the leading causes of death worldwide. Lung lesions, often discovered incidentally on chest CT, pose a diagnostic challenge due to their diverse etiology, including both benign and malignant nature. A key step in the assessment of these lesions is the evaluation of their morphological features in the CT image, size, and behavior over time. Nodules are divided into solid and subsolid according to their density. When surgical resection is necessary, solid lesions are palpable peroperatively, whereas subsolid lesions may be unidentifiable by palpation, and their precise localization is difficult. To spare patients from extensive surgery such as thoracotomy, it is advantageous to use one of the methods of preoperative marking of these lesions. Best practices include marking with mixtures containing patent blue and contrast agents, applied under CT guidance. This method allows accurate visualization of the localization of the lesion, which facilitates their resection by minimally invasive video-assisted surgery (VATS).

Case Presentation

A 51-year-old female patient was found to have a subsolid lesion in the right lung during a routine follow-up CT scan of the lung for a history of malignant melanoma. The lesion was followed for 4 years and showed slow size progression and change from a pure ground glass nodule to a subsolid nodule. Due to the persistence of the nodule, change in morphology, and size progression, the patient was indicated for surgical resection. Using preoperative labeling with a mixture of blue dye and contrast agent, the nodule was successfully located and sublobary VATS resected.

Conclusion

The color marking allowed accurate identification of the subpleurally located lesion, which would otherwise have been unvisualized and intangible, thus minimizing the need for more extensive surgery. This case highlights the key role of color marking in increasing resection success and surgical safety, particularly in small and subsolid nodules.

[Axial spondyloarthritis]

Axial spondyloarthritis (axSpA) is a common name for the non-radiographic form of the disease and radiographic axial spondyloarthritis, known as ankylosing spondylitis (AS). The disease is typically manifested at a young age, characterized by affection of axial skeleton, and in the most severe form can lead to complete ankylosis of the spine. Etiology of diseases have not yet been clarified, however, the genetic background, especially the binding to HLA-B27 antigen, is obvious. Clinical manifestations are dominated by chronic pain in the lower pain or buttocks that occurred in young age, in a large proportion of patients having the character of so-called inflammatory pain. In addition to the axial skeleton, axSpA there is also common affection of peripheral skeleton in the form of enthesitis, arthritis, and less often dactylitis. At present, enthesitis is considered as a hallmark of the entire spondyloarthritis group. Typical for axSpA is the frequent presence of extraskeletal manifestations in the form of uveitis, idiopathic intestinal inflammation and psoriasis. In the axSpA diagnosis, significant advances have been made in recent years in the field of imaging techniques. Magnetic resonance imaging can also identify the early stage of the disease before the development of structural lesions. Also, the newer concepts of the entire spondyloarthritis group, based on the 2009 ASAS (Assessment of SpondyloArthritis international Society) classification criteria, contributed to early diagnosis of the disease, and in particular to the underlying importance of association with HLA-B27 antigen and the presence of peripheral and non-articular manifestations. Non-steroidal anti-rheumatic drugs (NSAIDs) and TNFα blockers are effective axSpA therapy, which has been recently enhanced by interleukin 17 blockade (IL17).Key words: axial spondyloarthritis - biological treatment - enthesitis - extraarticular manifestations - magnetic resonance imaging - non-radiographic axial spondyloarthritis - sacroiliitis.

Diagnostic-therapeutic management of pulmonary nodules

BACKGROUND

Lung cancer is one of the leading causes of death worldwide, with incidence and mortality significantly affected by population ageing and changes in the prevalence of risk factors. Lung nodules, which are often detected incidentally on imaging studies, pose a significant diagnostic challenge as they may indicate both benign and malignant processes. Correct diagnosis and management of these nodules is therefore essential to optimize clinical outcomes.

PURPOSE

This article provides a comprehensive review of diagnostic and therapeutic approaches to pulmonary nodules, focusing on the assessment of malignant potential based on nodule morphology, size and growth potential. Risk factors influencing the decision-making process such as smoking, age and exposure to carcinogens are also discussed. In addition, key recommendations from the Fleischner Society and the British Thoracic Society are discussed in detail. The article analyses the benefits of modern imaging techniques, including the use of artificial intelligence (AI) in the diagnosis of lung nodules. AI technologies, particularly deep learning techniques, have shown high accuracy in detecting and assessing malignancy risk, and their use is increasingly complementary to expert clinical judgement. Finally, the article highlights the importance of a multidisciplinary approach to the diagnosis and management of lung nodules, and also mentions the implementation of a pilot lung cancer screening programme in the Czech Republic aimed at early detection of the disease. This programme has the potential to significantly reduce lung cancer mortality and improve patient prognosis.