Description Of Clinical Case Research Articles

Treatment of a four-year-old child with destructive pneumonia

BACKGROUND: Treatment of patients with destructive pneumonia remains one of the most difficult problems in pediatric surgery. Modern possibilities of antibacterial and intensive care, minimally invasive endoscopic intraluminal technologies, as well as surgical techniques have reduced the number of adverse outcomes up to 4%. The type of surgical intervention and the time of its performance depend on the disease form, child’s general state, local changes in the bronchi and pleural cavity, as well as on technical capabilities of the clinic.
 CLINICAL CASE DESCRIPTION: The article presents a clinical observation of the complex treatment of a 4-year-old patient with destructive pneumonia complicated by a bronchial fistula. Intensive and antibiotic therapy stabilized the child’s condition, eliminated manifestations of multiple organ failure, and drained the pleural cavity to resolve tension pyothorax. The programmed thoracoscopy provided an adequate sanation of the pleural cavity, assessed dynamics of the inflammatory process and allowed to position drains under visual control. The fistula of the lower lobe bronchus was closed with a valve bronchoblocker after elimination of the local erosive and ulcerative lesion. A clinical success of such management was manifested with inflammatory process remission, bronchopleural fistula closure, pleural empyema removal. Due to this, deblocking was done three months after discharge from the hospital. At the control examination, the patient had no fistula, most part of the affected lung was preserved, post-inflammatory changes in the pleural cavity were minimal.
 CONCLUSION: The favorable outcome after treatment of children with destructive pneumonia depends on personalized and multidisciplinary approach. Minimally invasive endoscopic techniques do contribute to the effective elimination of complications, to effective functional restoration of the affected lung and to better recovery of patients.

A clinical case of surgical treatment of a large kidney cyst in a 9-year-old girl with autosomal dominant polycystic kidney disease

BACKGROUND: Autosomal dominant polycystic kidney disease is currently the most common inherited form of cystic kidney disease, the frequency of which is about 1 per 400–1000 newborns, what makes the problem relevant. Its progressive course in patients with polycystic disease is primarily associated with the ischemic component, the severity of which depends on the number, location and size of cysts. Arterial hypertension, which is an autosomal dominant polycystic kidney disease complication, plays a leading role in renal failure progression. Given the current lack of specific treatment, the main therapeutic goal is to prevent complications, postpone the development of renal failure. Therefore, if there are large and giant cysts, surgical treatment is an effective modality and should be performed in a timely manner.
 CLINICAL CASE DESCRIPTION: The authors present a clinical case of a successful endovideosurgical cyst excision in a -year-old patient with a giant cyst in the right kidney, autosomal dominant polycystic disease, and hypertension of renal genesis.
 Endovideosurgical cystectomy in the patient with autosomal dominant polycystic kidney disease has become an important pathogenetic link in the treatment of this pathology. Currently, the patient is under dynamic follow-up for more than one year. During the follow-up period, the patient demonstrates relief of urinary syndrome in the form of disappeared haematuria, stabilization of albuminuria indices, improvement of blood flow parameters in the renal parenchyma, as well as stabilization of arterial pressure.
 CONCLUSION: The given clinical example demonstrates that reasonable surgical intervention with the choice of a rational method of access, taking into account the anatomical localization and size of the cystic formation, allowed to obtain a good result in the form of stabilization of renal hemodynamics in a patient with autosomal dominant polycystic kidney disease.

Acute suppurative thyroiditis in a 10-year-old child

BACKGROUND: Acute suppurative thyroiditis in children is a rare and potentially life-threatening thyroid disease that requires rapid diagnostics and treatment.
 CLINICAL CASE DESCRIPTION: A clinical case of a 10-year-old girl with a thyroid abscess is described. She had fever, painful neck swelling, sore throat, tachycardia, restricted neck movement, and dysphagia for 6–7 days. The treatment consisted of antibiotic therapy, incision and drainage of the abscess using local ozone therapy. It was found that causative agents were Staphylococcus aureus and Escherichia coli. The girl had a follow-up examination in 9 months after the discharge — there were no signs of thyroid pathology.
 CONCLUSION: Although acute suppurative thyroiditis is extremely rare in children, it occurs sometimes. Since this condition may be associated with a piriform sinus fistula, the child must be examined for it because of the risk of recurrence.

The asynchronous torsion of the main and accessory wandering spleens in an infant

BACKGROUND: To diagnose the torsion of the wandering spleen in infants is a challenging task. Torsion of the wandering spleen in such population is an extremely rare case. Among children under one year of age, the wandering spleen is more common in boys (2.5:1). A total of 26 cases of torsion of an accessory spleen were described in the literature. Asymptomatic course of the disease before the first episode of spleen torsion occurs in 70% cases. No case of asynchronous torsion of the main and accessory wandering spleens are described in the literature.
 CLINICAL CASE DESCRIPTION: This article describes a very rare clinical case of asynchronous torsion of the main and accessory wandering spleens in an infant. In the described case, basic clinical manifestations of the spleen torsion in an 8-month-old girl were typical for acute enteric infection. The child had laparoscopic splenectomy.
 CONCLUSION: The present article describes challenges associated with the diagnostics of this pathology, important role of spiral computed tomography, efficacy of diagnostic laparoscopy and relaparoscopy as well as the efficacy of laparoscopic spleen resection in case of spleen necrosis in an infant.

Peitz–Jaegers syndrome as a cause of intussusception in children

BACKGROUND: Intestinal intussusception is a common cause of acute intestinal pathology in children. Peitz–Jaegers syndrome is a rare disease with an autosomal dominant type of inheritance characterized by the development of hamartomic polyps in the gastrointestinal tract and pigmented spots on the skin and mucous membranes. It is a “precancerous” state which increases the risk of oncologic formations in the gastrointestinal tract and in genital glands. Peitz–Jaegers syndrome is associated with mutations in STK11 or LKB1 genes.
 CLINICAL CASE DESCRIPTION: The article describes the authors’ experience in surgical resolution of the intestinal intussusception with atypical course in a 6-year-old child. Diagnostic laparoscopy detected intussusceptions in the small intestine, one of which was immediately desinvaginated with instruments and the other one required conversion. During the surgery, dense tumor-like formations were identified; therefore, jejunum loop with revealed formations was resected. Further histological and other testings showed that these formations were hamartomic polyps. The patient had been preliminary diagnosed with Peitz–Jaegers syndrome which further was confirmed by genetic and histological analyses and gastroscopic examination. The postoperative period was uneventful; the child was discharged in the satisfactory condition on day 7 after the surgery.
 CONCLUSION: Consultations with a pediatric surgeon and gastroenterologist, examination of the upper and lower gastrointestinal tract, monitoring polyps’ onset or growth are stages of key importance in children with Peitz–Jaegers syndrome. Such an approach promotes minimization of risks associated with the course of this disease. To prevent emergency surgical situations, it is important to make genetic analyses for children with the family history of polypous syndrome in the gastrointestinal tract.

Nonbacterial osteomyelitis of the vertebral bodies and frontal bone: A description of a rare clinical case and a review of the literature

BACKGROUND: Nonbacterial osteomyelitis is a chronic autoinflammatory skeletal disorder of unknown origin characterized by sterile bone lesions and presenting more frequently in children. Spinal manifestations are often common in nonbacterial osteomyelitis; however, cases with skull involvement, except for the mandible, are generally rare.
 CLINICAL CASE: Herein, we report the case of an 11-year-old girl presenting with multifocal thoracic vertebral and frontal bone lesions, which led to destructive sinusitis. Nonbacterial osteomyelitis was diagnosed after a bone biopsy, which showed no evidence of granuloma, malignancy, or histiocytes. The histopathological findings were nonspecific inflammatory changes. Ibandronic acid was used to treat nonbacterial osteomyelitis. Clinical signs begin to improve after the first infusion. After the fourth infusion of ibandronic acid, the inflammation was reduced and frontal bone structure and thoracic vertebrae were restored.
 DISCUSSION: Bisphosphonate therapy can be used in nonbacterial osteomyelitis when response to nonsteroidal anti-inflammatory drugs is not optimal. The efficacy of bisphosphonate therapy reaches 75%. However, bisphosphonate therapy in nonbacterial osteomyelitis has not been developed. The paper contained literature about rare cases with skull involvement and problems in bisphosphonate therapy in pediatric nonbacterial osteomyelitis.
 CONCLUSIONS: Nonbacterial osteomyelitis is a treatable condition, whose care depends on a referral to a rheumatologist.

Features of the course of somatolactotrophic tumors of the pituitary gland. Description of clinical case

A patient aged 32 with complaints of primary infertility based on additional examination data (increased blood prolactin level, presence of pituitary gland formation according to magnetic resonance imaging of the brain) was diagnosed with prolactin-secreting pituitary microadenoma. At the same time, galactorrhea and menstrual disorders were not noted. Against the background of cabergoline treatment, a pregnancy occurred, which ended with the birth of a full-term healthy child. After delivery, the patient resumed dosing cabergoline 0.5 mg 1 once every two weeks, against the background of which a pronounced decrease in prolactin levels was observed, but there was a progression in the growth of pituitary adenoma (macroadenoma). No acromegaly traits were observed in the patient.Against the background of withdrawal of cabergoline, the patient underwent a study of tropical pituitary hormones, which revealed an increase in the level of growth hormone and insulin-like growth factor-1. During the oral glucose tolerance test with 75 grams of glucose, the somatotropin-producing activity of the pituitary macroadenoma was confirmed. At the age of 43, the patient underwent transsphenoidal adenomectomy, after which she experienced persistent remission for past 6 years.The purpose of this work is to focus the attention of practitioners on the manifestation of possible mixed hormonal activity of pituitary microadenomas.

Unrecognised autonomic dysreflexia in neurogenic lower urinary tract dysfunction with spinal cord injury as a reason for admission to a cardiac surgical unit

BACKGROUND: In Russia, spinal cord injury occurs in 0.7–6.8% of total injuries. Due to emergence of new rehabilitation protocols, it is extremely important to know the time of occurrence of consequences of spinal cord injury and adequate diagnosis of complications, which allows timely identification of life-threatening conditions of one of the body systems.
 Clinical case description. We present a clinical case of autonomic dysreflexia in neurogenic lower urinary tract dysfunction after traumatic cervical spinal cord injury in a 17-year-old girl. In traumatic spinal cord injury above the level of the sixth thoracic vertebra, autonomic dysreflexia as a variant of autonomic dysfunction is a common complication. This clinical case will be of interest to clinicians of all specialties who encounter patients with spinal cord injury. It is shown that misinterpreted symptoms of increased blood pressure during bladder filling were the cause of observation and treatment by a cardiologist for arterial hypertension, as well as hospitalization in the cardiac surgery department for planned surgical treatment of renal artery stenosis, which was thought to be the cause of the episodic increases in blood pressure. Lack of knowledge about the presence of autonomic dysfunction in spinal cord injury patients may have led to unnecessary surgical treatment. During the joint management of the patient with a pediatric cardiac surgeon, signs of autonomic dysreflexia were detected against the background of traumatic spinal cord disease at the level of the cervical spine, hypotensive treatment and planned surgical intervention were canceled.
 Conclusion. Subsequently, an adequate regimen of periodic bladder catheterization and antimuscarinic drug therapy was prescribed, which successfully reduced the dysreflexia.

The occurrence of age-related macular degeneration in the presence of a transferred, confirmed COVID-19

BACKGROUND: COVID-19 can affect the eyes and both the anterior and posterior segments of the eye. Retinal complications associated with COVID-19 have been reported.
 CLINICAL CASE DESCRIPTION: We present a clinical case of age-related macular degeneration that developed during the acute period of coronavirus infection. A patient with COVID-19 and pneumonia (CT-1) experienced sudden decrease in visual acuity within 1 month. A dark spot appeared in front of the left eye, which did not disappear despite eye movements, and distortion of objects was observed. The disease was manifested acutely. A complete ophthalmological examination revealed a sharp decrease in visual acuity and a positive Amsler test (distortion of lines at a distance of 30 cm). In the field of view, scotomas were noted in the center. Ophthalmoscopy revealed light and dark foci in the central macular zone of the retina. Cptical coherence tomography with an angiographic mode detected severe changes at the level of the neuroepithelium and retinal pigment epithelium with the formation of gray tissue. Aflibercept (approved for use in the Russian Federation, No. LP-003544) was intravitreally prescribed according to the clinical guidelines for treating age-related macular degeneration. After treatment with positive dynamics, visual acuity increased to 1.0, and the thickness of the retina decreased by 102 microns.
 CONCLUSION: The key objective in making a correct diagnosis was the use of optical coherence tomography with an angiographic mode. This method allows the visualization of the retinal layers without invasion The angiography mode allows the assessment of the state of the foveolar avascular zone and the density and perfusion of blood vessels, which enable the diagnosis of age-related macular degeneration and choroidal neovascularization. Timely antiangiogenic treatment, that is, a single intraocular injection, completely restored the visual acuity and visual field and normalized the state of the retina according to objective data of optical coherence tomography with angiography mode.

Ultrasound imaging of median nerve neurolipomatosis: literature review and clinical case description

Neurolipomatosis is a rare benign tumor of peripheral nerves. The nerves of the upper extremities are more often involved, in most cases, the median nerves in the carpal canal. Children and young people suffer mainly. The article describes a case of fibrolipomatous hamarthroma of the median nerve in a 24-year-old patient, the ultrasound image is compared with the results of intraoperative observation. Despite the characteristic clinical and pathomorphological picture of this condition, the issues of diagnosis and differential diagnosis remain relevant. A special role is given to ultrasound as a non-invasive, widespread method of lifetime diagnosis of the condition of peripheral nerves. The median nerve, due to its superficial location, is available for visualization, and understanding the ultrasound semiotics of fibrolipomatous hamartoma will allow timely determination of it at the stage of initial clinical manifestations and avoid unnecessary and aggravating neurological deficits of examination methods such as biopsy.

Dupilumab Efficacy and Safety in Severe Atopic Dermatitis in Children under 6 Years of Age: Two Clinical Cases

Background. Atopic dermatitis (AD) manifests during the first year of life in majority of all cases. The early disease onset is associated with the development of comorbid atopic conditions within the «atopic march» phenomenon. The AD pathogenesis is associated with genetic predisposition, epidermal barrier dysfunction, and immune dysregulation. T2-inflammation specifically determines the entire immune cascade of inflammatory reactions, and, thus, dictates the need of early drug intervention to modify the disease course. Clinical case description. This article presents two clinical cases of severe AD in children under 6 years of age. The treatment of both cases included genetically engineered biologic drug dupilumab. Continuous therapy for 4–5 months made it possible to relieve the skin manifestations of the disease.Conclusion. AD, manifesting in infancy, is associated with high risk of developing other atopic spectrum diseases in older age. The timely onset of biological therapy allows us to affect immune dysregulation, and thereby to prevent the comorbid atopic conditions development.

Treatment of a patient with chronic causalgia after surgical removal of the neuroma in the second interdigital space

BACKGROUND: Mortons neuroma is a common pathology of the forefoot. Etiopathologically, this disease can be attributed to nerve fibrosis, not a tumor. We now have various therapeutic options for neuromas, the most frequent of which is traction neurectomy. Recurrent pain affects up to 35% of patients with traction neurectomy, and one-third have recurrent stump neuroma produced by the proliferation of fibrous scar tissue around the remaining nerve elements. Conservative treatment methods are more commonly used to treat recurrent neuromas and residual pain, but surgical therapy is required in some cases. Despite the relatively high prevalence, the treatment of such patients is a challenging task for orthopedic traumatologists.
 CLINICAL CASE DESCRIPTION: We show the effective treatment of a patient with stump neuroma and primary Mortons neuroma in two stages. The second interdigital space nerve was transposed, and the deep, transverse metatarsal ligament of the third interdigital space was dissected in the first stage. The second stage consists of removing the sensitive scar, resecting the plantar nerve of the third interdigital space, and performing a Weil osteotomy.
 CONCLUSION: Consistent use of conservative surgical procedures, appropriate revision of the subcutaneous nerve, and excision of a sensitive scar allows for a successful therapeutic outcome, pain alleviation, and the ability to wear normal shoes.

Combination of Mucocele of the Appendix and Chronic Calculous Cholecystitis: Case Report

Background: The analysis of the data presented in the foreign and national literature shows that a combination of the appendix mucocele and calculous cholecystitis is extremely rare, and the implementation of simultaneous surgical treatment in the laparoscopic version is the optimal approach. Clinical case description. Here, we present a clinical case of chronic calculous cholecystitis in combination with mucocele of the appendix in an 84-year-old patient. The main complaint was pulling pain in the right iliac region. The diagnosis was made on the basis of the main and additional methods of examination: clinical picture, ultrasound, multispiral computed tomography and magnetic resonance imaging of the abdominal organs. In a planned manner, a simultaneous surgical intervention was performed consisting of laparoscopic appendectomy and cholecystectomy. The operation duration was 1 hour 15 minutes. The morphological examination confirmed the diagnosis of calculous cholecystitis and mucocele of the appendix. The patient was discharged in a satisfactory condition on the 4th day. Conclusion. This clinical case shows that the dynamic observation of mucocele of the appendix, even in elderly patients with a comorbid pathology, is unjustified. A simultaneous surgical intervention in the form of laparoscopic appendectomy and cholecystectomy treats the two nosologies and prevents repeated hospitalization and surgery.

Case report: gastrointestinal stromal tumour (GIST) in the small intestine

The analysis of contemporary scientifi literature, clinical recommendations, and the identifiation of challenges in the diagnosis, treatment, and postoperative care of patients encountered by non-oncology physicians are conducted. Gastrointestinal stromal tumors (GISTs) are neoplasms originating from the gastrointestinal tract’s mesenchymal cells, particularly from interstitial Cajal cells. They hold an intermediate position between benign and malignant tumors, occurring at a rarity rate of approximately 1 to 3 %. The description of this pathology in both domestic and foreign literature is infrequent. A clinical case description from personal practice is presented, detailing the assessment of preoperative research methods and surgical tactics, along with the results of histological and immuno-histochemical studies. An important aspect in the postoperative period involves assessing the risk of tumour recurrence and metastasis. Notably, GISTs are characterized by the absence of lymphogenic metastasis and an extremely low frequency of infitrative growth. Thus, it is now a common practice to perform resections without lymph node dissection. The primary method for defiitive diagnosis confimation is an immuno-histochemical study, crucial for determining the indications for targeted therapy. The rare incidence of GISTs in the small intestine in non-oncological medical practice, compounded by the limitations of endoscopic imaging methods for the small intestine, poses challenges in establishing a diagnosis during the outpatient examination.

Anomalies in the location of the carotid artery in the practice of a physician (with a clinical case description

The issue of atypical arrangement of neck vessels is quite urgent for doctors of various specialties. The absence of symptoms of aberrant arteries in most cases forces a more thorough patient examination. The internal carotid artery is most at risk of injury. Not only surgical operations, but also various anesthetic, endoscopic, and otolaryngological procedures can be potentially dangerous. This article describes the etiology of aberrations, population prevalence, screening methods for their detection, risk factors, and a clinical case.

Successful surgical treatment of infected aorto-femoral­ bifurcation prosthesis by its explantation and bifurcation bypass grafting outside the area of previous reconstruction. Clinical case description

Vascular graft infections are associated with a significant risk of mortality and morbidity and cost approximately $640 million per year in the United States. Clinical pattern depends on the time elapsed since the implantation and surgery location. A thorough collection of medical history and physical examination in combination with various imaging methods are often necessary to confirm a diagnosis. There are several treatment options for infected aortic grafts, including graft excision with extra-anatomic bypass grafting, in situ reconstruction or neo-aortoiliac system reconstruction. The treatment of infected endovascular aortic grafts is similar. In cases of infected peripheral shunts, graft preservation techniques may be used, but if these are not feasible, graft removal and revascularization through uninfected tissues are necessary. The authors discuss the diagnosis, general management and surgical approaches to the treatment of infected vascular grafts, as well as a clinical case of successful surgical management of an infected aortofemoral bifurcation prosthesis by its explantation and bifurcation bypass grafting outside the area of previous reconstruction. Keywords: graft infection, reconstructive surgery, re-intervention

Treatment of deep carious lesions with mineral trioxide aggregate: clinical case report

Introduction. Deep carious lesions are a dental disease widely spread among population of all ages. From clinical point of view, they have little symptoms and go unnoticed by the patients a long time, until they provoke dental pulp inflammations. If diagnosed and treated properly, the tooth can be treated conservatively with certain techniques of pulp vitality preservation. An important role in this process plays the innate capacity of regeneration of the pulp-dentine complex and the enhanced stimulating properties of new biomaterials used in dentistry. The aim of this clinical case report is to describe the clinical manifestations and the diagnostic algorithm used in deep caries and to establish a clinical guideline of treatment of deep carious lesion with a calcium silicate hydraulic cement. Material and methods. Description of clinical case of a permanent tooth with a deep carious lesion, treated by indirect pulp capping with mineral trioxide aggregate cement. Clinical and paraclinical methods of investigations were used, the patient was evaluated after 6 and 12 months after the received treatment. Results. The sensitivity to cold stimuli presented by the patient before the treatment attenuated shortly after he received dental care. After 6 and 12 months, the tooth is asymptomatic, the clinical findings and paraclinical parameters show no evidence of pulp inflammation. Conclusions. Mineral trioxide aggregate showed long term successful results when used as a biomaterial for vital pulp therapy.

Abnormal Uterine Bleeding in Adolescence Burdened with Severe Anemia: Clinical Case

Background. Abnormal uterine bleeding (AUB) in adolescence is one of the urgent problems of medicine nowadays. It is on the 2nd place among all the reasons for hospitalization in gynecological departments, and its incidence among girls during puberty is 50%. Clinical case description. This is the clinical case of 15-year-old girl admitted to the gynecology department with complaints on long-lasting bloody vaginal discharge, fatigue, dizziness. The diagnosis of «abnormal uterine bleeding in adolescence» burdened with iron deficiency anemia (IDA) was established according to laboratory and instrumental examinations. The patient underwent RBC-transfusion with specific buffy coat and was administered with hormonal hemostatic and anti-anemic therapy. Conclusion. We can conclude (with reference to this observation and the reviewed literature) not only that IDA is one of the most common complications of AUB in adolescence, but also what management should be used in such clinical cases.

Idursulfase Beta (Hunterase) Therapeutic Experience in a Patient with Mucopolysaccharidosis Type II

Background. Mucopolysaccharidosis type II (MPS II, Hunter syndrome) is an X-linked recessive disease caused by lysosomal enzyme iduronate-2-sulfatase deficiency resulting in progressive glycosaminoglycans (GAG) accumulation in tissues (dermatan sulfate and heparan sulfate). GAG accumulation in cells leads to the development of progressive pathological disorders, malfunction of various organs and systems, early disability, and decrease in life expectancy. Enzyme replacement therapy (ERT) reduces the rate of life-threatening conditions development in patient. ERT would be more effective if it is prescribed early, especially at preclinical stage. This is the time when there are no severe irreversible changes in the cell, thus, pathogenetic therapy will decrease GAG accumulation in lysosomes, slow down the pathological process, and improve patient's condition. Clinical case description. Male patient diagnosed with MPS II was administrated with ERT idursulfase beta at the age of 6 months. It led to milder disease course compared to proband uncle who had similar mutation in the IDS gene, severe disease phenotype, and later initiation of ERT (at the age of 2.5 years). Conclusion. Early ERT initiation in patients with MPS II significantly slows down development of severe and life-threatening complications, increases the duration and improves the quality of life.

Congenital Central Hypoventilation Syndrome (Ondine’s Curse): Clinical Case

Background. Congenital central hypoventilation syndrome (CCHS), or Ondine’s Curse, is rare, incurable and life-threatening disease characterized by autonomic nervous system disorders, it manifests with disability to maintain ventilation function during sleep. Sensitivity to hypoxia and hypercapnia is reduced in case of CCHS, thus, it leads to recurrent episodes of deep apnea. The world literature describes just over 1000 cases of this disease. Clinical case description. An infant born at 37th week of gestation, weight of 3330 g, had episodes of apnea and hypercapnia from the first day of life. CCHS was suspected by the 28th day of life after excluding other causes of respiratory disorders, and it was genetically confirmed by the 43rd day of life — pathogenic variant of PHOX2B gene was revealed. Mechanical ventilation has been initiated by the age of 1 month after disease worsening. Analysis of CCHS cases published in Russian-language medical literature was performed. Typical symptoms and timing of their manifestation, as well as the time before correct diagnosis were mentioned. Conclusion. Symptoms that can be suggestive of CCHS presence early after birth and can urge to perform all the necessary genetic testing that are crucial for timely treatment onset and for minimizing the negative effect of hypoxemia and hypercapnia on the child are described.