History Of Vomiting Research Articles

INVESTIGATION OF FOOD POISONING OUTBREAK IN A TEMPORARY CAMP USING MIXED METHODOLOGY APPROACH

Objectives: In the present study, a food poisoning outbreak was reported from a medical officer in-charge of the temporary camp, where a largegathering of around 400 boys and girls had consumed meal from a common kitchen during training event. Thus, the main objective of the study was to investigate the outbreak and institute preventive measures. Methods: The camps had a total strength of 400. Ten individuals reported with history of vomiting and diarrhea. Mixed methodology approach was used to carry out epidemiological investigation. Inspection of cookhouse and surroundings was carried out. Results: Ten individuals were affected. A short incubation period ranging from 4 to 6 h with median incubation of 5 h. Among cases, all had diarrhea with the number of episodes ranging from 3 to 5. Seven patients had vomiting (70%), two (20%) patients had blood in stools, and none reported with abdominal cramps and fever. A total of five food items were suspected for food poisoning. However, none had a significant association with outcome. In depth interview and descriptive analysis revealed that mayonnaise in sandwich was the cause for food poisoning. Conclusion: Food poisoning outbreak is a common occurrence now days. Hygiene and sanitation of cookhouse to be carried out routinely to prevent outbreak. Individuals in camps should also be educated of 5 Key points of food safety by the WHO.

P-EGS15 Gastric pneumatosis in an elderly patient with recurrence of gastric volvulus

Abstract Background Gastric pneumatosis (GP), defined as the presence of air in the gastric wall, is a rare CT finding. It is associated with a spectrum of conditions which can range from benign and self-limiting to severe with high mortality rate. A gastric volvulus occurs with a rotation of 180 degrees or more of the stomach around its longitudinal or transverse axis. It is a rare event, and can culminate in obstruction, strangulation, ischaemia and necrosis. We present a case of gastric pneumatosis in a patient suffering with hiatus hernia and a history of recurrent gastric volvuli. Methods An 83-year-old man presented with a history of vomiting and abdominal pain. His background included a known hiatus hernia with previous episodes of gastric volvulus. A computer tomography (CT) showed a gastric volvulus with air in the gastric wall, in the intrahepatic biliary tree and porta hepatis. Conservative management was pursued with IV PPI and antibiotics, keeping the patient nil by mouth. He improved clinically and a repeat CT scan showed regression of the gastric pneumatosis, with resorption of gas in the porta hepatis and regression of the pneumobilia. He was discharged home 12 days after his initial presentation. Results Gastric pneumatosis (GP) is described as a rare finding that can occur in conditions such as gastric emphysema (GE) and emphysematous gastritis (EG). GE is described as a more benign condition, usually self-limiting which can be managed conservatively in most cases and rarely requires surgical interventions. EG is a more severe condition with a high mortality rate, and more aggressive treatment is advocated. The diagnostic process can be challenging but literature shows lactate, the presence of metabolic acidosis and peritonitis can help differentiating between the two clinical entities and choosing the appropriate management plan. Conclusions This case described a patient presenting with a gastric volvulus with the presence of gastric pneumatosis, pneumobilia and portal venous gas. These findings were diagnosed as gastric ischaemia secondary to volvulus. In this case the patient made a good recovery after being managed conservatively. GP is a rare CT entity which can be found in the presence of GE or EG. Differentiating between the two can be a challenging process, aided by clinical examination as well as blood test results. Achieving the right diagnosis is key as radical surgical intervention is not always needed to guarantee a good outcome.

Abstract P136: Response to alpelisib in an adolescent with PIK3CA-mutated metastatic gastrointestinal stromal tumour

Abstract Introduction Gastrointestinal stromal tumours (GISTs) are mesenchymal neoplasms that arise in the gastrointestinal tract. While most GISTs are driven by mutations in cKIT or PDGFR, approximately 10% lack these variants and are referred to as ‘wild-type’. Wild-type GISTs are commonly succinate dehydrogenase (SDH)-deficient and are characterized by indolent, multi-focal disease at presentation. On occasion, patients experience symptomatic disease progression warranting treatment ; imatinib or sunitinib offer minimal benefit. PIK3CA mutations have recently been described in a small proportion of GIST. Case report A previously healthy 16-year-old female presented with a five-month history of vomiting and weight loss, compatible with gastric outlet obstruction. Computerized tomography demonstrated a large gastric mass, and multiple liver and peritoneal metastases. Biopsy showed nests of epithelioid cells with round nuclei, vesicular chromatin, and eosinophilic cytoplasm. The lesional cells were immunoreactive for CD117, DOG1, CD34, and smooth muscle actin, while negative for SDH-B immunohistochemistry, in keeping with SDH-deficient GIST. Germline and somatic panel sequencing were performed through the SickKids Cancer Sequencing Program along with RNA sequencing by Illumina TruSight RNA Pan-Cancer NGS analysis. Somatic analysis revealed a PIK3CA p.Glu545Lys (E545K) mutation at 0.12 variant allele fraction (VAF). The patient was also found to have germline heterozygous pathogenic splice variant in the SDHB gene c.75+1 G>T (p?). In the light of the molecular findings and no alternative curative options, compassionate access to alpelisib was sought. The patient started drug at the recommended adult dose of 300 mg by mouth daily, and after completing two 28-day cycles, showed marked improvement in her abdominal distension and discomfort. Her appetite improved with documented nutritional weight gain. Reimaging at this time showed a 20% reduction in the sum of maximum dimensions of target lesions (per RECIST 1.1). Repeat imaging after five months on treatment confirmed continued improvement with 25% reduction compared to baseline.The patient did not experience hypersensitivity, severe cutaneous adverse reactions, hyperglycemia or pneumonitis. She currently continues on alpelisib monotherapy. Conclusion We describe the first report of a clinically meaningful response to a PIK3CA inhibitor in an adolescent patient with advanced metastatic SDH-deficient GIST harbouring a somatic activating PIK3CA hotspot mutation. There is still much to be learned about the biology of pediatric/wild-type GIST. In these rare cases, we recommend referral to specialized centers and incorporation of comprehensive next generation sequencing into care. Sequencing should be performed both on germline and somatic DNA to evaluate for a cancer predisposition syndrome, along with possible druggable targets in PIK3CA, cKIT or PDGFRA. We believe that the lack of routine comprehensive genomic analysis may underestimate the frequency of such rare variants. Citation Format: Sarah Cohen-Gogo, Nisha Kanwar, Furqan Shaikh, Reto M. Baertschiger, Adam Shlien, David Malkin, Juan Putra, Ailish Coblentz, Anita Villani, Abha A. Gupta, Daniel A. Morgenstern. Response to alpelisib in an adolescent with PIK3CA-mutated metastatic gastrointestinal stromal tumour [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P136.

Synchronous concomitant pancreatic acinar cell carcin and gastric adenocarcinoma: A case report and review of literature

BACKGROUNDMultiple primary malignant tumors are two or more malignancies in an individual without any relationship between the neoplasms. In recent years, an increasing number of cases have been reported. However, concomitant primary gastric and pancreatic cancer reported a relatively small incidence, involving no pancreatic acinar cell carcinoma reports. Here, we present the first case of concomitant pancreatic acinar cell carcinoma and gastric adenocarcinoma.CASE SUMMARYA 69-year-old male presented to our department with a history of vomiting, epigastric pain, and weight loss. Imaging revealed space-occupying lesions in the stomach and the tail of the pancreas, respectively. The patient underwent laparoscopic radical gastrectomy and pancreatectomy simultaneously. The pathologies of surgical specimens were completely different: The resected gastric specimen was moderate to poorly differentiated adenocarcinoma, whereas the pancreatic tumor was consistent with acinar cell carcinoma. The patient was treated with six cycles of oxaliplatin and S-1 chemotherapy. As of March 2021, the patient was healthy without any recurrence or metastasis. After thoroughly reviewing the literature on simultaneous pancreatic and gastric cancers at home and abroad, we discussed the clinical characteristics of these rare synchronous double cancers. Most of the cases had undergone surgery and adjuvant chemotherapy, and all of the cases were pathologically confirmed by the postoperative specimen.CONCLUSIONSynchronous pancreatic acinar cells and gastric adenocarcinoma can occur and should be considered when tumors are found in these organs.

Metabolic Ketoacidosis in a Gravida Diagnosed with COVID-19: A Case Report

We present a case of term pregnancy which presented with chief complaint of Breathlessness, chest pain as well as a one day history of vomiting. She tested positive for COVID19 through reverse transcriptase polymerase chain reaction of nasopharyngeal swab and the symptoms were attributed to Pneumonia caused due to COVID19.However,the arterial blood gas showed metabolic acidosis with high anion gap. This was a non lactate acidosis with no hypoxemia. Most reasonably the state of pregnancy with increased energy demands along with increased metabolic maternal demand due to infection coupled with maternal starvation had resulted in this Ketoacidosis . In view of non progression of labor caesarian section was carried out and a healthy neonate was delivered. There was an initial improvement in maternal ketoacidosis post partum however optimal management of COVID19 pneumonia required oxygen support and use of corticosteroids. Thus we highlight how an unusual metabolic demands of pregnancy might mimic COVID 19.

CONSIDERATIONS FOR SODIUM-GLUCOSE TRANSPORTER 2 INHIBITOR THERAPY RESULTING IN EUGLYCEMIC DIABETIC KETOACIDOSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sodium-glucose transporter 2 inhibitors (SGLT2i) have recently become an increasingly popular treatment choice for type 2 diabetics. A rare complication of SGLT2i use is euglycemic diabetic ketoacidosis (EDKA), during which life threatening severe metabolic acidosis and ketonemia arises in the setting of glucose levels of <250 mg/dL. CASE PRESENTATION: A 40-year-old male with a history of presumed type 2 diabetes mellitus (DM-2) which was diagnosed six years prior was transferred to our intensive care unit with persistent diabetic ketoacidosis (DKA). Past medical history was positive for prior episodes of DKA. His diabetic medications included glimepiride, dapagliflozin, metformin, and degludec insulin. He presented with a one day history of vomiting and polydipsia. Despite five liters of intravenous (IV) fluids, IV bicarbonate, and IV insulin, he persisted with a high anion gap metabolic acidosis (HAGMA). Lab work revealed an anion gap of 32, an osmolar gap of 26 with a normal lactic acid, and blood glucose of 148 mg/dL [Figure 1]. Arterial blood gas (ABG) revealed a pH of 7.046 and bicarbonate of 3.2. He was treated with an IV bicarbonate drip, IV insulin drip, and high volume IV fluids. He also underwent monitoring with serial ABGs, frequent blood glucose checks, and basic metabolic panels. The HAGMA gradually resolved over the next 48 hours. Additional serology revealed a positive glutamic acid decarboxylase (GAD) antibody; indicative of latent autoimmune DM in adults (LADA). After improvement his glimepiride, dapagliflozin, and metformin were discontinued. He was ultimately transitioned from an IV insulin drip to a basal/bolus insulin regimen at discharge. DISCUSSION: SGLT2i medications enhance excretion and block reabsorption of filtered glucose from the proximal convoluted tubule, resulting in a state of glucose starvation thereby increasing the glucagon/insulin ratio [1]. The HAGMA seen in EDKA is thought to result from increased lipolysis due to the glucagon/insulin imbalance, ultimately leading to ketoacidosis [2]. The mechanism of ketone production in EDKA is similar to DKA; acetoacetic acid reduces to beta-hydroxybutyric acid [2]. EDKA is a rare but known complication in type 2 diabetics who are prescribed SGLT2i therapies. Use of SGLT2i is not recommended in those with autoimmune diabetes by the Food and Drug Administration as ketone-associated complications can be as high as 9% [3]. LADA is an anti-islet cell autoimmune adult-onset DM. In our patient, he was initially misdiagnosed with DM-2; however, his blood work revealed that he had LADA. CONCLUSIONS: As SGLT2i usage becomes increasingly more common, providers should be cognizant of the patient's diabetic history and ensure the correct etiology of their patient's diabetes. Additionally, critical care providers should remain vigilant of the phenomenon of EDKA and its predisposing risk factors. REFERENCE #1: Pfützner A, Klonoff D, Heinemann L, Ejskjaer N, Pickup J. Euglycemic ketosis in patients with type 2 diabetes on SGLT2-inhibitor therapy-an emerging problem and solutions offered by diabetes technology. Endocrine. 2017 Apr;56(1):212-216. doi: 10.1007/s12020-017-1264-y. Epub 2017 Mar 17. PMID: 28303514. REFERENCE #2: Plewa MC, Bryant M, King-Thiele R. Euglycemic Diabetic Ketoacidosis. 2021 Feb 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32119457. REFERENCE #3: Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. doi: 10.2337/dc15-0843. Epub 2015 Jun 15. PMID: 26078479; PMCID: PMC4542270. DISCLOSURES: No relevant relationships by Jonathan Ross Ang, source=Web Response No relevant relationships by Parth Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by Shaili Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response

A Gut-Wrenching Case of Hypereosinophilia

A 5-year-old male child of Afro-Puerto Rican ethnicity presents with a history of vomiting, abdominal pain, and diarrhea requiring recurring admissions to the hospital over a span of 3 months. Abdominal pain was periumbilical and exacerbated by food intake. He was initially treated by primary care physician with ranitidine and ondansetron, but symptoms were progressively getting worse. He has been afebrile throughout, and no new medications or exposures were associated with the onset of his symptoms.

A Rare Case of Cryptococcal Meningitis in a Child with a Congenital Heart Disease

Cryptococcal meningitis, which has a high mortality rate, is rare in immunocompetent children. Although many immunocompromised conditions are identified as predisposing factors, congenital heart disease in children is not well recognized as a predisposing factor for the disease. A 12-year-old female child presented with a progressively increasing headache for one month. There was history of vomiting and fever off and on. On examination, she had a pansystolic murmur and meningeal signs. Lumbar puncture was done; opening pressure was high (27 cm H2O) and white blood cell (WBC) count in cerebrospinal fluid (CSF) was slightly high. Gram staining, India ink preparation, and culture of CSF were negative. Cryptococcal antigen (CrAg) test was not available. Echocardiography showed a 12 mm ventricular septal defect (VSD). The patient was diagnosed as meningitis with VSD and treated with intravenous ceftriaxone and vancomycin; however, she did not improve after 7 days of antimicrobial treatment. She was then transferred to another hospital where India ink and culture of CSF showed cryptococcus; CrAg test was done, and it was positive. Despite the treatment with lyposomal amphotericin B and flucytosine, she died on 9th day of admission in pediatric intensive care unit. It is necessary for global advocacy for need of availability of CrAg test in resource-limited regions. Treating doctors should consider VSD, a congenital heart disease, as a predisposing factor for cryptococcal meningitis in children. As CrAg is more sensitive than India ink and culture, it should be the first line of investigation in suspected cases.

English

A 36-year-old non-smoker, chronic alcoholic female presented with recurrent episodes of epigastric pain and vomiting in the last 10 days. H/o similar episodes of pain 3 times, with last episode was noted 2 months back. She also had history of vomiting (3 episodes). Jaundice/melena/steatorrheas was not observed. Subsequently, contrast-enhanced computed tomography (CECT) of the patient was done and it showed well defined multiple cystic lesions with peripheral wall enhancement involving head and body of pancreas, largest measuring 24 X 22 X 22 mm in the head of the pancreas, the lesion was seen abutting antro-pyloric region anteriorly. Main pancreatic is mildly dilated measuring 4 mm in diameter. A well-defined heterogeneously hypodense (necrotic) para duodenal lesion, was noted inferior to uncinate process, m/s 22 X 20 X 20 mm, which is indicative of lymph nodal deposit. On magnetic resonance cholangiopancreatography (MRCP): few cystic lesions were seen scattered in the pancreatic parenchyma, with one of the cysts showing communication with main pancreatic duct (MPD) ab.

Canine disseminated peritoneal angiomatosis with arterial differentiation in a 10‐month‐old Rhodesian Ridgeback

AbstractA 10‐month‐old, male entire Rhodesian Ridgeback was presented with a 1‐week history of vomiting, small and large intestinal diarrhoea, hyporexia and weight loss. Physical examination revealed a palpable abdominal mass. Abdominal ultrasonography and contrast computed tomography demonstrated multiple cystic masses of varied size and wall thickness with no appreciable origin. An exploratory laparotomy revealed multiple mass lesions throughout the mesentery, located adjacent to blood vessels and varying in size from approximately 2 mm up to 13 cm in diameter. In histologic sections, the nodular structures resembled thick‐walled arteries. Immunohistochemistry confirmed positive cytoplasmic immunoreactivity for von Willebrand factor, CD31 and smooth muscle actin. This is, to the authors’ knowledge, the first case of disseminated peritoneal angiomatosis with arterial differentiation in the dog. The dog was euthanased due to the progressive nature of the mass lesions.

Accidental Magnet Ingestion in A Toddler: A Diagnostic Dilemma

Foreign body ingestion is common in children. Ingestion of foreign bodies with magnetic properties are less common, but can be associated with more severe complication, especially involving multiple magnets. We present a 16-month-old boy with developmental delay who developed small bowel perforation following multiple magnet ingestion. He had three days history of vomiting and abdominal distension associated with pain, suggestive of an acute intestinal obstruction. Abdominal imaging confirmed foreign body ingestion, and an exploratory laparotomy revealed two magnets attracted across the intestinal lining with resultant intestinal obstruction and perforation. Surgical removal of the magnets and the necrotic bowel tissue was complicated by post-operative wound dehiscence. After secondary suturing, the child subsequently made a complete recovery. We discuss the diagnostic dilemma in multiple magnet ingestion along with the importance of early recognition and prompt management due to the risk of more severe gastrointestinal complication associated with delayed intervention.

A Case of Hypocalcemia Secondary to Infection With SARS-CoV-2 Virus

Background: A Case of Hypocalcemia Secondary to Infection with SARS-CoV-2 Virus.Clinical Case: A 40 year-old obese male presented to the emergency department with a five day history of nausea, vomiting, shortness of breath, and nonproductive cough. Symptoms progressed culminating in a single episode of pre-syncope leading to his seeking medical care. Positive testing for the presence of SARS-CoV-2 as well as findings from computed tomography of the patient’s chest led to a diagnosis of COVID-19 and the patient’s admission to a COVID-19 ward, where treatment with dexamethasone, doxycycline, and 2 L oxygen via nasal cannula began. Blood testing on admission revealed profound hypocalcemia (6.2 mg/dL total and 3.5 mg/dL ionized) as well as newly diagnosed diabetes mellitus type 2 (T2DM) (HbA1c 13.0% on admission). Further electrolyte disturbances noted were consistent with his history of vomiting and untreated T2DM. Thyroid stimulating hormone and thyroxine levels showed primary hypothyroidism, but the patient’s parathyroid hormone level (16.5 pg/mL) was inappropriately normal. No other causes for hypocalcemia were identified. The patient’s hypocalcemia was treated with intravenous calcium gluconate and rose consistently through day six of hospitalization. Calcium fell sharply between day six and seven (7.6 mg/dL to 7.3 mg/dL) coinciding with worsening respiratory symptoms and requiring a doubling of oxygen dose from 2 to 4 L with subsequent improvement in hypocalcemia once underlying pulmonary function improved. Discussion: SARS-CoV-2 infection presenting with hypocalcemia has been well documented without definitive explanation [1]. Further, while the precise mechanism of SARS-CoV-2 virion export is unclear, the patient’s worsening hypocalcemia, respiratory symptoms, and concurrent presumable increased viral load suggests this is caused by a calcium-dependent exocytotic process [2]. 1: Marazuela, M., Giustina, A. & Puig-Domingo, M. Endocrine and metabolic aspects of the COVID-19 pandemic. Rev Endocr Metab Disord 21, 495–507 (2020). https://link.springer.com/article/10.1007/s11154-020-09569-22: Fehr A.R., Perlman S. (2015) Coronaviruses: An Overview of Their Replication and Pathogenesis. In: Maier H., Bickerton E., Britton P. (eds) Coronaviruses. Methods in Molecular Biology, vol 1282. Humana Press, New York, NY. https://link.springer.com/protocol/10.1007%2F978-1-4939-2438-7_1.

Emphysematous hepatic abscess and pyometra, both caused by Burkholderia cepacia, in a bitch

AbstractA thirteen‐year‐old female intact mixed dog was presented to the emergency service with a history of vomiting and apathy. The bitch was under treatment of prednisone for chronic cough. The patient was depressed and showed abdominal pain. Abdominal radiographs revealed an increased liver size, a rounded structure of gas opacity located within the liver and a soft tissue opacity mass in the caudal abdomen. The ultrasonographic findings of the abdomen were consistent with emphysematous hepatic abscess (HA), vacuolar hepatopathy, focal peritonitis and pyometra. Surgical drainage, lavage and omentalisation of the liver abscess were performed, followed by an ovariohysterectomy. Twelve hours after surgery, the patient died due to the suspected multiple organ failure. Culture of the abscess and uterine fluid revealed presence of Burkholderia cepacia. To the authors’ knowledge, this report represented the first description of HA presumably caused by the haematogeneous spread of Burkholderia cepacia from a uterine infection.

Analysis of the influencing factors and nursing strategy for acute atelectasis after traumatic brain injury surgery.

Acute atelectasis is common after traumatic brain injury (TBI), but the related factors and treatment are still unclear. This study is to analyze the independent risk factors for acute atelectasis after TBI and propose an interventional nursing strategy, in order to correct respiratory function and improve the prognosis of patients. The clinical data of 93 patients with TBI admitted to our hospital from April 2015 to October 2019 were retrospectively analyzed. Clinical data were analyzed by single factor analysis, the cutoff value of influencing factors was obtained by receiver operating characteristic (ROC) curve analysis, and the influencing factors for acute atelectasis after TBI were examined by multi-factor logistic regression. Twenty-two patients (23.66%) were complicated with acute atelectasis during the observation period, while the remaining 71 patients (76.34%) did not have acute atelectasis. Univariate analysis showed that there were significant differences in the Glasgow Coma Scale (GCS), history of vomiting and aspiration, mannitol use, mechanical ventilation, hypoalbuminemia, and serum hypoxia-inducible factor-1α (HIF-1α) between the acute atelectasis group and the non-acute atelectasis group (P<0.05). The AUC area of HIF-1α level predicting acute atelectasis was 0.896 [95% confidence interval (CI): 0.814-0.978, P=0.042], and the cut-off value was 2.12 mmol/L, with a sensitivity of 76.9% and a specificity of 93.3%. Logistic regression analysis showed that a history of vomiting and aspiration [odds ratio (OR) 3.908, 95% confidence interval (CI): 1.201-12.712], mechanical ventilation (OR 3.250, 95% CI: 1.139-9.271), hypoalbuminemia (OR 5.741, 95% Cl: 1.926-17.113), and HIF-1α ≥2.12 mmol/L (OR 6.623, 95% CI: 2.364-16.346) were independent risk factors for acute atelectasis after TBI. A history of vomiting and aspiration, mechanical ventilation, hypoalbuminemia, and high expression of HIF-1α are all independent risk factors for postoperative acute atelectasis in patients with TBI. In clinical practice, patients should be guided to swallow properly, breathe smoothly, eat well, and regularly check the relevant indexes.

Tension pneumoperitoneum secondary to duodenal perforation presumptively due to the administration of meloxicam in a cat

AbstractA 4‐year‐old neutered domestic cat was presented with a history of vomiting, anorexia, lethargy and severe abdominal distension. The cat was hypothermic and hypotensive. It had received a week course of meloxicam. Abdominal radiographies revealed the presence of a very large volume of peritoneal gas associated loss in peritoneal serosal detail and gastric dilatation. The presumptive diagnosis was tension pneumoperitoneum and peritonitis caused, most likely, by a gastrointestinal perforation. Exploratory laparotomy confirmed the presence of a duodenum perforation. At the end of the surgery, the cat suffered a cardiorespiratory arrest and died. Unfortunately, the post‐mortem examination was not allowed. Spontaneous pneumoperitoneum is a rare condition reported in cats. The incidence of non‐steroidal anti‐inflammatory drugs (NSAIDs) induced by gastroduodenal perforation in cats has been reported in a few cases. In the cat reported here, the authors suspect that duodenal perforation was secondary to NSAID administration.

English

A 46-year-old gentleman presented to casualty with a reducible right groin swelling (Figure 1) present since childhood which had suddenly become painful and irreducible for the past 6 hours. He gives history of absent right testis since childhood. There’s no history of vomiting, abdominal distension or obstipation. He had no surgeries in the past, no testicular disease or infertility problems. Physical examination revealed obstructed inguinal hernia with doubtful strangulation, absent right testis and normal appearing left testis. After evaluation, patient underwent emergency exploration of right inguinal hernia under general anaesthesia which revealed gangrenous small bowel, omentum in between external oblique aponeurosis and skin without a hernia sac (Figure 2) and; ectopic right testis in the superficial inguinal pouch (Figure 3). Segmental resection of gangrenous bowel with primary anastomosis and right orchidectomy performed through the same inguinal approach. Anatomical repair of posterior wall followed by approximation of external oblique aponeurosis was performed. Histopathology report showed gangrenous ileum with patchy necrosis; testis with tubular atrophy and hyalinisation, maturation arrest of spermatogonia and hyperplasia of interstitial Leydig cells. Post-operative recovery was uneventful.

Otitis Media and Internal with Brainstem Extension in a French Bulldog

Background: Otitis is a frequent condition in dogs, with a multifactorial etiology covering primary causes, predisposing and perpetuating factors. It is characterized by an inflammatory process of structures that make up the auditory system, with prevalence data ranging from 15 to 20%, which can occur in any age group and without sex predisposition. According to the location, it can be classified as uni or bilateral, affecting the outer, middle and / or inner ear, the latter two being associated with neurological changes such as vestibulopathy, facial nerve paresis and Horner's syndrome. The morbidity and mortality of otitis media and internal may increase with delay in diagnosis, resulting in delay in the correct treatment, and the extension to brainstem is described in felines and considered rare in dogs. The present study aims to report an atypical case of otitis media and internal, with extension to the brain parenchyma in a brachycephalic dog.Case: A 3-year-old bitch French Bulldog canine was seen, weighing 12 kg, with a history of vomiting, apathy, nystagmus, ataxia and acute evolution hemiparesis. As a result of adoption, it was not known about the animal's morbid past. On special physical and clinical examination, depressed mental status, changes in postural reactions, nostril stenosis with unilateral mucopurulent nasal discharge, corneal ulcer, palpebral and labial ptosis, absence of eyelid reflex and spontaneous strabismus were observed, all of these findings observed on the left side of the face. No signs of otitis external to otoscopy were found. The clinical signs found characterize left facial nerve paresis and peripheral and central vestibulopathy. Otitis media / internal and meningoencephalitis were suspected. Hemogram, serum biochemistry (glucose, urea, creatinine, alanine aminotransferase, total proteins, albumin, globulin, alkaline phosphatase, gamma glutamyltransferase, phosphorus, total bilirubin, cholesterol and total calcium), urinalysis, rapid tests for erlichiosis, anaplasms , borreliosis, heartworm, distemper and leishmaniasis, CSF analysis, neurological panel performed by PCR (Polymerase Chain Reaction) that tested the animal for Bartonellosis, Lyme Disease (Borrelia burgdorferi), Blastomyces dermatitidis, Cryptococcus sp., Virus West Nile, Distemper, Toxoplasmosis, Neosporose and Coccidioides sp. using conjunctival swab, whole blood, urine and CSF samples. The samples were negative for all of these tests. As an image exam, brain magnetic resonance was performed. In the latter, otitis media and left internal was observed with extension of the lesion to the brain parenchyma. CSF analysis showed cytological changes compatible with a non-suppurative inflammatory process, mild pleocytosis with predominantly mononuclear leukocyte infiltrate. As a form of treatment, antibiotic therapy and total ablation of the auditory canal with lateral bulectomy were performed, showing good results with reduced clinical symptoms.Discussion: It is concluded that although the diagnosis of otitis media and internal with extension to brainstem is more common in cats, it should be included as a differential for central vestibular disorders in dogs, and that the diagnosis together with early and effective treatment are important, since that the evolution of the infection to the central nervous system represents a risk to the patient.Keywords: vestibulopathy, meningoencephalitis, brachycephalic.Descritores: vestibulopatia, meningoencefalite, braquicefálico.Título: Otite média e interna com extensão para tronco encefálico em cão buldogue francês

Cardiac Tamponade Secondary to Hemangiosarcoma in a Dog

Background: Nonspecific clinical manifestations such as apathy, anorexia and diarrhea are common in the clinical routine, and therefore may mask the severity of its triggering factor. When patients presenting this symptomatology are referred to the care center, it is essential that a thorough investigation is performed to clarify the primary causes of these manifestations, and for this, complementary imaging exams may be necessary. The objective of this study is to describe the clinical and imaging aspects of a canine with cardiac hemangiosarcoma and to correlate with the pathophysiology of the alterations observed, in order to optimize the clinical care of patients with nonspecific clinical signs and affected by this alteration.Case: A 10-year-old Pitbull dog was treated with a history of vomiting, loss of appetite and diarrhea. Upon clinical examination, the animal presented dehydration level and distended abdomen. On ultrasound examination, hepatomegaly was observed, associated with signs of double layer in the gallbladder wall and the presence of moderate peritoneal effusion. On chest radiography, the cardiac silhouette showed an important increase in size with loss of shape and contours. Dorsal displacement of the trachea, greater contact of the heart with the sternum and displacement of the caudal vena cava were observed. In addition, an amorphous and poorly defined structure with radiopacity of soft tissues was observed in the region of the atrium and right ventricle, causing the obliteration of pulmonary fields. On echocardiographic examination, a significant amount of free anechogenic fluid was observed in the pericardial sac, confirming the suspicion of pericardial effusion, with consequent collapse of the wall of the right heart chambers during systole. Furthermore, an amorphous, poorly defined and heterogeneous structure was observed in the right atrium wall. Due to the location of the neoformation, the patient's general clinical condition, euthanasia was chosen. During the necropsy, the ocular, oral and preputial mucosae were moderately pale. In the abdomen, the presence of hydroperitoneum and hepatomegaly was observed. In the thoracic cavity, hemothorax, enlarged heart were identified and, in the right atrium, a reddish mass was identified. In addition, the lungs were whitish and hypercrepitating at the edges of the cranial lobes; the rest of the organ was moderately hyperemic, hypocrepitating. In histopathological examination of the liver, the centrilobular region showed chronic passive congestion associated with necrosis and multifocal degeneration of hepatocytes. Neoplastic proliferation of mesenchymal cells, moderately cellular, non-encapsulated, of infiltrative growth was observed in the heart. Neoplastic cells formed bundles, with a tendency to organize themselves into small blood vessels filled with red blood cells. The cytoplasm was moderate, elongated, indistinct, eosinophilic and homogeneous. The nucleus was large, unique, elongated, with finely dotted chromatin and sometimes with one or two nucleoli evident. Anisocytosis, anisocariosis and cell pleomorphism were moderate. Interwoven with neoplastic cells, a moderate presence of multifocal lymphohistioplasmocytic inflammatory infiltrate was observed. The definitive diagnosis of cardiac changes was hemangiosarcoma.Discussion: Hemangiosarcoma is a vascular endothelial cell neoplasm with high metastatic power and unfavorable prognosis. When located in the heart, it is commonly found in the auricle and right atrium and the cardiovascular changes caused by this neoplasm as well as the severity of these changes vary according to size and location. Clinical manifestations can be quite nonspecific and are usually associated with hemodynamic impairment, causing signs of right or left congestive heart failure.Keywords: heart, neoplasm, pathophysiology.Descritores: coração, neoplasia, patofisiologia.Título: Tamponamento cardíaco secundário ao hemangiossarcoma em cães

Risk factors for ventilator associated pneumonia in patients with trauma and head injury in a tertiary care teaching hospital of rural Gujarat

Ventilator associated pneumonia (VAP) is one of the major complications occurring in patients with mechanical ventilation, particularly in patients with trauma and head injury. The present study was conducted to determine the rate of VAP in patients with trauma and head injury, risk factors associated with them and their microbial profile as well as antimicrobial susceptibility patterns. A prospective observational study was conducted at Surgical Intensive Care Unit at tertiary care teaching hospital between 1st December 2016 and 31st May 2018. All patients with traumatic injury with or without head injury and who have been intubated and put on mechanical ventilation for more than 48 hours, were included in the study. Patients developing VAP were considered as cases whereas those who did not develop VAP served as controls. Out of 174 patients included in the study, 39 patients developed VAP with an incidence rate of 22.4% and incidence density of 21.7 per 1000 ventilator-days. Risk factors such as GCS &lt; 9 on admission, history of vomiting, craniotomy and tracheostomy were found to be statistically significant (p&lt; 0.05) for development of VAP. Duration of ICU stay (30±16 vs 8±4.9 days) and duration of intubation (25.85±16 vs 5.83±4 days) were statistically significant findings. Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae were the most common organisms isolated. Most of these organisms were multi drug resistant but were susceptible to colistin. Tracheostomy maintenance and infection control practices for patients undergoing surgical interventions such as craniotomy should be reviewed to bring down VAP rates.

RARE-39. MOLECULARLY CONFIRMED ATYPICAL CHOROID PLEXUS PAPILLOMA WITH INTRACRANIAL DISSEMINATION

INTRODUCTIONAmong choroid plexus tumors (CPTs), metastasis occurs more frequently as pathological grading increases. There could be an underestimation of pathological diagnosis if disseminated CPTs are diagnosed with lower grade tumors such as choroid plexus papilloma (CPP) or atypical choroid plexus papilloma (aCPP). Thus, molecular diagnosis using genome-wide DNA methylation profiling may be useful to clarify malignant potential among thetumor entity. Here, we report about a case of aCPP with intracranial dissemination that was molecularly diagnosed by methylation profiling. CASE DESCRIPTION: A 2-year-old girl presented with a history of vomiting. Brain magnetic resonance imaging showed a large tumor mass in the right lateral ventricle and diffuse enhancement surrounding her brainstem, which suggested dissemination. Gross total resection of the mass was performed. Intraoperative findings revealed multiple spot metastatic lesions on the inner wall of lateral ventricle. The pathological diagnosis was aCPP owing to the presence of a glandular structure with a papillary pattern suggesting a neoplasm of epithelial origin, increased cellularity, several necrotic areas, and an intermediate number of mitoses. The CPT-SIOP-2000 treatment protocol was followed without radiation therapy, and the disseminated lesion was disappeared during the chemotherapy. Methylation data of the current case was entered into a recently published classifier, and the tumor was classified as methylation class “plexus tumor, subclass pediatric A” with high confidence (calibrated score 0.96), which includes cases diagnosed as CPP and aCPPs.CONCLUSIONOur case indicates the clinical significance of molecular confirmation of diagnosis among CPTs, particularly lower grade tumors with dissemination.