Paradoxical ileocecal perforation during early anti-tuberculosis therapy: A rare case report

CSM 2014 Orthopaedic Section Poster Presentations (OPO1106–OPO1165, OPO2218–OPO2298, OPO3106–OPO3183)

BackgroundAcute kidney injury is a devastating postoperative complication. Renal replacement therapy is a treatment modality for acute kidney injury. Continuous renal replacement therapy is the treatment of choice for patients with hemodynamic instability. The main question in the management of acute kidney injury is when to initiate the renal replacement therapy. Several studies have demonstrated improvement in patients with septic acute kidney injury, following early continuous renal replacement therapy. To date, no guidelines have been established on the perfect timing to initiate continuous renal replacement therapy. In this case report, we did an early continuous renal replacement therapy as an extracorporeal therapy for blood purification and renal support.Case presentationOur patient was a 46-year-old male of Malay ethnicity, undergoing total pancreatectomy due to a duodenal tumor. The preoperative assessment showed that the patient was high risk. Intraoperatively, massive surgical bleeding was sustained due to extensive tumor resection; thus, massive blood product transfusion was necessary. After the surgery, the patient suffered from postoperative acute kidney injury. We performed early continuous renal replacement therapy, within 24 hours after the diagnosis of acute kidney injury. Upon completion of continuous renal replacement therapy, the patient’s condition improved, and he was discharged from the intensive care unit on the sixth postoperative day.ConclusionThe timing for the initiation of renal replacement therapy remains controversial. It is clear that the “conventional criteria” for initiating renal replacement therapy need correction. We found that early continuous renal replacement therapy initiated in less than 24 hour after the postoperative acute kidney injury diagnosis gave our patient survival benefit.

A Prospective Study of the Effect of IV Pentamidine Therapy on Ventricular Arrhythmias and QTc Prolongation in HIV-infected Patients

Skeletal tuberculosis (TB) is a very rare disease comprising 1-3% of the total population of TB patients. Skeletal TB most often involves the spine. Involvement of foot is uncommon. We presented a case of skeletal TB of left foot. The initial three-phase bone scan showed a strongly positive result indicating osteomyelitis of left foot. Further evaluation confirmed the diagnosis of skeletal TB. Three-phase bone scan revealed partial resolution during anti-TB therapy. A negative study was shown one year later after clinical resolution of the disease. The successful treatment of skeletal TB requires early diagnosis and early anti-TB therapy. The definitive diagnosis of skeletal TB is isolation of bacteria from a bone biopsy. In clinical practice, noninvasive methods are useful diagnostic tools including clinical information, imaging studies, and laboratory findings. Three-phase bone scan is a sensitive test for diagnosis of skeletal TB. In cases of suspected skeletal TB, it can allow assessment of entire skeleton and provide guidance for biopsy in early stage when radiological imaging is normal. In cases with symptoms of bone infection, tuberculosis should be considered in differential diagnoses if bone scintigraphy is positive. Finally, three-phase bone scan might be helpful in monitoring treatment response of anti-TB therapy.

Predictors for Outcome and Treatment Delay in Patients With Tuberculous Meningitis

Cryptococcosis presenting as endobronchial obstruction and lung collapse is an extremely rare occurrence. While these patients were treated with antifungal agents, unfortunately, half of them showed a suboptimal response. A 45-year-old immunocompetent male was admitted to the hospital due to a cough, yellow phlegm, and dyspnea persisting for 5 months. Chest computer tomography revealed a mass in the right main bronchus accompanied by right lower lobe atelectasis. Endobronchial cryptococcosis presenting as endobronchial obstruction and lung collapse. Early rigid bronchoscopic therapy was performed to resect endobronchial obstruction, which combined with antifungal agent. The patient recovered well with completely clinical and radiologic resolution at 1 year follow-up. This case provides a good example of successful utilization of the early respiratory interventional therapy combined with antifungal agent in obstructive endobronchial cryptococcosis.

The efficacy of early immunosuppressive therapy without invasive therapy, such as endovascular or surgical revascularization, for pulmonary hypertension due to Takayasu arteritis (TAK-PH) remains to be elucidated. We herein report two cases of TAK-PH due to pulmonary arteritis successfully treated with early immunosuppressive therapy. A literature review of 42 cases of TAK-PH with pulmonary artery involvement showed that the cases treated with immunosuppressive therapy early after the onset (within 12 months) had a higher erythrocyte sedimentation rate and better outcome without invasive therapy than those treated later. TAK-PH may be successfully treated with immunosuppressive therapy without invasive therapy when diagnosed early with high disease activity.

Since December 8, 2019, an acute respiratory illness has spread rapidly in China, causing 3,097 people to die as of March 7, and it has become a global crisis. The common symptoms are fever, fatigue, dry cough, myalgia, and dyspnea. This case report presents a 36-year-old male who was diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected pneumonia on February 2, 2020. This patient received veno-venous extracorporeal membrane oxygenation (V-V ECMO) last for 10 days as salvage treatment as his condition became critical in the acute setting. As soon as his status became stable, he began to receive an early rehabilitation program performed by our rehabilitation team. After 43 days of treatment under the efforts of our teamwork, the patient was able to walk 800 meters, and then was discharged the next day. To our knowledge, this is the first report of early physical therapy for a patient with coronavirus disease 2019 (COVID-19) who was receiving extracorporeal membrane oxygenation (ECMO) whilst awake. This case indicates that early physical rehabilitation is safe and feasible and resulted in an expedited recovery using ECMO whilst awake. The goals for physiotherapy management include avoiding atelectasis, airway clearance, weaning and increasing the functional level. This report may contribute to the current literature on early physical therapy rehabilitation programs for awake ECMO patients.

Case report - IntroductionGranulomatous disorders are diverse in their aetiologies and presentations. We present an unusual case of severe psoriatic arthritis patient who subsequently developed multiple granulomatous diseases over time, granulomatous interstitial nephritis, granulomatous sarcoidosis with hilar lymphadenopathy and localised laryngeal granulomatous inflammation secondary to lambda type amyloidosis.Case report - Case description52-year-old gentleman with arthritis mutilans secondary to severe poorly controlled psoriatic arthritis was followed up in Rheumatology clinic. Earlier therapy with leflunomide and methotrexate provided inadequate control. Golimumab, despite giving a good response, was stopped in 2013 after 5 months of treatment due to acute kidney injury. Renal biopsy revealed granulomatous interstitial nephritis, thought to be Golimumab-induced based on the timing of usage and reversibility with discontinuation. He was then trialled on Ustekinumab and Secukinumab in 2016 and 2017 respectively with variable response.He also had a few-years history of voice change (high pitched) and sore throat which he attributed to recurrent colds. He denied dysphagia or breathlessness, and he did not have stridor. He has never smoked and only drank alcohol occasionally. ENT team noted white deposits on erythematous and thickened false vocal cords and posterior glottis with a thin web on microlaryngoscopy, which histologically proved to show granulomatous inflammation, potentially consisting of amyloid, although congo red stain was negative. On further investigation, including SAP scan, he was diagnosed with localised lambda type amyloid. Increasing throat pain and worsening dysphonia prompted change of management from conservative to a surgery at a specialist centre and an input from speech and language therapy team.During this time, consideration for Etanercept for his joint and skin disease was put on hold, pending further management of laryngeal amyloidosis. Furthermore, he presented to hospital with breathlessness in 2019, where his chest X-ray showed bulky right hilum and a follow-up CT chest revealed calcified right hilar and mediastinal lymphadenopathy, ground glass opacification and consolidation. Histology from hilar node was suggestive of sarcoidosis, with stain negative for amyloid.He underwent removal of false vocal cords for his symptomatic laryngeal amyloidosis. He continues to be followed up at the local Rheumatology, Dermatology and ENT team.Case report - DiscussionGranulomatous diseases have vast aetiologies, including infectious, immunological, neoplastic, and chemical-induced processes. The age at which they affect patients and tissue they involve also vary hugely. This is the first reported case of three seemingly unrelated granulomatous diseases occurring in a single patient with severe refractory psoriatic arthritis. Retrospective reassessment of the histology samples supported that these are three separate pathologies. It is very unusual for one patient to acquire multiple separate granulomatous diseases, which was why the diagnostic process of this patient was challenging. In this case, managing the original underlying psoriatic arthritis was particularly difficult due to interruptions of treatment for adverse drug effects and investigations and treatment of subsequent granulomatous diseases. The case also raises questions about possible currently unknown association between the pathologies.Case report - Key learning pointsKey points are the uniqueness of this case and that it highlighted the possibility of currently under-reported association between these three granulomatous conditions. As ever, a multidisciplinary approach to managing such a complex patient is important for the provision of good care.

Glycemic control of type 2 diabetic patients with coronavirus disease during hospitalization: a proposal for early insulin therapy.

BACTERIAL TRACHEITIS IN A PATIENT AFTER INTUBATION

Introduction: Tibial plateau fractures are complex condition that affect functional knee movement. The case report would draw attention to the importance of early physical therapy in these cases. Case report: A 33-year-old Brazilian man, had a motorcycle accident that resulted in a right tibial plateau fracture. After three months post-op of osteosynthesis patient came to start the rehabilitation process. Results: During the physical therapy evaluation, we observed an important capsular restriction with reduction of the motion range (just 15º right knee flexion), and muscular hypotrophy of right lower limb. Late rehabilitation process included: active and passive mobilization of knee; progressive discharge of weight in right lower limb; progressive muscle strengthening of the right lower limb and proprioceptive training. After three months of rehabilitation, we observed little improvement in knee range of motion (35º right knee flexion), and improvement of muscle strength and gait. Conclusion: In Brazil, motorcycle accidents that result in the fracture of the lower limb are frequent. In this report, the difficulties and complications of the late rehabilitation process were observed. This case report seeks to draw attention to the future inclusion of physical therapy in hospital routines, along with the referral of patients to early clinical rehabilitation process with the objective of obtaining optimal recovery of these patients.

IntroductionSub-Saharan Africa shoulders the highest burden of global sepsis and associated mortality. In high HIV and tuberculosis (TB) prevalent settings such as sub-Saharan Africa, TB is the leading cause of...

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Background: In testicular carcinoma the early diagnosis is very important because with an early therapy there are good chances for long-term survival (50–90%). Metastases of a testicular carcinoma are at first lymphogeneous, hematogeneous only in late stages. Case Report: This is a case report about a 28-year-old man, whose testicular carcinoma (left testis) had already been operated on (unripe teratoma with parts of an embryonic carcinoma, an endodermal sinus tumor and a chorion carcinoma). Because of the elevated tumor marker AFP an FDG PET (F18-fluorodeoxyglucose positron emmission tomography) investigation was made. CT (covering thorax, abdomen and pelvis) and ultrasound of the testis showed no pathological results. In the FDG PET a significant pathological FDG uptake in the right testis was found. Histology showed an unripe teratoma with parts of an embryonic carcinoma, an endodermal sinus tumor, and a chorion carcinoma. It was a second carcinoma of the contralateral testis. Conclusion: F18-FDG PET was a sensitive and reliable modality for diagnosis in this patient.