Level Of Suspicion Research Articles

Acute intestinal obstruction in pregnancy after previous gastric bypass: A case report

Intestinal obstruction is an extremely rare condition among pregnant women, but it can be life-threatening for both mother and fetus. A woman in her late twenties with no history of previous pregnancies was admitted to hospital due to regular preterm contractions and cervical shortening. Seven days after her admission, while the contractions had stopped and cervical length was stable, she complained of acute abdominal pain. Bowel obstruction was suspected due to the patient's history of gastric bypass 5years earlier for weight loss. Computed tomography was not performed due to risk of fetal irradiation. Conservative management was attempted, but the patient stopped passing flatus and started vomiting. The fetus was delivered by emergency exploratory laparotomy, during which small bowel obstruction due to adhesions was identified and resolved. Although uncommon during pregnancy, small bowel obstruction is far more common in women who have had previous abdominal operations, especially involving the stomach. Obstetricians must maintain a high level of suspicion since this condition can be life-threatening for both the mother and the fetus.

Outcome of Pediatric Neuroblastoma at the Children’s Hospital and Institute of Child Health, Lahore

Objective: To demonstrate outcome of pediatric neuroblastoma at The Children’s Hospital and Institute of Child Health, Lahore. Study design: Descriptive observational study Place and duration: The study was conducted in Pediatric Hematology Oncology department, The Children’s Hospital and the Institute of Child Health, Lahore in twelve months from March 2020 to February 2021. Methodology: Study was conducted on total of 60 patients of diagnosed neuroblastoma. Main variables of study were age, parent’s education, socioeconomic status, traveling distance, LTS, and INSS stage, metastatic sites, tumor size and outcome. SPSS version 23.1 was used for data analysis. Test of significance was applied taking p value ≤0.05 as significant value. Results: Regarding histopathology, fifty eight 96% patients had neuroblastoma while 4% patients had ganglioneuroblastoma. Life threatening symptoms were present in 85% patients. Most common primary sites were suprarenal 45%, retroperitoneum 25%, pre/paravertebral 11%, posterior mediastinal 11%, others 6%. Metastasis were present in 40% patients at diagnosis and most common metastatic sites were bone marrow 21%, bone 8% and both 10%. Six(10%) patients with stage 2 showed complete remission ,2(3%) partial remission, 2(3%) patients with stage 3 achieved complete remission ,19(34%) partial remission, 4(7%) patients with stage3 expired, 18(30%) patients with stage 4 were put on palliation initially, 2(3%) patients with stage 4S showed complete remission. Conclusion: The survival outcomes of children with neuroblastoma who were treated at the children hospital lahore between march-2020 and fab-2021are compareable to those in developed and developing countries. A high level of suspicion for neuroblastoma is necessary, especially in children under five years of age with an abdominal mass. This can only be ensured through proper education of health care providers about this aggressive childhood malignancy. Advanced disease presentation is common, high-risk neuroblastoma is considered challenging and has one of the least favourable outcomes among cancers. Late diagnosis due to cultural and socioeconomic barriers and lack of care at primary care level and poor referral to oncology units owing to deficient health care system are still considered the major contributory factors for poor outcome. However, newer treatment strategies are mandated to improve outcomes in pediatric patients who are at high-risk and display relapse. Moreover, multidisciplinary approach with the establishment of infrastructure is the need of time to provide integrated care. Keywords: Neuroblastoma, Outcome, Management, Children

P43 A complicated road to diagnosis: Auto inflammatory bone disease

Introduction/BackgroundAuto inflammatory bone disorders are characterized by chronic non-infectious osteomyelitis and inflammation-induced bone resorption. It results from aberrant activation of components of the innate immune system. The auto inflammatory bone disorder includes chronic non-bacterial osteomyelitis (CNO) and its severe form chronic recurrent multifocal osteomyelitis (CRMO); synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome; Majeed syndrome; deficiency of interleukin-1 receptor antagonist (DIRA) and cherubism. The most common among this is CRMO/CNO. The disease can affect any part of the body but the metaphyseal region of the long bones, clavicle, and vertebra are the most commonly affected site.Description/MethodA 9 year old girl presented with five month history of swelling over right periocular and temporal region, associated with skin discoloration and difficulty in opening her eyes. She also reported headache more in the right frontal region. She had on and off exacerbations of skin discoloration and headaches. There was no history of fevers, weight loss, night sweats, skin lesions or arthritic symptoms. She did not have a personal or family history of inflammatory or autoimmune disorders. She is under ophthalmology elsewhere since the age of 3 months with a right divergent squint and history of right squint surgery at 6 years.Physical examination revealed swelling involving right infraorbital and temporal region, which was soft and not tender to touch with associated erythema in the same site. There were no signs of meningism or altered mental status. Musculoskeletal examination was unremarkable.Her blood test results showed mild increase in platelets (476 * 109), CRP 8mg/L, ESR (18mm/hr). IgG4 titres were mildly raised (1.16g/L). Other immunologic markers including rheumatoid factor, human leukocyte antigen B27, antinuclear antibody and anti-neutrophil cytoplasmic antibody were normal.Histopathological examination of bone and soft tissue of her right orbital rim showed low grade non-specific chronic inflammation with extensive appositional remodelling of bone suggestive of CRMO/SAPHO. No evidence of malignancy/infection.Later whole body MRI was performed to identify the extent of disease. MRI whole body was performed which showed multiple areas of bone marrow oedema and periostitis within the appendicular and axial skeleton, bilateral gluteal enthesitis and sacroilitis. There are some features that are atypical for CRMO (asymmetrical involvement, transphyseal involvement including epiphyseal involvement of the left humerus). Also noted to have right-sided periorbital oedema, oedema of the right masticator muscles and temporalis. Further planned to do dedicated MRI of left humerus with contrast.Discussion/ResultsIt can be difficult to consider what the problem is when a health care provider is presented with a group of seemingly disparate signs and symptoms with a history and time course that do not match classic (or commonly atypical) disease presentations. Common things happen commonly, so when symptoms occur without the usual co-occurring symptoms, unusual symptoms or time courses, it can be challenging.The current patient presented with periocular swelling with headache and skin discolouration. The differentials can be Langerhans cell histiocytosis, IgG4-related disease, osteoblastoma, and osteosarcoma. There were no hepatosplenomegaly, lymphadenopathy, also the mass was soft to palpate, and hence the above differentials were unlikely. Patient was initially evaluated at tertiary oncology centre and malignancy ruled out. The histopathology slides were reviewed and reported as mentioned above. In view of no skin manifestations, CRMO was the likely diagnosis considered. Hence MRI whole body performed.Barrani et al reported a similar type of unusual case of a 12-year-old girl with CRMO arising with recurrent episodes of left supraorbital headache, followed by the appearance of a periorbital dyschromia. Magnetic resonance imaging (MRI) of the skull and orbits revealed an important subacute inflammatory process. However, a few months later, the child presented a painful swelling of the left clavicle; the histological examination of the related biopsy allowed us to establish the diagnosis of CRMO.The follow up with our patient is quite a short duration and she might evolve later in the disease course giving more clarity!Key learning points/ConclusionIn evaluating a diagnostic dilemma, starting the laboratory evaluation helps to begin the process of trying to find an answer and can also help the families as “something is being done.”Chronic recurrent multifocal osteomyelitis can present with unifocal lesions, atypical locations or absence of recurrence.A high level of suspicion is paramount to avoid unnecessary biopsies and repeated antibiotic regimens.Families will often be quite concerned and support for them is also necessary and close communication and follow up is appropriate.

Epidemiologic Features and Surgical Treatment of Spontaneous Pyogenic Spondylodiscitis in Bangladesh

Background: Spontaneous pyogenic spondylodiscitis is an uncommon clinical condition. But in our country it is not infrequent. High level of clinical suspicion is necessary for diagnoses of spontaneous pyogenic spondylodiscitis. There is no study regarding this issue in Bangladesh. Objective: The objective of this study was to see the epidemiological feature and types of surgical treatment of spontaneous pyogenic spondylodiscitis in Bangladesh Materials and Methods: This is a retrospective observational study. This study was done in the Department of Neurosurgery, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh. The study period was January, 2016 to July, 2021 for a period of 5.5 years. 17 patients who were undergone surgery included in the study. The data were collected from questionnaires and hospital records and analyzed. Results: In our study the highest incidence was found in 4th (23.52%) and 6th (29.42%) decade of life which was around 53%. The male to female ratio was about 2: 1.The present study showed the most common involvement was in lumbar region (35.31%), in dorsal and sacral region it was 23.52% and the cervical region in 17.65%. Regarding surgical treatment in cervical region both anterior (with fixation) and posterior approach was done, in dorsal, lumbar and sacral region posterior approach with or without fixation was done. Conclusion: In Bangladesh the incidence of Spontaneous pyogenic spondylodiscitis is relative high. It is more common in advance age with male predominance. Most frequently affected region was lumber. Surgical technique was individualized for every case. Bang. J Neurosurgery 2022; 11(2): 64-69

Types of Fundus Involvement in Intraocular Tuberculosis.

OBJECTIVE:To evaluate the patients who were treated for intraocular tuberculosis retrospectively and present our findings and share our experience.MATERIAL AND Methods:This study was a descriptive, cross-sectional, retrospective study. Patients who were followed up with the diagnosis of intraocular tuberculosis in the Ophthalmology and Pulmonary Medicine Departments of Dokuz Eylul University Faculty of Medicine in the last 15 years and received anti-tuberculosis therapy were included.Results:A total of 16 eyes of 10 patients with a diagnosis of intraocular tuberculosis uveitis who were treated with anti-tuberculosis therapy were included in this study. The mean age was 48.1 [14.6] years (mean [standard deviation]). Four were [40%] male and 6 [60%] were female. Patients with tuberculosis uveitis had bilateral involvement (7 of 10 patients [70%]). Intraocular tuberculosis was presented in 7 eyes of 4 patients with serpiginous like choroiditis, 2 eyes of 2 patients with choroidal tuberculomas, 4 eyes of 2 patients with choroidal tubercles (miliary tuberculosis), and 3 eyes of 2 patients with intermediate uveitis. The mean duration from admission to treatment was 18.1 ± 17.4 days (range: 6-56 days). All patients in this study received a 4-drug regimen anti-tuberculosis therapy, Paradoxical reaction occurred in 30% of the patients. Eight patients had systemic steroid therapy and 4 had also topical steroid therapy. The mean length of follow-up was 14.7 months (standard deviation = 15.1, range: 6-48 months). Reactivation of intraocular tuberculosis was not observed in any patients.Conclusion:High level of suspicion is a must for diagnosing intraocular tuberculosis. A complete ophthalmic examination can be performed in patients with suspected or proven tuberculosis. Early diagnosis and prompt treatment of intraocular tuberculosis can prevent serious complications and loss of vision.

Bacteremia tuberculosis among HIV-negative children in China.

ABSTRACTImportanceBacteremia tuberculosis (TB) is a severe form of extrapulmonary TB. Studies assessing bacteremia TB in children are limited, especially for HIV‐negative children.ObjectiveTo explore the detailed clinical features of the bacteremia TB in children under 18 years of age.MethodsWe reviewed the clinical records of the patients retrospectively and collected the strains isolated from their blood cultures. We used mycobacterial interspersed repetitive‐unit‐variable‐number tandem‐repeat (MIRU‐VNTR) to characterize the bacterial genotypes and alamarBlue to determine their drug susceptibility profiles. Polymerase chain reactions and DNA sequencing were used to identify drug‐resistant mutations.ResultsThere were 13 pediatric bacteremia TB patients, 10 of whom were diagnosed with Bacillus Calmette–Guérin (BCG) bacteremia TB. Thirteen patients aged from 0.30 to 11.58 years were enrolled, of whom 76.92% were boys. All had fevers before hospitalization, and 76.92% had respiratory symptoms. All had received BCG vaccinations, and 46.15% had adverse post‐vaccination reactions. Compared with Mycobacterium tuberculosis, BCG bacteremia was more likely to appear in younger children. Patients with BCG bacteremia had primary immunodeficiency diseases, and lower CD4, IgA, and IgE levels.InterpretationBacteremia TB was rapidly fatal in a large proportion of the immunodeficient children. Because classic findings may not be diagnostically specific, a high level of clinical suspicion is required, especially for patients with certain types of immunosuppression. Studies are needed to develop rapid diagnostic tests and to determine the value of empirical therapy in childhood bacteremia TB.

P9.54: Graft Versus Host Disease Following Liver Transplantation: A Serious Complication

Introduction: Graft-versus-host-disease (GVHD) after liver transplantation (LT) is a severe complication with high mortality rate (85%). Risk factors, diagnosis and management is challenging. Donor T-lymphocytes play a main role in the immunological attack against the host. We report a case and a comprehensive review of the literature. Around 160 patients are reported in literature with an estimated incidence of 0.5 to 2% of liver transplant. Liver transplantation from hepatocellular carcinoma (HCC) and alcoholic liver disease seems to be the main prevalent diagnosis of patients who developed GVHD. Method: We present a 62-years old male patient with hepatitis C-virus (HCV) cirrhosis and successfully downstaged to Milan criteria HCC. Orthotopic liver transplantation was performed after 6 months of surveillance and discharged uneventfully after 7 days. One month later patient developed abdominal cramps, diarrhea and cutaneous erythema. Mild leukopenia with normal liver and renal function, blood and stool samples were negative, clostridium and other pathogens were also ruled out. Abdominal CT-scan showed moderate distal ileum and colon wall edema. At colonoscopy stellate ulcers was found, biopsy was taken as well to skin lesions. Colon biopsy showed acute inflammation with severe mucosal damage and apoptosis. Skin biopsy showed interphase vacuolar dermatitis. GVHD was suspected and donor lymphocyte chimerism was positive with 5%.Results: Methylprednisolone was initiated then anti-thymocyte globulin and adalimumab were added. Bacterial, viral and fungal prophylaxis were given. The patient recovered and discharged in good conditions. Five months later the patient developed acute severe pneumonia with extensive lung necrosis that required mechanical ventilation but progressed to refractory respiratory distress and the patient died after 6 months following liver transplantation. Conclusion: This is the first GVHD case after liver transplantation reported in Mexico. The diagnosis requires a high level of clinical suspicion. There is no strong consensus about the best management, but literature agrees that steroids, IL-2 antibodies, alpha-tumor necrosis factor inhibitors and antibiotics for opportunistic pathogens must be considered.

Furuncular cutaneous myiasis in Saudi Arabia

Myiasis is the infestation of a living vertebrate by a fly's larva, completing its obligate life cycle. Exposed skin remains the most affected site. The botfly, Dermatobia hominis , is the most common cause of cutaneous furuncular myiasis in tropical areas. Few cases have been reported in Saudi Arabia, mainly in the Southern region. A one-year-old medically free child presented to our pediatric surgery clinic with a painful, itchy discharging nodule on the inner aspect of his right forearm for one-week. The patient's mother and sibling had a similar former presentation after visiting Taif city. We dilated the central punctum and extracted the larva fully intact. The larva was identified morphologically as Dermatobia hominis by a parasitologist. The lesion was left to heal secondarily, which resulted in an acceptable cosmetic result and minimal scarring. Raising this clinical entity's awareness between pediatric surgeons will set aside misdiagnosis, delayed management, and possible complications. A high level of suspicion and careful history taking are required to recognize myiasis, particularly in patients with a recent history of global traveling or those with close contact with cattle.

Coexistence of pachyonychia congenita and hidradenitis suppurativa: more than a coincidence.

The coexistence of pachyonychia congenita (PC) and hidradenitis suppurativa (HS) has been described in case reports. However, the pathomechanism underlying this association and its true prevalence are unknown. To determine the genetic defect underlying the coexistence of PC and HS in a large kindred, to delineate a pathophysiological signalling defect jointly leading to both phenotypes, and to estimate the prevalence of HS in PC. We used direct sequencing and a NOTCH luciferase reporter assay to characterize the pathophysiological basis of the familial coexistence of HS and PC. A questionnaire was distributed to patients with PC registered with the International Pachyonychia Congenita Research Registry (IPCRR) to assess the prevalence of HS among patients with PC. Direct sequencing of DNA samples obtained from family members displaying both PC and HS demonstrated a missense variant (c.275A>G) in KRT17, encoding keratin 17. Abnormal NOTCH signalling has been suggested to contribute to HS pathogenesis. Accordingly, the KRT17 c.275A>G variant resulted in a significant decrease in NOTCH activity. To ascertain the clinical importance of the association of HS with PC, we distributed a questionnaire to all patients with PC registered with the IPCRR. Seventy-two of 278 responders reported HS-associated clinical features (25·9%). Disease-causing mutations in KRT17 were most prevalent among patients with a dual phenotype of PC and HS (43%). The coexistence of HS and KRT17-associated PC is more common than previously thought. Impaired NOTCH signalling as a result of KRT17 mutations may predispose patients with PC to HS. What is already known about this topic? The coexistence of pachyonychia congenita (PC) and hidradenitis suppurativa (HS) has been described in case reports. However, the pathomechanism underlying this association and its true prevalence are unknown. What does this study add? A dual phenotype consisting of PC and HS was found to be associated with a pathogenic variant in KRT17. This variant was found to affect NOTCH signalling, which has been previously implicated in HS pathogenesis. HS was found to be associated with PC in a large cohort of patients with PC, especially in patients carrying KRT17 variants, suggesting that KRT17 variants causing PC may also predispose to HS. What is the translational message? These findings suggest that patients with PC have a higher prevalence of HS than previously thought, and hence physicians should have a higher level of suspicion of HS diagnosis in patients with PC.

Early Imaging Identification of Traumatic Mesenteric and Bowel Injury: An illustrative case of bucket-handle mesenteric avulsion injury with delayed presentation as small bowel obstruction

Traumatic small bowel and mesenteric injuries (SBMI) are uncommon sequelae of blunt trauma. Imaging findings in SBMI can be subtle with varying degrees of sensitivity and specificity, requiring a high level of suspicion given the high associated morbidity and mortality. Imaging findings include seat-belt distribution subcutaneous edema, flexion-distraction fractures, free fluid without a source, asymmetric bowel wall thickening, interloop edema, bowel ischemia, pneumoperitoneum, and even delayed bowel obstruction. A specific subtype of SBMI is an avulsion injury of the small bowel mesentery, which is described as a “bucket handle” defect within surgical literature. This case report highlights the temporal evolution of imaging findings present in cases of traumatic SBMI and is illustrative of how those clinical and imaging findings can inform management decisions.

Homocystinuria presents with generalized tonic-clonic seizure and Broca's aphasia

Homocystinuria follows an autosomal recessive pattern and transpires due to Cystathionine beta-synthase enzyme deficiency. This condition is associated with thrombotic and thromboembolic complications due to an increase in homocysteine and methionine levels in the plasma and urine. We present a case of an Indian adolescent boy who presented to us with generalized tonic clinic seizure and Broca's aphasia he was diagnosed as having homocystinuria type 1, and he responded well to treatment.Background: Stroke and seizure disorders in young adults have increased substantially and are a relatively common disorder that presents in the emergency department in all age groups. Secondary seizures are more common and manifest as a result of another underlying pathology. This case demonstrates the importance of considering rarer causes of thrombosis such as arterial thrombosis, even in younger patients, with no obvious risk factors or comorbidities. A detailed medical history and thorough investigations need to be taken to identify a potentially treatable underlying cause.Objective: To increase awareness about this rare etiology and help clinicians to have a higher level of suspicion to diagnose this condition and prevent future life-threatening complications in younger patients with thrombotic and thromboembolic events.  Â

Cutaneous lymphomas in African American/Black patients: pitfalls and presentations.

This review describes and highlights differences in clinical presentations of cutaneous lymphomas (CLs), particularly in darker skin types, i.e., Skin of Color (SOC). We illustrate differences in clinical features on physical exam that can be a diagnostic challenge and suggest ways to recognize and identify these conditions at an early stage through a high level of suspicion. The review includes a summary of the epidemiology of various CLs, specifically highlighting the presentation and incidence in African American/Black patients, where the data are available. We also include a discussion of adult HTLV-1-associated T-cell leukemia/lymphoma (ATLL) which, although a systemic T-cell lymphoma, may present with skin manifestations and mimic MF, other CTCL subtypes, or other inflammatory dermatoses. Finally, this review highlights the possible use of imaging modalities, such as dermoscopy and reflectance-confocal microscopy, in diagnosing and recognizing cutaneous lymphomas in patients with darker skin types.

An interesting case of acute pancreatits

Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis but it is relatively rare and requires a high level of clinic suspicion. We report a 30 years old male with no co-morbidities who is a non-alcoholic, non-smoker presented with epigastric pain associated with vomiting for two days. His vitals were stable and systemic examination was unremarkable. Serum lipase levels were elevated [7365 U/l (<40 U/l)]. Computed Tomography of the abdomen suggested acute pancreatitis with extensive peri-pancreatic inflammatory changes with no evidence of pancreatic necrosis. Serum triglycerides were found to be elevated (3450 mg/dl). A diagnosis of HTG induced acute pancreatitis was made. During evaluation he was found to be diabetic. He was treated with intravenous fluids, IV insulin infusion, and other supportive measures. He was started on statins, fenofibrate and omega 3 fatty acids. His condition improved and triglyceride levels after two days were in a declining trend and he was discharged on the same. He was currently under follow up and his serum amylase, serum lipase, serum triglycerides were normal. This case report provides insight into rare cause of acute pancreatitis-HTG which if diagnosed at the earliest can be treated promptly.

EP-34 A rare cause of upper abdominal pain – left gastric artery trapped in gastric band

Abstract Introduction Gastric banding has become one of the most commonly performed bariatric operations worldwide. Recognised complications are divided into; the laparoscopic approach, the band or the procedure itself. Gastric band misplacement is a rare but recognised early complication. Case description A 58-year-old patient presented to a district general hospital with a 6 day history of epigastric pain, incomplete dysphagia, vomiting, and constipation. Gastric band surgery had been performed 10 years prior in a UK tertiary centre. Diagnostic workup suggested the left gastric artery was trapped in the gastric band with no features of necrosis, perforation or obstruction. The patient was referred to the upper gastrointestinal surgical team and the band was removed laparoscopically and the patient had an uneventful recovery. Discussion Symptoms of gastric band misplacement may include nausea, vomiting, dysphagia, and upper abdominal pain. It is unusual that a malpositioned gastric band resulted in symptoms over 10 years after the procedure. Radiological evidence of gastric band misplacement in the literature is only reported in 0.07% of cases in plain radiograph. Surgical technique and experience are important to prevent band slippage, especially when considering the chosen placement and securing method. Conclusion This case describes an important late rare finding of complication following gastric band surgery. Consideration should be made in management for patients with gastric band presenting with gastrointestinal symptoms and a high level of clinical suspicion is needed to investigate and manage these patients.

EP-283 A rare cause of headache – cerebral sinus venous thrombosis after COVID-19 vaccination

IntroductionCerebral sinus venous thrombosis (CSVT) is a rare complication of COVID-19 vaccination. There is an incidence of 0.55 per 100,000 person-months. We describe a case of CSVT post COVID-19 vaccine.Case descriptionA 58-year-old male presented to a district general hospital after being involved in an RTC with a 3 month history of left sided headache which had followed his first COVID-19 vaccine (AstraZeneca). No focal neurological deficits were elicited. Blood results were unremarkable. Radiological workup suggested left transverse and sigmoid sinus thrombosis with no other intracranial complications. The patient was admitted and managed with low molecular weight heparin with an uneventful recovery.DiscussionCSVT is a rare and sometimes fatal disease. An increased risk of CSVT after COVID-19 vaccination has been suggested. An underlying immunological mechanism is suspected with the involvement of platelet factor-4 (PF4) antibody. Headache is the most common presenting symptom with onset within one week of vaccination. Positive D-dimer, PF4 IgG assay and thrombocytopenia may also support the diagnosis. CSVT may progress to major complications including intracranial haemorrhage and even death. Prompt diagnosis and appropriate treatment prevents neurosurgical intervention such as decompressive craniotomy and may improve neurological outcome.ConclusionThis case describes an important and rare finding of complications following COVID-19 vaccine. Consideration should be made in management for patients with a recent history of COVID 19 vaccination presenting with features of headache. A high level of clinical suspicion is needed to investigate and manage these patients appropriately with potential CSVT.

Fat Embolism Syndrome Complicated by Acute Pulmonary Thromboembolism after Bilateral Femoral Shaft Fractures: Two Nightmares in The Same Patient

Fat embolism syndrome (FES) is an uncommon but fatal complication usually in orthopedic trauma especially after a long bone fracture. A high level of suspicion should be kept in mind when a patient of long bone fracture develops hypoxia, confusion or rash in the absence of infection and other causes of respiratory failure. Concomitant FES and pulmonary thromboembolism (PTE) is a more rarer entity in comparison to FES and pulmonary thromboembolism as separate entities. There are few cases reported in literature wherein patients developed concomitant FES and pulmonary embolism. Almost in all cases fat embolism syndrome and pulmonary embolism occurred either simultaneously or pulmonary thromboembolism was complicated by FES. We report a case wherein patient initially developed FES pre-operatively which was later on complicated by acute pulmonary thromboembolism in the post-operative period.

Pediatric Cranial Dog Bite Injuries: More than Meets the Eye.

Case PresentationA six-month-old female presented to a community hospital with small lacerations to the scalp, face, and left eyelid from a dog bite injury. Computed tomography imaging revealed an impacted right frontal bone fracture and left superior orbital fracture, prompting transfer, neurosurgical repair, and infectious disease management of the injury.DiscussionThis report highlights the importance of having a high level of suspicion for deeper injury in pediatric and especially infant craniofacial dog bites, obtaining radiographic imaging, and initiating appropriate multidisciplinary triage to prevent life-threatening infection and complications.

Surgical management of post-COVID invasive rhino-orbito-cerebral mucormycosis and its outcomes: Role of neurosurgeons in a tertiary care center

Background: Mucormycosis, which was previously considered to be rare, has emerged with a new challenge in patients infected with or recovering from COVID-19. Immunocompromised patients are particularly prone to developing this disease. The most common form of presentation is rhino-orbito-cerebral mucormycosis (ROCM). We present various neurosurgical approaches to an entire spectrum of its clinical manifestations.Methods: This is a retrospective study of patients who were admitted to the neurosurgery department with ROCM and a history of COVID-19 infection between November 1, 2020, and September 1, 2021. All cases of ROCM underwent contrast-enhanced computed tomography/magnetic resonance imaging of the brain, paranasal sinuses, and orbit. A tissue biopsy was sent for histopathological analysis. All confirmed cases received liposomal amphotericin B and surgical treatment was immediately undertaken.Results: Out of 200 patients with ROCM, 40 patients presented with neurological manifestations. Seven out of 40 patients had focal lesions in the brain and skull bone that needed neurosurgical intervention along with sinus debridement and antifungal treatment. These seven patients presented with different clinical manifestations: large-vessel stroke (one), medium-vessel stroke (one), frontal lobe abscess (one), frontal bone osteomyelitis (two), isolated central nervous system involvement (one), and mucor mimicking trigeminal schwannoma (one). The surgical intervention included decompressive craniectomy, frontal craniotomy, subtemporal craniotomy, and a minimally invasive supraorbital keyhole approach.Conclusion: In high-risk patients, a high level of clinical suspicion combined with appropriate investigations should be performed as soon as possible. Symptoms and early warning signs should not be overlooked, as treatment delays can be fatal. A minimally invasive surgical approach is possible in view of decreasing the morbidity of large craniotomy.

Evaluation of Provider Assessment of Clinical History When Using the HEART Score.

ObjectiveThe HEART Score is a clinically validated risk stratification tool for patients with chest pain. Using five parameters (History, Electrocardiogram, Age, Risk factors, and Troponin), this instrument categorizes patients as low, moderate, or high risk for major adverse cardiac events within six weeks after evaluation. Of these parameters, History is the most subjective, as providers independently assign their level of clinical suspicion. Overestimation of history, and ultimately the HEART Score, can result in increased resource utilization, expense, and patient risk. We sought to evaluate bias in provider assessment of history when determining the HEART Score.MethodsEmergency medicine (EM) and Cardiology providers received surveys with one of two versions of clinical vignettes randomized at the question level and were asked to estimate the history component of the HEART Score. Vignettes differed by age, risk factors, sex, and socioeconomic status (SES), but both versions should have received the same score for history. Statistical analysis was then used to assess differences in history assessment between vignettes.ResultsOf the 884 responses analyzed, most providers overestimated the historical portion of the HEART Score when assessing risk factors, patient distress, age, and lower SES. Many underestimated history with knowledge of a previous negative stress test. When controlling for specialty, the universal theme was overestimation by EM providers and underestimation by cardiologists. Despite the presence of hypertension, gender differences, and the appearance of mild distress, cardiologists were more likely to correctly estimate history compared to EM providers. SES consideration generally led to an underestimation of history by cardiologists. These findings were all statistically significant.ConclusionOur study demonstrates that both EM and cardiology providers overestimate history when considering prognosticators that are frequently viewed as concerning. Further education on proper usage of the HEART Score is needed for more appropriate scoring of history and improved resource allocation for hospital systems.

Gallbladder volvulus with gangrenous cholecystitis - A case report.

Introduction and importanceGallbladder torsion (volvulus) is a very rare pathology that occurs when the gallbladder rotates on the cystic duct/cystic artery axis, resulting in blockage of bile drainage and blood flow.Case presentationWe present the case of an elderly 87-year-old female who experienced acute gallbladder torsion. The patient presented with acute left chest pain that radiated to the patient's back and nausea but no emesis. A thorough physical examination, serologic studies, abdominal ultrasound, and computed tomography scan revealed gallbladder dilation, a thickened wall, enlarged common bile duct (approximately 1 cm), and the presence of pericholecystic fluid, all of which were consistent with acute cholecystitis. Laparoscopic cholecystectomy led to an intraoperative diagnosis of completely gangrenous gallbladder volvulus (GBV) with a 360-degree counter clockwise rotation. The pathology led to a final diagnosis of acute necrotizing cholecystitis without evidence of malignancy.Clinical discussionGBV (gallbladder torsion) is typically observed in elderly patients at a female-to-male ratio of 4:1 and a median age at presentation of 77 years. Few advancements have been made in accurate diagnosis of GBV using clinical findings or the results of radiographic imaging, leading to accurate preoperative diagnoses in only 25 % of patients.ConclusionThough GBV usually presents with right upper quadrant pain, our patient had the rare presentation of left sided chest pain mimicking acute coronary syndrome. GBV is an uncommon condition that occurs frequently in the elderly, particularly in women. Accurate preoperative diagnosis remains daunting, since clinical, laboratory, and radiographic findings often lead to an incorrect diagnosis of acute cholecystitis. Prompt diagnosis necessitates a high level of suspicion, and laparoscopic cholecystectomy is the recommended treatment/management.