Left Thoracic Region Research Articles

Rupture of the internal jugular vein and tension pneumothorax in a penetrating neck-lung injury due to iron splinters: a case report

Background: Penetrating neck injuries are relatively rare but pose significant challenges due to the concentration of vital structures in this area. This case report presents a unique in-stance of a 20-year-old male with a penetrating neck injury caused by iron splinters, resulting in the rupture of the internal jugular vein and tension pneumothorax.Case Presentation: The patient, a 20-year-old male, presented with restlessness, chest pain, rapid breathing, and a penetrating wound on the left side of the neck. Initial management included needle decompression for tension pneumothorax and radiological assessments to localize the foreign body. C-arm revealed that the foreign body had penetrated the upper left thoracic region and lung parenchyma. The surgical intervention involved repairing the internal jugular vein and performing pulmonary resection to remove the iron splinters.Conclusions: This case highlights the importance of a multidisciplinary approach in managing complex penetrating neck injuries. Advanced imaging techniques and timely surgical interventions are crucial for optimizing patient outcomes. Future research should focus on refining diagnostic protocols and exploring minimally invasive surgical techniques to improve the management of such injuries.

Empyema necessitans caused by methicillin-resistant Staphylococcus aureus: a case report and literature review

BackgroundEmpyema necessitans (EN) is a rare condition characterized by pleural infection with pus spreading into adjacent soft tissues. Although Mycobacterium tuberculosis and Actinomyces israelii are common causative agents, methicillin-resistant Staphylococcus aureus (MRSA) is relatively rare, but it is associated with high mortality in empyema cases. We aimed to report a unique case of EN caused by MRSA and present a literature review to better understand this rare condition.Case presentationA 69-year-old man with a history of right ureteral stone presented with fever and left anterior thoracic pain. A physical examination revealed redness and swelling in the left thoracic region. Imaging studies confirmed EN with fluid accumulation around the sternocostal joint of the left first rib. MRSA was identified from blood and pleural fluid cultures. The patient received antimicrobial therapy, and a chest tube was inserted for drainage. Despite initial improvement, vertebral osteomyelitis was diagnosed on day 17. The antimicrobials were subsequently terminated after 6 weeks, but vertebral osteomyelitis recurred, and treatment was resumed and completed on day 215.ConclusionEN caused by MRSA is rare, and the literature review revealed 14 cases from human sources. Positive blood cultures were observed in 40% of cases, and metastatic infections were present in 30% of cases. Osteomyelitis was the most common type of metastatic lesion. All the patients underwent drainage. Patients with MRSA-associated EN frequently develop disseminated lesions and should therefore be carefully examined. Moreover, appropriate treatment with antibiotics and drainage is necessary for a good prognosis. Although the prognosis appeared to be favorable in our review, publication bias and treatment challenges for metastatic infections should be considered.

Damage Control in Cervico-Thoracic’s Transition Wound: Case Report

The case addresses a patient who suffered a penetrating wound by a knife in right anterior cervical region (zone I) and left thoracic region that was admitted with signs of hemorrhagic hypovolemic shock (class III). The emergency surgical approach in patients with cervical trauma is indicated in cases of shock that is refractory to volume replacement, murmurs in the cervical region, and intense active bleeding. It is also suggested to avoid approaching non-expandable hematomas due to the risk of rebleeding. In this case, the patient had bleeding in the orifice of the cervical region and signs of shock. First, bleeding control was performed with Foley catheter placed in the wound and a massive transfusion protocol was initiated in the emergency room. Then, the patient was referred to the operating room. The management of penetrating neck injuries is based on anatomical division of the cervical region into zones I, II and III. Zone II is the area where most lesions are observed, followed by zones I and III.

Zosteriform Eruption on the Chest and Abdomen.

A 50-year-old man presented with erythematous macules and papules with a dermatomal distribution on the left thoracic region with associated pain of 3 weeks’ duration. The lesions persisted after treatment for herpes zoster.

Neonatal minimal invasive management of a prenatal gunshot trauma: case report

BackgroundPrenatal penetrating gunshot trauma represents a challenging scenario for healthcare providers. Trauma is the leading non-obstetric cause of morbidity and mortality during pregnancy, and even though rare, firearm injuries have the most fatal outcomes and higher fetus mortality rates. Understanding the mechanism of injury in order to identify the possible injuries and adequate management is essential. In this paper, we discuss the case of a newborn with prenatal gunshot trauma, the treatment used, and the outcome of conservative and minimally invasive management.Case presentationWe present the case of a male newborn, 37 weeks of gestational age and weighing 3050 g, delivered through an emergency cesarean section with prenatal gunshot trauma. Two skin wounds were found, one in the arm and another in the left thoracic region. The patient presented with respiratory distress, bilateral pneumothorax, and pneumoperitoneum, requiring high-frequency mechanical ventilation and the placement of bilateral thoracic drains. The pneumoperitoneum was attributed to pulmonary barotrauma, with no suspicion of abdominal hollow viscera lesion. A right thoracoscopy was performed after 24 h of conservative management for the removal of the foreign body. Both the mother and the baby had a positive outcome, with no further treatment needed.ConclusionsFor the improvement in the result of trauma events, an adequate intervention and coordinated efforts from multidisciplinary clinical and surgical teams are required. For gunshot wounds, entry, trajectory, the final position of the bullet, and pathological findings in images need to be analyzed before taking the patient to the operative room. Chosen with strict selection criteria, some patients could benefit from conservative management.

Stress Analysis of Thoracolumbosacral Orthosis (TLSO) for Scoliosis deformity and its Effects on Gait Cycle

This work involved two major parts: the first one is the experimental part which included treatment of scoliosis deformity by manufacturing thoracolumbosacral orthosis, measuring the cobb angle of deformity, measuring the gait cycle data and walk path for both legs and suggesting a composite material to improve the mechanical properties of the orthosis and finally the interface pressure between trunk and orthosis is measured for twelve points covering of the total TLSO surface area by using f-socket devise. The second part of this study is the numerical simulation part during which the stresses are calculated using Ansys software for calculating stresses due to interface pressure loading boundary condition. The result shows no deference in gait cycle phases but the clear difference noted in walking path due to deviate center of mass, maximum pressure recorded left thoracic region with 900KPa due to correct spinal deformity while the minimum pressure recorded at right chest with l40KPa because of it is tissue region and Maximum value of stress was recorded at the left thoracic region with 2.81MPa due to Maximum interface pressure at this point.

Suicide by self-inflicted stab wound to the heart: a rare case of suicide from Nepal

Suicide, or the deliberate act of killing oneself, accounts for a substantial number of unnatural deaths each year in many countries. Though death by self-stabbing is quite uncommon, the left part of the chest represents one of the elected sites of self-inflicted wounds because of the knowledge of the situation of the heart and that the injuries to the heart are severe. We present a case of suicidal stab to the left thoracic region involving the heart.DOI: http://dx.doi.org/10.3126/jcmsn.v10i2.12952 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(2); 33-35

Unusual hyperpigmented patches, an undeveloped breast and a cataract in a female with incontinentia pigmenti

AbstractA 19‐year‐old female and her mother visited our department with a history of unusual reticular brown‐black patches on their trunks and limbs since infancy. Besides the obviously fulsome hyperpigmentation, the daughter also showed other unusual clinical manifestations such as generalized hypohidrosis, especially on the hyperpigmented patches, cicatricial alopecia, a cataract on her right eye, abnormal teeth and a right dysplastic breast. The mother had a median diastema between her maxillary central incisors, hypoplasia of the enamel, hypohidrosis and hyperpigmented patches on her left thoracic region. Analysis of the NEMO (NF‐κB essential modulator) gene in the patient and her mother revealed a deletion of exons 4–10. Their EDA and EDAR genes were normal.

Use of vacuum-assisted closure to maintain viability of a skin flap in a dog

A 4-year-old sexually intact male Labrador Retriever-Poodle mix was admitted to the hospital for treatment of a wound in the left thoracic region. The wound had been debrided and primary closure had been performed by the referring veterinarian 4 days previously. The dog had a 20-cm-long wound covered by a large flap of skin that extended caudally from the scapula over the left side of the thorax. A 3-cm defect was evident at the cranioventral aspect of the wound, from which purulent material was being discharged. The skin flap was necrotic, and the skin surrounding the flap was bruised. Signs of pain were elicited when the wound and surrounding region were palpated. Other findings, including those of thoracic radiography, were unremarkable. The wound was debrided, and vacuum-assisted closure (VAC) was initiated for 3 days until a healthy bed of granulation tissue developed. A reconstructive procedure was performed with a rotation flap 3 days after VAC dressing removal. The VAC process was reinitiated 2 days following reconstruction because of an apparent failing of the skin flap viability. After 5 days of VAC, the flap had markedly improved in color and consistency and VAC was discontinued. Successful healing of the flap occurred without the need for debridement or additional intervention. Use of VAC led to a good overall outcome for the dog, with complete healing achieved. Additional evaluation of this technique for salvaging failing skin flaps is warranted in dogs, particularly considering that no reliable method for flap salvage in veterinary species has been reported to date.

The examination of biophysical parameters of skin (transepidermal water loss, skin hydration and pH value) in different body regions of normal cats of both sexes

The purpose of this study was to evaluate transepidermal water loss (TEWL), skin hydration and skin pH in normal cats. Twenty shorthaired European cats of both sexes were examined in the study. Measurements were taken from five different sites: the lumbar region, the axillary fossa, the inguinal region, the ventral abdominal region and the left thoracic region. In each of the regions, TEWL, skin hydration and skin pH were measured. The highest TEWL value was observed in the axillary fossa (18.22g/h/m(2)) and the lowest in the lumbar region (10.53g/h/m(2)). The highest skin hydration was found in the inguinal region (18.29CU) and the lowest in the lumbar region (4.62CU). The highest skin pH was observed in the inguinal region (6.64) and the lowest in the lumbar region (6.39). Statistically significant differences in TEWL were observed between the lumbar region and the left side of the thorax region (P=0.016), the axillary fossa (P=0.0004), the ventral region (P=0.005), and the inguinal region (P=0.009). There were significant differences in skin hydration between the lumbar region and the left thorax (P=0.000003), the axillary fossa (P=0.002), the ventral abdomen (P=0.03), and the inguinal region (P=0.0003) as well as between the thorax and the ventral abdomen (P=0.005). TEWL was higher in females (15g/h/m(2)) than in males (4.57g/h/m(2)). Skin hydration was higher in females (13.89CU) than in males (12.28CU). Significant differences were not found between males and females for TEWL and skin hydration. Skin pH was higher in males (6.94) than in females (6.54), which was significant (P=0.004).

(228) Repetitive paravertebral nerve block using a mixture of ketamine, bupivacaine and methylprednisolone for pain relief in intractable post herpetic neuralgia

We present a case of postherpetic neuralgia (PHN) treated successfully with repetitive paravertebral blocks (PVB) with bupivacaine, ketamine and methylprednisolone. A 65-yr-old male patient, ASA II, weight 55 kg, previously healthy was referred with 24 month left sided parietal chest pain diagnosed as PHN with 8–9/10 on VAS scale. Previous pain treatment included non-steroidal anti-inflammatory drugs and tramadol, combined with oral oxcarbazepine 600 mg per day and amitryptyline 75 mg per day with no improvement. A few months later, gabapentin was added at a dose of 300 mg three times per day that was increased gradually to 1800 mg per day over a 6 month period. Upon presentation, the patient was still complaining of persistent pain with a VAS 8-9/10 in the left thoracic region mainly at T4 extending to T7 associated with mood changes and sleep disturbance. Physical examination revealed an allodynia and hyperaesthesia of the corresponding dermatomes. A unilateral left sided paravertebral block at T4–T5 levels was performed with 20 ml of bupivacaine 0.125% in ketamine 25 mg and methylprednisolone 80 mg. Sedation was achieved with midazolam 2-4 mg. Three more PVB injections were given on weekly interval with the same mixture in 40 mg of methylprednisolone. Blood pressure, ECG, and SpO2 were continuously monitored throughout the procedure and for two hours in the recovery room. There were no serious complications. The patient obtained satisfactory pain relief (VAS 3) over a 6 month follow-up period. Our report showed that weekly paravertebral injections of a mixture of bupivacaine, ketamine and methylprednisolone for 4 weeks resulted successfully in sustained pain relief for PHN.

Visualization of cardiac dipole using a current density map: detection of cardiac current undetectable by electrocardiography using magnetocardiography

A close relationship exists between electric current and the magnetic field. However, electricity and magnetism have different physical characteristics, and magnetocardiography (MCG) may provide information on cardiac current that is difficult to obtain by electrocardiography (ECG). In the present study, we investigated the issue of whether the current density map method, in which cardiac current is estimated from the magnetic gradient, facilitates the visualization of cardiac current undetectable by ECG. The subjects were 50 healthy adults (N group), 40 patients with left ventricular overloading (LVO group), 15 patients with right ventricular overloading (RVO group), 10 patients with an old inferior myocardial infarction (OMI group), and 30 patients with diabetes mellitus (DM group). MCGs were recorded with a second derivative superconducting quantum interference device (SQUID) gradiometer using liquid helium. Isopotential maps and current density maps from unipolar precordial ECG leads and MCGs, respectively, were prepared, and the cardiac electric current was examined. The current density map at the ventricular depolarization phase showed one peak of current density in the N group. However, in the OMI group, the current density map showed multiple peaks of current density areas. In the RVO group, two peaks of current densities were detected at the right superior region and left thoracic region and these two diploles appeared to be from the right and left ventricular derived cardiac currents, respectively. Moreover, there was a significant correlation between the magnitude of the current density from the right ventricle and the systolic pulmonary arterial pressure. The current density map at the ventricular repolarization phase in the N group showed only a single current source. However, abnormal current sources in the current density maps were frequently detected even in patients showing no abnormalities on isopotential maps in the LVO, DM, and OMI groups. The findings herein suggest that opposing dipoles of the ventricular depolarization and repolarization vectors were summed and evaluated as a single dipole in the electrocardiogram. However, MCG facilitated the detection of multiple dipoles because of its superior spatial resolution as well as difference in physical properties between magnetic and electrical fields. Our results suggest that MCG with a current density map is useful for detecting cardiac current undetectable by ECG in an early stage.

Upregulation of Cerebrospinal Fluid and Peripheral Prostaglandin E2 in a Rat Postoperative Pain Model

Analgesic management of postoperative pain associated with thoracic surgery remains a difficult clinical challenge. In the present study we used a thoracic muscle incision model to characterize pain-related behavior and changes in prostaglandin E2 (PGE2) in both thoracic cerebrospinal fluid (CSF) and incision site tissues. A deep muscle incision was made in the left thoracic region of rats anesthetized with isoflurane, propofol, or spinal bupivacaine. Thoracic CSF and incision site tissue concentrations of PGE2 were monitored for 6 h using microdialysis loop catheters. Postoperative pain-related behavior was assessed by recording exploratory locomotive activity. Thoracic muscle surgery decreased rearing and ambulation. Oral ketorolac or rofecoxib 3 mg/kg restored normal rearing and ambulation. Postoperative CSF PGE2 concentration increased most (threefold) with spinal anesthesia, and not at all with propofol. With surgery under isoflurane or spinal bupivacaine, presurgical oral administration of ketorolac or rofecoxib 3 mg/kg reduced postsurgical CSF PGE2 levels and tissue PGE2 levels. Intrathecal ketorolac (4 microg) reduced CSF PGE2 after surgery without affecting tissue PGE2 levels, whereas intrathecal L-745,337 (80 microg) did not reduce CSF PGE2. Thoracic surgical wounds increase pain-related behavior and CSF and tissue PGE2 levels, all of which can be attenuated by oral cyclooxygenase inhibitors.

Varicella-Zoster Virus Encephalitis in a Patient Undergoing Unrelated Cord Blood Transplantation for Myelodysplastic Syndrome-Overt Leukemia

Varicella-zoster virus (VZV) infection of the central nervous system (CNS) is rare after hematopoietic stem cell transplantation (SCT). Here, we describe the first patient who developed VZV encephalitis after cord blood transplantation (CBT). A 35-year-old man with myelodysplastic syndrome-overt leukemia underwent CBT. On day +23, a neutrophil count consistently greater than 0.5 x 10(9)/L was achieved. On day +42, 1 mg/kg per day of prednisolone therapy was initiated for grade III acute graft-versus-host disease (GVHD). Then, the dose of prednisolone was slowly reduced. For exacerbation of chronic GVHD, the dose of prednisolone was again increased to 1 mg/kg per day on day +231. On day +265, localized cutaneous zoster in the left thoracic region occurred, but soon resolved after acyclovir therapy. On day +309, he suddenly developed diplopia. Subsequently, right facial palsy and hearing impairment occurred. No skin rash was observed. Magnetic resonance imaging (MRI) scans revealed multifocal abnormal high-signal intensity in the CNS. A high level of VZV DNA was detected in a cerebrospinal fluid specimen. He was diagnosed with VZV encephalitis. Acyclovir was given intravenously for 40 days. Four months after the onset, the neurologic symptoms had incompletely resolved. MRI scans showed substantial resolution but with mild residual lesions. The present report indicates that VZV should be considered as a possible causative agent in patients who develop multifocal neurologic symptoms of the CNS after SCT.

Ex vivo evaluation of a roller screw linear muscle actuator for an implantable ventricular assist device using trained and untrained latissimus dorsi muscles.

In this study, the power output and contraction length of trained and untrained canine latissimus dorsi (LD) muscles were measured using a roller screw linear muscle actuator (RSLMA). The RSLMA consisted of a roller screw-nut assembly and translation unit to convert the linear pull force of the muscle into an axial displacement of the roller screw. When a cable wound around a spool attached at each end of the roller screw nut was pulled in either direction, the nut was rotated which in turn advanced the roller screw in the axial direction. Under anesthesia, a Telectronics myostimulator (Model 7220) was implanted in the subcutaneous area of the canine left thoracic region with its bipolar intramuscular leads implanted around the thoracodorsal nerve and the distal muscle. A total of 6 dogs went through the myostimulator implantation, followed with 8 weeks of continuous stimulation. After completion of the training, the contraction lengths of the trained and untrained LD muscles were measured, and they were 4.25 and 5.5 cm, respectively, while the instantaneous power outputs were 4.24 and 8 W, respectively. Although untrained muscles could provide much higher instantaneous power immediately following the start of the stimulation, it diminished rapidly. On the other hand, the trained muscle showed prolonged fatigue resistance. The thoracolumbar and humeral approaches in attaching the actuator cable did not show a difference with respect to muscle power output. The trained LD muscle can provide sufficient power in the range of 3-4 W to drive a left heart assist device, but its long-term evaluation awaits development of an appropriate muscle-device interface for chronic in vivo application.

Pain relief for crushed chests.

<h3>Background and Aims</h3> Post-herpetic neuralgia is a persistent pain condition that occurs after an acute vesicular rash of herpes zoster heals¹.The intense and disabling pain affect the patient‘s quality of life, his quality of sleep and his ability to perform daily activities. This report describes a treatment case of postherpetic neuralgia with ultrasound-guided PRF. <h3>Methods</h3> The case was a 56-year-old woman with a two-month history of continuous pain and burning in the anterior and left thoracic region, left arm. At her first visit, the VAS was 10/10.The patient was in lateral decubitus position on the operating table with slight hyperextension of the neck (figure 1). After preparation of the neck region, a sterile linear probe was placed transversely on the medial edge of the sternocleidomastoid muscle. In this position the body and the transverse process of C6 were identified. The probe was slid caudally to identify the transverse process of C7. Under constant ultrasound guidance and fluoroscopy, a 22 G 100 mm radiofrequency needle was introduced and advanced until it reached the anterior margin of the lungus colli muscle (figure 2). Subsequently, a thermocouple connected to a radiofrequency generator was inserted to reproduce the patient‘s paresthesia via sensitive stimulation (50 HZ), 0.7–0.9 mV. The pulsed radiofrequency treatment was performed with 1200 pulses at 42°C. <h3>Results</h3> At the end of the procedure the patient reported Vas 0. <h3>Conclusions</h3> However, further studies would be needed to assess whether the proposed technique could be considered a valid therapeutic tool for pain control.

Congenital Diaphragmatic Hernia

This case, I wish to report not as anything especially new but rather to suggest the advisability of making examinations of infants who reveal some obscure condition not diagnosable by physical examination and other methods, as used by various specialists. After reviewing literature and securing direct information from many prominent roentgenologists, we have discovered that while congenital diaphragmatic hernia is a rare condition, it is not so rare as we formerly presumed it to be. Much valuable information has been gathered over the last few years through the means of X-ray examinations, particularly during the World War. A large percentage of these hernias, however, were determined to be traumatic; but it has also been proven that congenital hernias have persisted over a long period of time, in some cases the final and ultimate conclusions of which were arrived at by the X-ray method of diagnosis. The case I here report was referred to the X-ray Department of the Wichita Hospital from the obstetrical service of Drs. John D. Clark and George A. Little. The case came without a conclusive diagnosis, but I learned afterward that a suspicion of something of the sort was the reason for suggesting this X-ray examination. Oct. 31, 1923, no history given, Baby H., 4 days old. A radiogram, No. 1, previous to barium meal, as is observed, reveals a distention of die left chest wall with many air pockets observed and extending up to the third interspace. Heart shadow pushed to the right and almost to the right chest wall. Gas also is observed in an enclosure left of the lumbar spine (stomach). Patient was placed in antero-posterior position during this exposure. With these observations in mind it was suggested to referring physician that a barium meal be administered which we hoped would prove our conclusion of diaphragmatic hernia, and also help to determine the portion of the bowel contained in the herniated region. Two days after first examination a barium mixture was given in a feeding of mother's milk and observed under the fluoroscope. (Exposure No. 2.) During this procedure we find the gastric chamber rotated forward, the lesser curvature posterior, the pylorus being obstructed from view, and barium content is observed passing into the jejunum. Baby was placed in a 45-degree angle and (No. 3) filling was revealed within a few minutes. A complete lateral view (No. 4 and then No. 5). All of this procedure extended over a period of less than one hour. Our conclusion was congenital diaphragmatic hernia with the jejunum and portions of the large bowel herniated into the left thoracic region. An autopsy a few days later proved our diagnosis. So far as we have been able to ascertain no case of congenital diaphragmatic hernia younger than seven weeks has been reported, diagnosed by X-ray or other methods. Such a case was reported by Dr. O. H. McCandless in the Journal of Radiology some four or five years ago.

A Basal-Cell Epithelioma of the Rat

The tumor to be described arose spontaneously in a young male rat, about five months old, weighing 60 grams. When first observed, it appeared as a flattened oval mass, about 2.5 by 1.5 cm. in diameter, occupying the skin of the left thoracic region, and resembled an epithelioma such as occurs frequently on the human face. At the center the tumor was ulcerated, with an uneven granular surface. The margins of skin about this were nodular, raised, thickened, and slightly undermined, and of a reddened shiny appearance which shaded rather abruptly into the normal tissues. The consistency of the mass was distinctly firm, and it was freely movable on the deeper parts. The tumor was removed by operation, and the major part of it was inoculated into 204 rats and, in two places, into its bearer. Serial paraffin sections which were made of the remaining tissue showed the following histological characteristics: The tumor was in direct connection with the skin (fig. 1) and extended into the subcutaneous tissue but not into the muscle; it was composed of rounded and irregular alveolar masses of cells having the same staining and morphological characteristics as the basal cells of the epidermis and skin appendages (fig. 2). There were all gradations from typical basal cells to those of a spindle shape. The cells were of small size, with a deeply staining nucleus and relatively small amounts of protoplasm giving the alveoli a very dark appearance. In places these cells were in strands and whorls resembling a spindle-cell sarcoma (fig. 3). Here and there, in the center of cellular areas, were glandular (fig. 4) or cystic structures filled with cell debris and lined by squamous cells in layers; there was, however, no production of keratin. The overlying skin was not abnormal except at one point where the strands of tumor cells and the basal layer of the epidermis were continuous. Staining with the Bielschowski method showed no intercellular collagen fibrils. The interalveolar connective tissue showed marked proliferation and in places resembled sarcoma. As may be seen in the photomicrographs there was an unusual amount of lymphocytic infiltration about the tumor alveoli.