Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy

alkiviadis.1961 shared this article with you from Inoreader Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy Via BMJ Case Reports Last 6 Issues Upper gastrointestinal (GI) endoscopies are performed for several reasons. The overuse of endoscopy has negative effects on the quality of healthcare and pressurises endoscopy services. It also results in the complications. These complications include pneumoperitoneum, pneumomediastinum and subcutaneous pneumomediastinum. However, it is worth noting that these complications rarely occur during endoscopy of the upper GI tract. These complications, when they occur, indicate perforation of the retroperitoneal space or peritoneal cavity. In this article, we discuss a case of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema after upper GI endoscopy. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Spontaneous extrusion of a dexamethasone intravitreal implant (Ozurdex)

alkiviadis.1961 shared this article with you from Inoreader Spontaneous extrusion of a dexamethasone intravitreal implant (Ozurdex) Via BMJ Case Reports Last 6 Issues A 59-year-old man with diabetic macular oedema was treated with a dexamethasone intravitreal implant (Ozurdex) to his right eye. Immediately after injection, the implant was noted to have extruded into the perilimbal subconjunctival space. The remnants of the implant were expeditiously removed the following day to avoid corneal decompensation and permanent corneal oedema. Endothelial decompensation secondary to the migration of dexamethasone implants into the subconjunctiva l space or anterior chamber is a recognised complication of Ozurdex injection. The patient recovered well postoperatively with no further complications. He was planned for a new Ozurdex implant 1 month later. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Continuous acellular material accumulation in the anterior chamber associated with corneal endothelial changes

alkiviadis.1961 shared this article with you from Inoreader Continuous acellular material accumulation in the anterior chamber associated with corneal endothelial changes Via BMJ Case Reports Last 6 Issues This case series included two healthy adults who showed continuous production of acellular materials in the anterior chamber without inflammation. The materials were membrane-like in case 1 and amorphous in case 2; they gradually changed shape and location over several years. During follow-up, there were no changes in vision, the iris or the chamber angle. Anterior segment optical coherence tomography confirmed the attachment of the membrane to the corneal endothelium. Spec ular microscopy showed normal endothelial counting with reversal of the normal light/dark patterns that occasionally returned to normal appearances. Although acellular materials were observed unilaterally in both cases, abnormal endothelial images were noted in both eyes of case 1. Histopathological examinations demonstrated the absence of cellular components with negative immunostaining for collagen IV, vimentin and α-smooth muscle actin. Serial ophthalmic examinations and histopathological findings suggest that the production of acellular material was associated with alterations of the corneal endothelium. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Murine typhus mistaken for COVID-19 in a young man

alkiviadis.1961 shared this article with you from Inoreader Murine typhus mistaken for COVID-19 in a young man Via BMJ Case Reports Last 6 Issues Fever is a widely recognised presenting symptom of COVID-19. Consequently, other febrile illnesses may be difficult to distinguish from COVID-19—leading to delays in diagnosis and treatment. One such illness is murine typhus, a fleaborne illness with worldwide distribution caused by Rickettsia typhi. It often presents with fever, headache and myalgia, all of which have been commonly reported with COVID-19. Although the disease is usually mild with a good prognosis , there have been reports of severe illness and death. I present a case of murine typhus in a young male who had 2 weeks of headaches and daily fevers during the COVID-19 pandemic. He was ultimately tested for murine typhus when his occupation as a dog trainer was queried, and he experienced resolution of symptoms after treatment with doxycycline. During this pandemic, clinicians must be vigilant of other febrile illnesses whose symptoms overlap with COVID-19. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Early diagnosis of spontaneous heterotopic pregnancy successfully treated with laparoscopic surgery

alkiviadis.1961 shared this article with you from Inoreader Message: Celia Soares, Ana Maçães, Mariana Novais Veiga and Marta Osório Author affiliations Obstetrics and Gynecology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal Correspondence to Dr Celia Soares; celia.cmsoares@gmail.com http://dx.doi.org/10.1136/bcr-2020-239423 Request Permissions Description An 18-year-old nulliparous woman presented to our emergency department with a history of severe hypogastric pain with vomiting for 2 days and unknown date of last menstrual period. The patient had no relevant medical history and she was not taking any medication, including ovulation inductors. On clinical examination, she was haemodynamically stable, reported pain on palpation of the left iliac fossa but had no rebound tenderness. Transvaginal ultrasound revealed an evolutive 6 weeks' gestational age intrauterine pregnancy (IUP; figure 1A) and a non-cystic extraovarian mass (58×35 mm; figure 1B,C) with surrounding fluid in the left adnexa (figure 1). Two corpus luteum cysts were seen, one in each ovary. The blood results were normal and the human chorionic gonadotropin levels were 15 797 mIU/mL. Figure 1 Download figure Open in new tab Download powerpoint Figure 1 Transvaginal ultrasound image of an evolutive 6 weeks' intrauterine pregnancy (A). Left ovary (23×10 mm) (B) and, next to it, a non-cystic heterogeneous mass (58×35 mm) (C) with moderate free fluid (D). A heterotopic pregnancy (HP) was suspected, so the patient was admitted. In the first hours of hospitalisation, despite remaining haemodynamically stable, the patient had worsening abdominal pain, presenting at this time point with rebound tenderness and anaemia (haemoglobin 102 g/L). Ultrasound reassessment revealed a moderate amount of free fluid, consistent with the acute blood loss noted in the dropping haemoglobin. An exploratory laparoscopy was performed and revealed a moderate haemoperitoneum, an open left fallopian tube in its distal portion, and a clot and trophoblastic tissue in the pouch of Douglas (figure 2). A left salpingectomy was carried out. The pathological examination confirmed the diagnosis of tubal ectopic pregnancy (EP). She was discharged on day 2. The remaining pregnancy was uneventful. The patient delivered a healthy live baby girl at 39 weeks by vaginal delivery following a spontaneous labour. Figure 2 Download figure Open in new tab Download powerpoint Figure 2 Left fallopian tube open at its distal portion with clot and trophoblastic tissue in the pouch of Douglas. HP is defined as the coexistence of at least two pregnancies in different implantation sites and its incidence in spontaneous pregnancies is estimated to be 1/30 000.1 Predisposing risk factors include previous history of EP, tubal surgery, pelvic inflammatory disease, use of an intrauterine device, in vitro fertilisation in the current pregnancy, in utero diethylstilbestrol exposure and smoking.2 3 The main symptoms of HP are abdominal pain, adnexal mass, peritoneal irritation and an enlarged uterus,1 which can mimic other gynaecological causes (miscarriage, EP, IUP with haemorrhagic corpus luteum and adnexal torsion) and non-gynaecological ones (appendicitis, cholecystitis, bowel obstruction or pancreatitis).4 Due to these unspecific clinical symptoms, the diagnosis of HP is often delayed and only made after a ruptured EP,1 which is associated with a considerable risk of maternal morbidity and mortality (0.50 per 100 000 live births).4 5 Despite its low sensitivity (33%) in the detection of HP, transvaginal ultrasound is the gold standard for diagnosis.6 7 Although ultrasound evaluation of an early gestation should include the adnexa, the diagnosis of an IUP often leads to the mistaken exclusion of the hypothesis of a concomitant EP.4 We present a rare case of a spontaneous HP in a woman with no obvious predisposing risk factors. Patients with no risk factors account for a minority of the cases of HP.3 Despite the low suspicion index, transvaginal ultrasound with systematic evaluation of the adnexa allowed an early diagnosis of such a rare case of HP. There are several cases reported of HP where EP was not detected initially.7 8 A key insight of the presented report is that careful adnexal ultrasound assessment mitigates the risk of missing an EP in the presence of an IUP. A timely diagnosis of HP offers more treatment options to patients. In the reported case, the patient underwent a laparoscopic salpingectomy. The uterus was not manipulated, to preserve the IUP. This is considered the safest treatment approach by most authors.5 7 Patient's perspective At first, I was very happy to know that I was pregnant as it was a desired pregnancy. I was far from imagining what was to come next. I never thought that from an emotional and physical point of view, it would be so painful. I had never experienced anything like this before in all my life. When it was told to me that I would have to undergo a surgical procedure, I was quite scared and somewhat afraid. From that moment on, I cannot remember anything. I must say that after waking up, I felt much better, without pain, but with some fear of what might still happen. Fortunately, everything went well and the pregnancy went smoothly. Despite the huge scare that was in the early hours, everything ended up going normal, and nowadays, fortunately, I have an extremely healthy, active child with no health problems or disabilities. Regarding the medical team in general, but particularly the team responsible for the operation, I would like to emphasise that they were extremely competent, attentive and especially very careful. I leave a huge thanks to everyone and I would also like to highlight the nurses and health assistants because they have had a fundamental role in my recovery. Learning points Heterotopic pregnancy (HP) is a life-threatening, difficult-to-diagnose condition. To exclude a possible ectopic pregnancy, it is important to evaluate the adnexa carefully through ultrasound, even if an intrauterine gestational sac is already confirmed and even if there is no apparent risk factor. HP tends to be overlooked after confirming an intrauterine pregnancy. When a diagnosis is established on time, the number of pregnancies that reach term after treatment is significant. References ↵Reece EA, Petrie RH, Sirmans MF, et al. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol 1983;146:323–30.doi:10.1016/0002-9378(83)90755-Xpmid:http://www.ncbi.nlm.nih.gov/pubmed/6344638PubMedWeb of ScienceGoogle Scholar ↵Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril 1996;65:1093.pmid:http://www.ncbi.nlm.nih.gov/pubmed/8641479CrossRefPubMedWeb of ScienceGoogle Scholar ↵Talbot K, Simpson R, Price N, et al. Heterotopic pregnancy. J Obstet Gynaecol 2011;31:7–12.doi:10.3109/01443615.2010.522749pmid:http://www.ncbi.nlm.nih.gov/pubmed/21280985CrossRefPubMedGoogle Scholar ↵Ramalho I, Ferreira I, Marques JP, et al. Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: a case report. Case Rep Womens Health 2019;24:e00144. doi:10.1016/j.crwh.2019.e00144pmid:http://www.ncbi.nlm.nih.gov/pubmed/31709156PubMedGoogle Scholar ↵Eom JM, Choi JS, Ko JH, et al. Surgical and obstetric outcomes of laparoscopic management for women with heterotopic pregnancy. J Obstet Gynaecol Res 2013;39:1580–6.doi:10.1111/jog.12106pmid:http://www.ncbi.nlm.nih.gov/pubmed/23875926PubMedGoogle Scholar ↵Webster K, Eadon H, Fishburn S, et al. Ectopic pregnancy and miscarriage: diagnosis and initial management: summary of updated NICE guidance. BMJ 2019;367:l6283.doi:10.1136/bmj.l6283pmid:http://www.ncbi.nlm.nih.gov/pubmed/31722871FREE Full TextGoogle Scholar ↵Gibson KR, Horne AW. Ruptured heterotopic pregnancy: an unusual presentation of an uncommon clinical problem. BMJ Case Rep 2012;2012. doi:doi:10.1136/bcr-2012-007423. [Epub ahead of print: 28 Nov 2012].pmid:http://www.ncbi.nlm.nih.gov/pubmed/23192579Google Scholar ↵Fatema N, Al Badi MM, Rahman M, et al. Heterotopic pregnancy with natural conception; a rare event that is still being misdiagnosed: a case report. Clin Case Rep 2016;4:272–5.doi:10.1002/ccr3.502pmid:http://www.ncbi.nlm.nih.gov/pubmed/27014450PubMedGoogle Scholar Early diagnosis of spontaneous heterotopic pregnancy successfully treated with laparoscopic surgery Via BMJ Case Reports Last 6 Issues View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Adenocarcinoma of the urinary bladder with inferior vena cava thrombus

alkiviadis.1961 shared this article with you from Inoreader Message: Harkirat Singh Talwar and Vikas Kumar Panwar Author affiliations Urology, All India Institute of Medical Sciences—Rishikesh, Rishikesh, India Correspondence to Dr Vikas Kumar Panwar; vikaspanwar.dr@gmail.com http://dx.doi.org/10.1136/bcr-2020-237772 Statistics from Altmetric.com Request Permissions Description Adenocarcinoma of the bladder is an unusual malignancy arising most commonly from the dome and posterior wall of the bladder. It has a male predominance seen during the sixth and seventh decade.1 It arises from the urothelium although has a pure glandular histology.2 Haematuria is the most common presenting symptom and various cystoscopic morphologies exist like solid, papillary, sessile or ulcerated. Notable risk factors for adenocarcinoma include schistosomiasis, chronic irritation, cystocoele and exstrophy bladder. Adenocarcinoma of the bladder may be primary in origin or may be secondary to involvement by adjacent organs. Urachal adenocarcinoma although a separate entity is frequently grouped with bladder adenocarcinoma. No case has been ever reported in the literature of a bladder carcinoma with inferior vena cava (IVC) thrombus. This is a first case of its kind to be reported with tumour extending through the iliac veins into the IVC. A 60-year-old man presented with haematuria and history of transurethral resection of bladder mass done elsewhere. General and physical examination revealed no positive findings and he had a poor performance status. Histopathology was suggestive of adenocarcinoma of the urinary bladder with tumour infiltrating the deep muscle. Contrast enhanced CT scan revealed 7.2×6.5 cm mass arising from the dome and the right posterolateral wall of the urinary bladder and extending into right ureter for a length of 3.5 cm causing gross hydroureteronephrosis (figure 1). The mass was seen extending into the small bowel mesentery and the mesorectal fascia and seminal vesicles. An enhancing tumour thrombus was also seen for a length of 5.2 cm in the distal IVC extending into bilateral common iliac veins and the right internal and external iliac veins. Metastatic work up revealed extensive lesions in the lungs and the skeleton (figure 2). Creatinine clearance of the patient improved to 70 mL/m in post insertion of the nephrostomy tube. The patient was started on low-molecular weight heparin and also received palliative chemotherapy. The patient succumbed to illness 3 months after presentation. Figure 1 Download figure Open in new tab Download powerpoint Figure 1 Coronal sections showing the bladder mass and the inferior vena cava thrombus (A) and the upstream right hydroureteronephrosis as a result of the bladder mass and right ureteric extension (B). Figure 2 Download figure Open in new tab Download powerpoint Figure 2 Axial section of the thorax revealing multiple parenchymal pulmonary metastatic deposits. Prevention of pulmonary embolism is of utmost priority in such patients with anticoagulation and IVC filter being the mainstay.3 Although low-molecular weight heparin is preferred with total/near total tumour thrombus or those with a bland thrombus, IVC filter may be required in patients when anticoagulation fails or is contraindicated. Treatment of the malignancy according to standard guidelines is mandated thereafter.4 Radical cystectomy and pelvic lymph node dissection remains the standard of care for localised disease as chemotherapy has not shown to improve outcomes in adenocarcinoma of bladder. Platinum-based chemotherapy regimens used against urothelial carcinoma are not effective against adenocarcinoma. Majority of patients have muscle invasive disease at presentation and prognosis remains poor with adenocarcinoma of urinary bladder having a poorer stage by stage survival outcome as compared with its urothelial counterpart. Learning points Primary adenocarcinomas of the urinary bladder are rare tumours and are usually detected at an advanced stage and thus have poor prognosis. Bladder cancers can present with inferior vena cava (IVC) thrombus with a possible route being through the internal and common iliac veins. This is the first case to be reported of a bladder carcinoma with IVC thrombus. Anticoagulation and prevention of pulmonary embolism remains the top priority in such cases followed by stage-based management following standard guidelines. References ↵Dadhania V, Czerniak B, Guo CC. Adenocarcinoma of the urinary bladder. Am J Clin Exp Urol 2015;3:51–63.pmid:http://www.ncbi.nlm.nih.gov/pubmed/26309895PubMedGoogle Scholar ↵Grignon DJ, Ro JY, Ayala AG, et al. Primary adenocarcinoma of the urinary bladder. A clinicopathologic analysis of 72 cases. Cancer 1991;67:2165–72.doi:10.1002/1097-0142(19910415)67:8<2165::AID-CNCR2820670827>3.0.CO;2-Mpmid:http://www.ncbi.nlm.nih.gov/pubmed/1706216CrossRefPubMedWeb of ScienceGoogle Scholar ↵Pandhi MB, Desai KR, Ryu RK, et al. The role of inferior vena cava filters in cancer patients. Semin Intervent Radiol 2016;33:071–4.doi:10.1055/s-0036-1581090pmid:http://www.ncbi.nlm.nih.gov/pubmed/27247473PubMedGoogle Scholar ↵Black PC, Brown GA, Dinney CPN. The impact of variant histology on the outcome of bladder cancer treated with curative intent. Urol Oncol 2009;27:3–7.doi:10.1016/j.urolonc.2007.07.010pmid:http://www.ncbi.nlm.nih.gov/pubmed/18367107PubMedGoogle Scholar Adenocarcinoma of the urinary bladder with inferior vena cava thrombus Via BMJ Case Reports Last 6 Issues View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Extended pulsed radiofrequency as a part of multimodal pain management in a refractory case of Bernhardt-Roth syndrome

alkiviadis.1961 shared this article with you from Inoreader Extended pulsed radiofrequency as a part of multimodal pain management in a refractory case of Bernhardt-Roth syndrome Via BMJ Case Reports Last 6 Issues Bernhardt-Roth syndrome (BRS) is a neurological condition characterised by pain, burning or numbness in anterolateral thigh due to entrapment of the lateral femoral cutaneous nerve (LFCN). The possible aetiologies can be mechanical, iatrogenic, neuropathic or idiopathic. After consent for possible publication, we are discussing a case of pain management in a 38-year-old patient with BRS secondary to diabetes. The coherent history, uncontrolled glycaemic status and reduced nerve conduction velocity for LFCN helped reach the diagnosis. Initial treatment with pharmacotherapy, steroid LFCN block and conventional pulsed radiofrequency (PRF) provided moderate temporary pain relief. Extended PRF over 8 min provided significant analgesia without any complications. Physical therapy, adequate glycaemic control and extended PRF provided complete pain relief and improved function over 6 months of follow-up duration. Hence, a cautious multifaceted approach targeting the basic aetiology with extended PRF helped achieve significant analgesia in our refractory case of BRS. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.