Clinical Entity Research Articles

Clostridium perfringens-induced massive hemolysis treatment with blood purification to target toxins: a case report.

Clostridium perfringens can rarely cause severe systemic infections, usually from an abdominal source, associated with massive hemolysis, which is usually fatal. Hemolytic anemia and acute renal injury resulting from toxin action are critical for the development of multiple organ dysfunction syndrome (MODs), making this condition a real emergency, requiring multispecialty skills and aggressive multimodal therapies. We herein describe a case of septic shock from acute cholecystitis with massive hemolysis caused by C. perfringens in a 55year-old man that was successfully treated with early blood purification and continuous renal replacement therapy (CRRT) along with antibiotic therapy and surgery. The effect of the enormous amount of toxins produced by Clostridium which elicit a strong cytokine response and the damage caused by the hemolysis products are the main pathogenetic mechanisms of this rare but lethal clinical entity. The main goal of treatment is to remove toxins from plasma, block toxin action, and further production by achieving bacterial killing with antimicrobial agents and controlling the infectious focus, remove waste products and prevent or limit multiorgan damage. Blood purification techniques play an important role due to a strong pathophysiological rationale, as they can remove toxins and cytokines as well as cell-free products from plasma and also replace renal function. Although this condition is rare and robust data are lacking, blood purification techniques for C. perfringens-induced massive hemolysis are promising and should be further explored.

Post-traumatic hemorrhage in a large sacral Tarlov cyst causing acute radiculopathy

Symptomatic Tarlov cysts (TCs) are an under-recognized clinical entity that should be considered in the differential for lower back pain. These are more common in women and can also be a cause of pelvic pain. Hemorrhagic TCs have been rarely reported in the literature, with symptoms ranging from lower back pain and radiculopathy to symptoms of cauda equina syndrome. We report on a female patient in her 50s who presented with radicular symptoms as a consequence of TC hemorrhage. Magnetic resonance imaging is the gold standard investigation, and this showed post-traumatic hemorrhage causing irritation of the sciatic nerve. Hemorrhagic TC is an important differential to consider in the setting of acute radicular pain, and the symptoms can be resolved with conservative management.

Pseudomyxoma Peritonei: A Challenging Clinical Diagnosis. Case Report and Review of the Literature.

Pseudomyxoma peritonei (PMP) is a clinical entity of subtle onset abdominal pain, ascites, and distention associated with characteristic imaging. In most cases, laparoscopic exploration will give the definitive diagnosis and histopathologic verification. However, usually there are difficulties in the diagnosis of this disease. Herein, we present a case of a 51-year-old female who developed ascites over 5 months. An investigational laparotomy established the diagnosis of PMP, after the discovery of a mucinous, grey-brown tumor that was CK20 positive and CK7 negative. Subsequently, chemotherapy with oxaliplatin combined with 5-FU (FOLFOX4 regimen), was initiated and the patient survived for 30 months. We also present a comprehensive review of the English literature concerning the different symptoms and radiological findings of this rare entity. According to the literature review, 35 cases of PMP with different clinical and radiological findings have been described. In the majority of the cases, ultrasound, computed tomography or magnetic resonance imaging was orientating towards a proper diagnosis before a diagnostic laparotomy. The combination of a clinical picture with the characteristic imaging findings enables a prompt diagnosis of PMP, making prognosis more favorable.

Surface-enhanced Raman spectroscopy analysis of menstrual cycle: From biochemical changes to diagnostics of vaginal infections

Analysis of vaginal fluid is essential for the diagnosis of cervical cancer, various infections and the increasingly common infertility as well. Surface-enhanced Raman spectroscopy (SERS), which is an ultrasensitive technique, provides information from the molecular level of the analysed system and together with chemometric methods, can be a perfect diagnostic tool. However, the variety of processes naturally occurring during the menstrual cycle has a definite impact on the biochemistry of vaginal swabs. This study adopted SERS to track the biochemical changes recorded in spectra of analysed clinical entities during two menstrual cycles. Using Partial Least Squares Regression (PLSR) technique, we demonstrated the spectral information typical for three types of body fluid: menstrual blood (MB), menstrual spotting (MS) and vaginal fluid (VF). The hormonal changes during the menstrual cycle can be reflected in SERS spectra and allow distinction between the fertile and infertile phases. Significantly larger data separation was observed due to infection rather than hormonal fluctuation. These results give a firm foundation for the diagnosis of vaginal infections regardless of the menstrual cycle’s day.

Left prefrontal intermittent theta burst stimulation ameliorates tinnitus distress and symptoms of depression – A feasibility study

Tinnitus remains a notoriously difficult to treat clinical entity. 1–2% of the entire population report relevant emotional distress due to tinnitus, and causal treatments are lacking. Repetitive transcranial magnetic stimulation (rTMS), most commonly of auditory cortical areas, has shown mixed results in the past. Prefrontal rTMS, including intermittent theta burst stimulation (iTBS) has shown more promising results in the treatment of depression, and clinical data suggests a meaningful overlap between tinnitus and depression. Therefore, we performed a feasibility study of 28 consecutive patients with tinnitus treated with an iTBS protocol over the left dorsolateral prefrontal cortex for three weeks.After treatment, we observed significant ameliorations of tinnitus distress as measured by the Tinnitus Handicap Inventory Questionnaire (THI), the Tinnitus Functional Index (TFI), the Mini-Tinnitus Questionnaire (Mini-TQ) and also of depression as measured by the Major Depression Inventory (MDI). Effect sizes were small to moderate and short-lived. Treatment response rates, defined as improvement of the THI of at least 7 points, were 35.7%. At follow-up twelve weeks after end of treatment, severity of tinnitus and depression returned to approximately baseline level on a descriptive level. Amelioration of depressive symptoms correlated only with TFI change, but not that of other measures of tinnitus distress. The data suggest that a prefrontal iTBS protocol might be applied in the treatment of tinnitus and open avenues for future neurostimulatory treatments other than those of auditory regions.

Rhabdomyolysis in a Burned Patient Stuck in a Well – a Case Report

Aim: Rhabdomyolysis is a rare clinical entity. Its manifestation might be acute or delayed, with an acute episode frequently accompanied by severe clinical signs, while delayed rhabdomyolysis presentation has a more benign progression. Case report: Here we report a case of a 70-year-old patient with combined rhabdomyolysis, brachial plexus injury, second-degree burn injuries and acute kidney injury with an unusual cause of injury and subsequent mild clinical course. Conclusion: Even with a benign clinical course, one must think of rhabdomyolysis in uncertain injury mechanisms or questionable circumstances, and prompt laboratory diagnosis and fluid supplementation should be undertaken.

Acute and non-acute decompensation of liver cirrhosis (47/130).

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases.

Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature. Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports. MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval. MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.

New-Onset, Treatment-Resistant Inflammatory Bowel Disease after Administration of Secukinumab for Plaque Psoriasis: A Case Report and Review of the Existing Literature.

Aberrant activation of the IL-23/IL-17 axis leads to inflammatory phenotypes with overlapping clinical characteristics. Inhibition of IL-17 has mostly an anti-inflammatory effect, but sporadic cases of new-onset IBD have been reported. We present the case of a 65-year-old male patient with new-onset Crohn's-like disease after treatment with secukinumab for skin psoriasis. Discontinuation of the IL-17 inhibitor and high-dose corticosteroid treatment were efficient initially, but a relapse was noted during corticosteroid tapering. Administration of certolizumab pegol did partially relieve the patient, but disease remission was only achieved with subcutaneous risankizumab therapy. Clinical trials and real-world data indicate sporadic cases of new-onset IBD in patients receiving IL-17 inhibitors. Interestingly, our case is a "treatment-resistant" one since treatment with a biologic disease-modifying drug (bDMARD) usually leads to disease remission. As such, it is crucial to investigate the special characteristics of this clinical entity.

Estimulación del ganglio de Gasser para dolor neuropático del trigémino refractario

Background and objectivePainful trigeminal neuropathy is a complex clinical entity due to its severity and refractoriness to pharmacological and interventional management. We describe our experience in treating refractory painful trigeminal neuropathy (RPTN) with Gasserian ganglion stimulation (GGS). Materials and methodsSix patients with RPTN were treated with GGS in our unit between 2019 and 2022. The following data were collected: socio-demographic characteristics, triggering event, duration of the disease and treatment received prior to surgery, pre- and post-intervention visual analogue scale score, follow-up time, and pre- and post-intervention functionality and quality of life. ResultsAll patients were women who had received aggressive first-, second-, and third-line pharmacological, non-pharmacological, and interventional management before being referred for GGS. Patients reported a 50-72% decrease in pain on visual analogue scale and improved functionality during follow-up. ConclusionsGGS is a promising therapeutic alternative for patients with RPTN. Although the initial outcomes and experience are encouraging, RPTN is recommended on the basis of safety, reproducibility, and trends observed in clinical practice.

Diagnóstico y tratamiento de la miocarditis y la miocardiopatía inflamatoria. Documento de consenso SEC-GT de miocarditis

Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.

Biography of Muscle Tension Dysphonia: A Scoping Review

Background: Muscle Tension Dysphonia is a relatively new clinical entity that, despite being one of the most frequent causes of functional dysphonia, is little-known by many otorhinolaryngologists. Objective: The objective of the current work is to describe the evolution of Muscle Tension Dysphonia—the concepts and the ways it has been diagnosed and treated—from its first descriptions to our current knowledge. Design: A scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. A search of three bibliographic databases was performed to identify original articles on Muscle Tension Dysphonia. Study selection and characterization was conducted by three independent reviewers and was further reviewed by a fourth individual. In case of relocating any of the studies, it was performed by agreement of two reviewers. We excluded articles not written in English or Spanish, letters to the editor, review articles, studies of the pediatric population, articles related to dysphagia, and other publications that were not relevant. Results: The search identified 1144 articles published from 1983 to December 2022. A total of 581 studies were repeated and another 462 were excluded because they were not written in English or Spanish, were not original articles, or were not relevant to the objective of the study. Finally, 101 articles were included in the review. The articles included in the review were divided into three groups considering the objective and conclusions of each study: 21 articles were classified as “Etiology and Physiopathology”, 29 articles as “Diagnosis”, and 51 articles were included in the “Treatment” group. Conclusions: The concept of Muscle Tension Dysphonia has been developed during the last forty years. For its diagnosis, endoscopic visualization of the larynx is crucial, but must be combined with the patient’s clinical history and other methods can also be useful. This entity should be addressed in a multidisciplinary approach, with the active participation of speech therapists. Most therapeutic options include voice education, vocal hygiene, and rehabilitation of the voice.

Isolated teratozoospermia: revisiting its relevance in male infertility: a narrative review.

Basic semen analysis is the first step in the evaluation of male infertility. It includes an assessment of sperm morphology which is believed to reflect on overall spermatogenesis and sperm function. Teratozoospermia, defined as abnormal sperm morphology, is frequently present in association with severe oligoasthenozoospermia, but isolated teratozoospermia (in the presence of normal counts and motility) is a poorly understood clinical entity with conflicting implications in terms of fertility potential and treatment strategies. The following paper aims to: (I) discuss the classification of sperm morphology, causes, and molecular mechanism of teratozoospermia; (II) analyze the clinical significance and potential treatment options of isolated teratozoospermia as a cause of male infertility and a predictor of fertility outcome; and (III) provide a SWOT (strengths, weaknesses, opportunities, and threats) analysis based on the existing literature on this topic. A comprehensive search from database inception to 25 April 2023 was conducted in PubMed for relevant papers relating to isolated teratozoospermia in male infertility. Finally, seven systematic reviews/reviews/meta-analyses and 81 original articles were synthesized into the current narrative review. Classification of sperm morphology has evolved significantly since the first edition of the World Health Organization (WHO) Manual of Human Semen Analysis. Kruger's strict criteria are the most used classification and have been shown to correlate with fertility outcomes. There are many causes of teratozoospermia including genetic and environmental factors and physical conditions like varicocele. Teratozoospermia correlates with sperm DNA damage, elevated oxidative stress, low antioxidant function, and apoptotic alterations, which can result in impaired spermatozoa function and lower pregnancy rates. However, the clinical correlation between teratozoospermia and assisted reproductive technology (ART) outcome shows conflicting data with recent meta-analyses suggesting that isolated teratozoospermia was not associated with poor fertility outcomes from ART and that intrauterine insemination (IUI) can be an effective option even in the presence of teratozoospermia. There is very limited data on effective therapeutic options to treat idiopathic isolated teratozoospermia. The opportunity for future research is huge to fill the gap in the medical literature on this topic. Contemporary literature on isolated teratozoospermia shows conflicting results in terms of its actual clinical implication in male infertility and the utility of available treatment options. Further research is warranted on this clinical entity to improve sperm function and future paternity.

Epipericardial Fat Necrosis and Covid-19.

Epipericardial fat necrosis (EFN) is a rare and self-limiting cause of acute chest pain. We describe a case of EFN in a patient with a recent coronavirus disease (COVID-19). A 55-year-old male presented with a sudden onset of left-sided pleuritic chest pain for the past two days. The patient was diaphoretic, tachypneic, and tachycardic. Acute coronary syndrome was ruled out. A computed tomography (CT) pulmonary angiogram revealed an ovoid encapsulated fatty mass surrounded by dense appearing tissue. Patient symptoms improved remarkably with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). EFN typically presents with a sudden onset of excruciating chest pain. Misdiagnosis, under-diagnosis, and mismanagement are unavoidable. EFN is incidentally diagnosed on CT scan. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects visceral adipose tissue and appears to increase the risk of EFN by promoting inflammatory cytokine production and death of adipocytes. EFN is a rare cause of acute chest pain. SARS-CoV-2 is likely to induce EFN. This rare clinical entity should be considered in the differential of acute chest pain especially in patients with active or recent COVID-19. Epipericardial fat necrosis (EFN) is a rare cause of acute pleuritic chest pain that is often misdiagnosed and mismanaged.SARS-CoV-2 can possibly increase the risk of EFN and this entity should be considered in the differential of chest pain, especially in patients with active or recent coronavirus disease (COVID-19).Clinician awareness of EFN and its potential association with COVID-19, can reduce unnecessary testing and emotional distress.

Heterogeneity in Measures of Illness among Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Is Not Explained by Clinical Practice: A Study in Seven U.S. Specialty Clinics.

Background: One of the goals of the Multi-site Clinical Assessment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (MCAM) study was to evaluate whether clinicians experienced in diagnosing and caring for patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) recognized the same clinical entity. Methods: We enrolled participants from seven specialty clinics in the United States. We used baseline data (n = 465) on standardized questions measuring general clinical characteristics, functional impairment, post-exertional malaise, fatigue, sleep, neurocognitive/autonomic symptoms, pain, and other symptoms to evaluate whether patient characteristics differed by clinic. Results: We found few statistically significant and no clinically significant differences between clinics in their patients' standardized measures of ME/CFS symptoms and function. Strikingly, patients in each clinic sample and overall showed a wide distribution in all scores and measures. Conclusions: Illness heterogeneity may be an inherent feature of ME/CFS. Presenting research data in scatter plots or histograms will help clarify the challenge. Relying on case-control study designs without subgrouping or stratification of ME/CFS illness characteristics may limit the reproducibility of research findings and could obscure underlying mechanisms.

Acute testicular pain revealing nephretic lithiasic colic: A case report with literature review

Acute testicular pain is a common issue in urology. While spermatic cord torsion and orchiepididymitis are typical causes, renal colic is a rare clinical entity that can manifest as acute testicular pain. In this case report, we present the case of a young patient who experienced acute right testicular pain without radiation, accompanied by microscopic hematuria. An abdominopelvic CT scan revealed a stone in the right lumbar ureter with upstream dilation. Emergency treatment consisted of diverting urine using a JJ catheter and performing flexible ureteroscopy with remote stone extraction. This observation highlights that not all cases of acute testicular pain are due to torsion of the spermatic cord. In this report, we will review the relevant literature.

A case report on the use of Ayurveda in the treatment of Iron Deficiency Anaemia

Among pregnant women and young children, nutritional iron deficiency anaemia is a worldwide public health concern and the leading cause of anaemia. Iron deficiency anaemia is often caused by blood loss or mal-absorption. Iron deficiency anaemia and Pandu Roga are very similar clinical entities. Pitta Pradhan Vyadhi is Pandu Roga. The vitiated Doshas in Pandu Roga cause a disruption in tissue metabolism, which results in Dhatu-Shathilya in all of Dhatu. Paleness is the dominant colour across the body. The Rasavaha and Raktavaha Srotasas play a significant role in the development of Pandu. In this case study, we see a 22-year-old female patient with iron deficiency anaemia who, after a month of treatment with Ayurvedic formulations in the Pandu Roga line of treatment and iron-rich dietary supplements, experienced a dramatic improvement in her symptoms (less swelling, no pallor, increased energy, decreased palpitation, and hair loss of 10 strands per day) and an increase in her haemoglobin level (from 8.6g/dl to 12.7g/dl) at a very rapid pace. The Samprapti of Pandu Roga may be broken with the aid of the formulas. Iron deficiency anaemia (Pandu) may be effectively treated with Ayurvedic medication.

A cross sectional study on serum homocysteine levels in women with unexplained infertility at rural hospital setup and its correlation with ovulation

This cross-sectional study aims to investigate the serum homocysteine levels in women diagnosed with unexplained infertility at a rural hospital setup and its correlation with ovulation patterns. Unexplained infertility is a challenging clinical entity, with a limited understanding of its underlying mechanisms in resource-constrained healthcare settings. The study will include women between 21 and 45 years of age, diagnosed with unexplained infertility, who have not received any prior fertility treatments. Data will be collected through blood samples to measure serum homocysteine levels, and ovulation assessments using hormonal analysis and ultrasound monitoring of the menstrual cycle. Descriptive statistics will summarize participants’ characteristics, while comparison tests will be employed to assess the association between serum homocysteine levels and unexplained infertility. Correlation analysis will explore the relationship between serum homocysteine levels and ovulation parameters. Furthermore, multiple regression analysis will identify independent associations between serum homocysteine levels and ovulation, controlling for potential confounding variables. This study aims to provide valuable insights into the role of serum homocysteine in unexplained infertility and its potential impact on ovulation patterns in women in a rural healthcare setup. The findings may contribute to understanding the pathophysiology of unexplained infertilities and pave the way for targeted therapeutic interventions. Ethical considerations will ensure participant privacy, and all data will be managed with the utmost confidentiality. The study’s results will be reported transparently, adhering to ethical guidelines, to offer evidence-based guidance for managing unexplained infertility in rural healthcare settings.

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas: An individual participant data meta-analysis.

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGCs) of the pancreas is a rare neoplasm that accounts for less than 1% of all pancreatic malignancies. The aim of this study was to review the literature regarding UC-OGC, and to highlight its biological behavior, clinicopathologic characteristics, prognosis, and therapeutic options. A systematic review of the literature in PubMed/Medline and Scopus databases was performed (last search October 31st, 2023) for articles concerning pancreatic UC-OGC in the adult population. Fifty-seven studies met the inclusion criteria, involving 69 patients with a male-to-female ratio of 1.1:1 and a mean age of 62.96. Main symptoms included abdominal pain (33.3%), jaundice (14.5%), weight loss (8.7%), while fourteen patients (20.3%) were asymptomatic. Surgical resection was performed in 88.4% of cases. Survival rates at one, three, and five years were 58%, 44.7%, and 37.3% respectively. Sex, age, size (cut-off of 4 cm), location, and adjuvant treatment did not significantly affect patient survival. UC-OGC of the pancreas is a rare subtype of undifferentiated pancreatic carcinoma with a better prognosis than conventional pancreatic ductal adenocarcinoma or undifferentiated carcinoma without giant cells. The establishment of a dedicated patient registry is imperative to further delineate the optimal treatment for this uncommon clinical entity.

Solitary plasmacytoma: A case report

Plasmacytoma is a discrete, unifocal, and monoclonal neoplastic proliferation of plasma cells. It may present as one of the three distinct clinical entities: multiple myeloma (MM), solitary plasmacytoma of the bone, and extramedullary plasmacytoma. Solitary plasmacytoma of the bone accounts for 3% of all plasma cell neoplasms. About 50% of the cases of solitary plasmacytoma of the bone transform into MM. The most commonly involved sites are vertebrae and long bones. It is extremely rare in jaws. We are presenting a case of solitary plasmacytoma of the maxilla in a 59-year-old female patient with comprehensive clinical, radiological, histological, and immunohistochemical features.