Conservative management of a button battery tracheoesophageal fistula in a resource-limited setting: a case report

Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7years of work involving 2116 women repaired in three hospitals across the country. This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n=2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.

Rhabdomyosarcoma is a fairly common soft tissue sarcoma among children. Genitourinary rhabdomyosarcoma accounts for one tenth of rhabdomyosarcomas in the West African sub-region. However, its occurrence and management are yet to be reported in our resource limited study setting. Care of such patients could be a daunting task. A comprehensive paediatric oncology service should be advocated to optimize the chances of survival. A seven-month old boy was referred to our facility on account of posterior urethral valve. A week’s complaint of crying on micturition, with associated passage of scanty urine and irritability, although he was apparently well since birth with no urinary complaints. A suprapubic mass was palpated on abdominal examination. Digital rectal examination revealed a nodular pelvic mass. Open cystostomy done and histopathology showed embryonal rhabdomyosarcoma of the urinary bladder. Chemotherapy was commenced on a modified Malignant Mesenchymal Tumour protocol of the International Society of Paediatric Oncology group. The mass was reduced by a third after six cycles of chemotherapy. In resource limited settings, the management of paediatric genitourinary rhabdomyosarcoma, using multidisciplinary and multimodal approach to include the hub for comprehensive paediatric oncology services should be advocated to optimize chances of survival.

Button battery ingestion: A serious pitfall of diagnosis of ingested foreign bodies in children from resource-limited settings – A case report

A congenital tracheo-esophageal fistula of the H-type is a rare variant. The diagnosis is usually missed because of mild symptoms. A long history of coughing during liquid intake and nocturnal cough may aid in the diagnosis. A delay in the diagnosis may have a deleterious effect on the lung because of recurrent infections. Surgery is the cornerstone of management. Self-expandable metallic stents (SEMS) do not have a role in the management of these fistulae. We report a case of a missed diagnosis of a congenital H-type fistula managed as an acquired tracheo-esophageal fistula with two attempts at conservative management with a tracheal self-expandable metallic stent. The difficulties and disadvantages of using self-expandable metallic stents for the management of benign tracheo-esophageal fistulae are also discussed.

Background Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects on women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource-constrained settings. Objective The objective of this study is to describe the magnitude, etiology, diagnosis, management, and outcomes of iatrogenic ureterovaginal fistula in Uganda over a 12-year period. Methods A retrospective review of charts for women who had fistula repair at four fistula repair centers in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a history of leakage of urine through the vagina following a pelvic surgery, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without a Boari flap. The outcome of surgery was successful fistula repair with urine continence and was determined at two months post-surgery. Results Overall, 477 women were managed for genitourinary fistulae during the study period. Approximately one in every 10 women with genitourinary fistula had an iatrogenic ureterovaginal fistula (n=47, 9.8%). The mean age of women with ureterovaginal fistula was 31.9(SD: ±11.8) years. The majority of ureterovaginal fistulae (n=33, 70.7%) followed cesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). Clinical assessment was accurate in diagnosing ureterovaginal fistula. Successful fistula repair was achieved in 45 (95.7%) cases. Conclusion Iatrogenic ureterovaginal fistulae are common in Uganda, and most follow cesarean section performed at lower-level health facilities by medical officers. In resource-limited settings where advanced diagnostic techniques are not available or not affordable, simple stepwise clinical evaluation is effective in making a diagnosis. Open ureteral reimplantation with or without a Boari flap has a high successful repair rate.

MDR-TB is a matter of growing concern especially in children. The case presented here is a four years MDR-TB girl belonging to the Saharia tribe, a high TB burden ethnic group in central India. She was noticed by the project staff during contact tracing visit to the family as her father had MDR TB. The sputum smear and Cartridge- Based Nucleic Acid Amplification Test (CBNAAT) tests confirmed the diagnosis of M. tuberculosis with Rifampicin resistance. She was promptly initiated on shorter MDR regimen under National TB Elimination Programme (NTEP) and was monitored regularly with successful outcome at the end of the treatment. Though household contact investigations are integral part of NTEP, it is rarely done routinely in resource-limited settings, thereby missing a large number of children with TB disease. The carefully performed household contact investigation in this case, led to prompt detection and timely treatment of this MDR-TB girl in the remote setting who was otherwise missed by the routine programme surveillance. This also led to a favorable outcome. The findings emphasize the need for strengthening household contact tracing mechanism in the national TB elimination programme particularly in hard to reach and marginalised ethnic populations in the country.

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the "first chance is the best chance".

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the “first chance is the best chance”.

Intracerebral hemorrhage (ICH) is a rare but severe complication of preeclampsia, significantly contributing to maternal morbidity and mortality, particularly in resource-limited settings. The underlying mechanisms include endothelial dysfunction, cerebral autoregulation failure, and breakdown of the blood-brain barrier. This case report aims to highlight a unique presentation of severe preeclampsia complicated by ICH, emphasizing barriers encountered in resource-limited settings and discussing long-term implications and prognosis. A 35-year-old multiparous woman presented two days postpartum with altered mental status, aphasia, and right-sided hemiparesis. Her pregnancy was complicated by severe preeclampsia and intrauterine fetal death. Computed tomography (CT) revealed a left basal ganglia hemorrhage extending into the ventricles. She received conservative management including antihypertensive medications, magnesium sulfate for seizure prophylaxis, and anti-edema therapy. Despite limited diagnostic resources, laboratory evaluations ruled out coagulopathies and vascular anomalies. After 20 days of multidisciplinary care, significant neurological recovery was achieved. Follow-up after four weeks demonstrated complete functional recovery, with resolution confirmed by repeat CT. This case uniquely underscores the critical importance of timely multidisciplinary care and robust antenatal monitoring in mitigating severe complications such as ICH associated with preeclampsia. The patient's full recovery highlights the potential for successful conservative management even in resource-constrained environments. Future clinical practice and research should focus on improving antenatal care accessibility, patient education, and developing context-specific management guidelines to reduce maternal morbidity and mortality in similar settings.

Liddle syndrome, a rare form of monogenic hypertension, poses significant diagnostic and therapeutic challenges due to its phenotypic variability and the need for genetic testing. The rarity of the condition, coupled with the limited availability of first-line treatments such as epithelial sodium channel (ENaC) blockers, makes this case report particularly urgent and novel, highlighting alternative management strategies in resource-limited settings. The aim of this case report was to present the diagnostic challenges, therapeutic strategies, and clinical outcomes of a patient with Liddle syndrome who did not have access to ENaC blockers, emphasizing the importance of early recognition and personalized treatment. A 35-year-old female presented with resistant hypertension (190/100 mmHg) and bilateral limb weakness. Laboratory results revealed persistent hypokalemia, hypernatremia, and metabolic alkalosis. Low aldosterone levels, alongside clinical and family history, led to the diagnosis of Liddle syndrome. Genetic testing was not conducted due to resource limitations, and ENaC blockers were unavailable. The patients were managed with a combination of alternative antihypertensive agents, potassium supplementation, and a low-sodium diet. Although this approach led to modest improvements in blood pressure and motor strength, persistent hypokalemia and hypernatremia underscored the suboptimal control of the syndrome's underlying pathophysiology in the absence of ENaC blockers. This case highlights the challenges faced in resource-limited settings and the need for innovative strategies to manage rare conditions like Liddle syndrome. Liddle syndrome's diagnostic and therapeutic challenges underscore the critical importance of early recognition and access to targeted therapies. In the absence of ENaC blockers, alternative treatment strategies can provide some benefit, but they often fall short of optimal management. This case emphasizes the need for enhanced clinical awareness, improved access to genetic testing, and the development of personalized treatment approaches to achieve better patient outcomes.

IntroductionPoint-of-care ultrasound (POCUS) is accepted as an important tool for evaluating patients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2 Identifying the etiology and type of shock is time-critical since treatments vary based on this information. Clinicians typically rely on the history, exam, and diagnostics tests to identify the etiology of shock. In resource-limited settings where there is reduced access to timely laboratory and diagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock. Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causes of shock in resource-limited settings.Case ReportWe discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, with acute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a ruptured pulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expedite definitive surgical intervention.ConclusionIn resource-limited settings where there is reduced access to timely laboratory and diagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock.

Introduction and importanceCholedochal cysts are rare congenital bile duct anomalies that lead to cystic dilatations of the biliary tree. This condition is very rare in Africa. When these cysts exceed 10 cm in diameter, they are referred to as giant choledochal cysts, which are much rarer. Giant choledochal cysts present both a diagnostic and surgical challenge. We present a case of a giant Choledochal cyst surgically managed in a resource limited setting with excellent outcome. Case presentationA 17-year-old female presented with 4 months history of progressive abdominal distension associated with abdominal pain, yellow discoloration of eyes, and occasional constipation. Abdominal CT-scan revealed a huge cystic mass in the right upper quadrant extending inferiorly to the right lumbar region. Complete excision of a type IA choledochal cyst was done plus cholecystectomy in addition to bilioenteric reconstruction. The patient recovered uneventfully. Discussion and conclusionTo the best of our knowledge, this is the largest giant Choledochal cyst reported in literature. Even in a resource limited settings, sonography and a CT scan may be all that is required to make a diagnosis. During surgical excision, the surgeon should take extra caution to carefully dissect the adhesions off the giant cyst for a successful complete excision.

Methaemoglobinaemia is a rare condition of unknown prevalence. Diagnostic tests in resource limited settings are very rare but clinical signs can be a good guide. We set out to describe a case of Methaemoglobinaemia, raise awareness among practitioners in resource limited settings and to share experiences in its diagnosis and management. A previously well three and a half year old girl was admitted with central cyanosis of sudden onset. She underwent clinical, laboratory and radiological evaluation. Having been in a resource limited setting, the process of making a diagnosis was slow and difficult. After the diagnosis, the treatment was not available in the country but we managed to get it all the way from Nairobi, Kenya. A diagnosis of Methaemoglobinaemia was made using Spectrophotometry and she was successfully treated using 2 doses of intravenous Methylene blue. The cause of Methaemoglobinaemia was established to have been nitrites from food preservatives.

BackgroundFollowing a knowledge management analysis, Médecins Sans Frontières (MSF) – a medical humanitarian non-governmental organisation (NGO) – identified significant loss of medical knowledge from the field, owing primarily to the absence of a platform on which to share clinical lessons learned in humanitarian and resource-limited settings (HRLS). Wishing to address these missed opportunities to retain important scientific and pragmatic knowledge, the NGO has begun to actively encourage its clinicians to publish case reports/series that bring new and/or practical insights of benefit to patients and population groups. In parallel, we wished to obtain a clearer understanding of how case reports (CRs)/series can best play their role as ‘first-line evidence’ from HRLS, especially in areas suffering from a significant lack of data.MethodsWe developed a survey with closed and open questions on ‘The value of CRs from HRLS’ to explore primarily (1) the reasons why this form of evidence from HRLS is often lacking, (2) what makes a case report/series worth sharing with the wider global health community, and (3) how we can ensure that published case reports/series reach their target audience.ResultsOver a 6-month period, 1115 health professionals responded to the survey. Participants included clinicians and public health specialists from all over the world, with a majority based in Africa. The main reason cited for the dearth of CRs from HRLS was that practitioners are simply not writing and/or submitting reports (as versus having their papers rejected) due mainly to (1) a lack of skills and (2) time constraints. A large majority of respondents felt the CRs are a valuable tool for HRLS given their ability to discuss how cases are managed with rudimentary means as well as to draw attention to emerging or underestimated public health problems and neglected populations.ConclusionWe conclude that the clinical knowledge gained in resource-challenged settings is being underutilised in the interest of patients and global health. Consequently, clinicians in HRLS need greater access to basic training in scientific investigation and writing in addition to awareness as to the potential value of sharing their clinical experience with a view to broadening evidence production from high-income to low-income settings.

Olanzapine, an atypical antipsychotic, is widely used for treating psychiatric conditions such as schizophrenia and bipolar disorder. Accidental overdose in children is rare but can lead to severe clinical effects. This case report discusses the management of a 5-year-old male who accidently ingested 180mg of olanzapine, the highest reported dose in a child around 5 year. A 5-year-old boy accidentally ingested 180mg of Olanzapine, resulting in loss of consciousness and central nervous system depression. He exhibited hyperglycemia, elevated lactate, and prolonged prothrombin time, but no significant cardiovascular issues. Following intubation and supportive care, including intravenous medications and mechanical ventilation, the child gradually improved. He was discharged in stable condition with follow-up instructions. Olanzapine toxicity in children presents with a variety of symptoms, including somnolence, hypotension, and neurological impairments, which are dose-dependent. Even in case of an exceptionally high overdose, the absence of cardiovascular toxicity supports safety profile of olanzapine. Common laboratory findings include hyperglycemia, elevated liver enzymes, and metabolic disturbances. Management involves airway protection, supportive care, and monitoring, as no specific antidote exists. Prompt and appropriate care, even in severe cases under limited resource settings, can lead to favorable outcomes. In cases of high-dose accidental olanzapine poisoning in children, it is essential to begin quick intervention and comprehensive supportive care to achieve successful outcomes and can be managed even in limited resource settings. Preventive measures are crucial to avoid such incidents, and careful monitoring is essential in managing pediatric olanzapine overdose.