Grand Rounds Articles

Frozen corneas in the desert: a case report

19 Jan 2012

This is a rare case of freezing of the corneas in extremely cold conditions. A large proportion of the worldsâ�� population inhabits areas where frequent exposure to subzero temperatures is common. Early recognition, appropriate referral and treatment of frozen corneas may help to minimize any potential complications that can develop later on, as well as reduce pain and suffering for the patient. A 39-year-old white man presented with a 48-h history of severe bilateral ocular pain, redness and photophobia. He denied any recollection of infection, trauma or foreign body entering the eyes, and his symptoms started after boarding a long-haul flight from Canada to the United Arab Emirates. During his stay in Canada the patient had frequently participated in winter sports, and right up until departure, had been exposed to an extremely cold outdoor environment. On examination he was found to have bilateral diffuse staining of the corneal epithelium. No other cause of such corneal injury could be found from the history or clinical examination, and his features were thought to be due to corneal freezing with subsequent thawing of tissue. He was started on intensive ocular lubricants, topical antibiotics, together with a mydriatic agent and topical non-steroidal anti-inflammatories. Subsequently his symptoms and visual acuity rapidly improved. After 1 week his unaided visual acuity was back to 6/6 and he was subsequently discharged. Freezing of the corneas is uncommon and occurs in individuals who have kept their eyes open in high-wind-chill and freezing temperatures without protective goggles. Soldiers, pilots, skiers, bicyclists, ice skaters, and snowmobilers and mountaineers are at particular risk. Treatment focuses on controlling inflammation and preventing secondary infection, and includes cycloplegia, eyelid closure with a dressing, topical lubricants, antibiotics and steroids. The prognosis is favourable provided there has been no damage deep to Bowman's layer. Severe keratitis may require lamellar and penetrating keratoplasty. Corneal freezing injuries should be kept in mind in emergency rooms particularly in areas where outside temperatures are extremely cold, and where members of the public are routinely exposed to high wind chill such as participants in winter sports and also military personnel. Educating these groups of people about potential injuries to cold is important for prevention of lasting permanent damage to the ocular structures and other tissues in the body.
by Imran Ansari and Chris Canning

Two cases of oromandibular dystonia referred as temporomandibular joint disorder

19 Jan 2012

Oromandibular dystonia is thought to originate from a dysregulation of centrally mediated movement, whereby repetitive or sustained spasms of the masticatory, facial, or lingual muscles result in involuntary, and possibly painful jaw movement. Here we present 2 unique cases of oromandibular dystonia referred as temporomandibular joint disorders.
by A. Viswanath and S.M. Gordon

Behçet disease

28 Dec 2011

In 1937, Professor Hulusi BehÃ§et, a Turkish dermatologist, described two cases of relapsing ulceration of the mouth, eye and genitalia, a triple symptom complex that now characterizes the multisystem disorder that was named after him. The periodic relapses led BehÃ§et to attribute these symptoms to a viral infection. This was subsequently found to be inaccurate and current evidence now favours a multifactorial aetiology with an immunological basis.
by S.F. Viggor, A.M. Willis and A.S.M. Jawad

A rare presentation of Beals syndrome; a newly recognized connective tissue disorder

28 Dec 2011

Beals syndrome is an autosomal-dominant connective tissue disorder, similar in many respects to Marfan syndrome, characterized by multiple flexion contractures, arachnodactyly, severe kyphoscoliosis, abnormal pinnae, and muscular hypoplasia. This relatively new syndrome contrasted with Marfan by much less incidences of eye and heart anomalies and the congenital presence of contractures. It was found by Beals and Hecht in 1972 when they identified 2 cases of Beals syndrome; it was also thought that the original case described by Marfan in 1896 was actually a case of contractural arachnodactyly rather than a case of Marfan syndrome. Beals syndrome has distinct features, however, and is caused by a mutation in the fibrillin-2 gene (FBN2) in 5q23; Marfan syndrome is caused by mutations in fibrillin-1. We present a case of a patient with Beals syndrome who presented to the emergency department with a history of fractures; and on this presentation with a fracture of the distal tibia and fibula. To our knowledge, this is not documented in the literature and is a characteristic not documented in relation to Beals syndrome.
by Phyo Kyaw, Asiri Arachchi and Abhinav Vasudevan

Synchronous abdominal tuberculosis and adenocarcinoma of the colon

9 Dec 2011

This case report describes a young man in his early 20s who was found to have synchronous adenocarcinoma of the colon and abdominal tuberculosis. This is a rare finding and it is discussed whether a dampened immune response by the cancer allowed a latent tuberculosis infection to become active or vice versa.
by E. Jane H. Turner, Kumuthan Sriskandarajah, Louis Temple and Paul X. Toomey

Constrictive pericarditis after tuberculosis in adolescence

9 Dec 2011

Constrictive pericarditis is a difficult diagnosis that requires a high degree of clinical suspicion due to unspecific signs and symptoms. We present a 73-year-old patient with symptoms of chronic heart failure. Cardiac catheterization revealed the diagnosis of constrictive pericarditis, likely as a late consequence after tuberculosis in adolescence. The patient underwent complete pericardectomy and had marked clinical improvement at follow-up. We describe the investigation and treatment options of this condition.
by Irina Kozarez, Gerhard Schuler and Steffen Desch

A rare case of double mesenteric liposarcoma

9 Dec 2011

Primary mesenteric liposarcoma is a rare malignant tumour of mesenchymal origin. Under the MeSH classification, mesenteric liposarcoma appears to be classified with retroperitoneal neoplasms. Two synchronous mesenteric liposarcomas must be very unusual. We report a rare case of double mesenteric liposarcoma in a 66-year-old female patient. She was treated with wide surgical resection alone without adjuvant chemotherapy and she recovered fully.
by Chee Ching Chan and Essam Ghareeb

Benefits of lead delivery using a guidewire in pacemaker lead insertion

9 Dec 2011

Pacemaker implantation is an established therapy for patients with sinus node disease or atrioventricular block. However, we sometimes encounter cases in which delivery of the leads is technically difficult. The buddy wire technique is known to be useful in delivering stents when difficulties are encountered due to vessel tortuosity or calcification during percutaneous coronary intervention. In this report, we present two successful cases of lead delivery using a guidewire when it was difficult to pass the pacing lead through the brachiocephalic vein due to an acute angle.
by Yoshinori Yasuoka, Yoshiki Noda, Hidenori Adachi, Tetsufumi Nakashima, Motohiro Kosugi, Ryo Araki, Takahiro Imanaka, Ryo Matsutera, Susumu Hattori, Kiyoshi Kume, Haruhiko Abe and Tatsuya Sasaki

An unusual abdominal mass in a young male

6 Dec 2011

Solitary fibrous tumour is a rare spindle cell neoplasm of uncertain histogenesis and unpredictable biological behaviour, which was first described in the pleura and subsequently in many extrapleural locations. The clinical, radiologic and histologic features of a case of pelvic extraperitoneal solitary fibrous tumour in a young male are presented.
by Samira Nikpour-Valiseh, Marcus Lim and Bijendra Patel

Bilateral quadriceps tendon rupture in a seasoned marathon runner with patellar spurs

4 Nov 2011

We present the case of a healthy seasoned marathon runner who sustained bilateral quadriceps tendon rupture following a low-energy fall. Radiographs demonstrated bilateral patellar spurs. Our case report serves to highlight the importance of maintaining a high index of clinical suspicion in patients of all ages. This is the first report of bilateral quadriceps rupture in the presence of bilateral patellar spurs.
by Angelos Assiotis, Ioannis Pengas and Krishna Vemulapalli

High-grade pleomorphic liposarcoma of the breast

17 Oct 2011

Liposarcoma is a mesenchymal neoplasm of uncertain pathogenesis. It is the second most common soft tissue sarcoma, found uncommonly in the breast, and constitutes less than 1% of all malignant breast tumors. We report a case of a 50-year-old woman with a pleomorphic type liposarcoma of the breast.
by Tiffany Whitsell, Karen Marcovis, Sandy Ruhs, Matthew Andres and Susan Beck

Medulloblastoma in a case of migraine-like headache with head tilt: a case report

17 Oct 2011

This is the case of a 7-year-old girl with a history of migraine headaches who presented with a head tilt to the left and worsening headaches. Papilloedema was found on ophthlamoscopy. She had an intermittent history of migraine-type headaches for the past year. Oral naproxen 375â��mg twice daily provided some relief of the headaches initially but they slowly worsened and head tilt appeared. A medulloblastoma was diagnosed on computed tomography and the histology was confirmed at surgical resection. There was no evidence of metastatic spread. The patient was given radiotherapy and chemotherapy and was tumor free at 6 months.
by Ayesha Younas

Inadvertent diathermy self-injury: a cautionary tale

16 Sep 2011

There are numerous reports of inadvertent injury to patients as a result of diathermy. This potential risk also applies to the surgical team. We report a case of a full thickness diathermy burn to the surgeon, occurring due to faulty diathermy forceps. Such incidents should be reported to minimize risk of injury.
by G.A.C. Wheble, F. Pakzad and J.S. Hurren

Single-stage subtotal colon resection in Chilaiditi syndrome: report of a case

16 Sep 2011

Chilaiditi syndrome is rare, often challenging to diagnose and difficult to treat. In general, patients have a long history of symptoms from early childhood. Emergency surgery is usually performed in the case of volvulus or obstruction. Detorsion, colopexy or partial colonic resection have been proposed. However, these methods may lead to a recurrence of the disease. In this article we present a patient with Chilaiditi syndrome who had a single-stage subtotal colectomy and anastomosis. A 20-year-old man was referred to hospital in February, 2004. He had a long medical history but no surgical history. Episodes with emergency visits were documented over the previous 3 years. Chilaiditi sign was seen on the upright abdominal radiograph as free air under the right diaphragm caused by the interposition of the transverse colon between the liver and the diaphragm. The patient underwent a subtotal colectomy with an anastomosis between the ascending colon and the rectum. To our knowledge, this is the only reported case of a single-stage subtotal colon resection associated with Chilaiditi syndrome.
by S.N. Potemin and S.E. Gumenyk

Does every black necrotic lesion need surgical debridement?

12 Aug 2011

A 4-year-old boy with beta-thalassemia major who underwent a successful bone marrow transplant (BMT), presented with a necrotic looking scalp lesion. Debridement was initially suggested but a punch biopsy showed Aspergillus fumigatus. Antifungal therapy was commenced and the lesion healed with minimal scarring. Invasive fungal infections are a major cause of morbidity and mortality in immune-compromised patients. Invasive aspergillosis (IA) has been on the increase since 1980. The most common manifestation of IA after BMT is invasive pulmonary aspergillosis. Primary cutaneous aspergillosis is extremely rare in the paediatric BMT population. There is scanty information regarding management of these lesions in children. Excision and skin grafting of these lesions is not the ideal treatment in the immune compromised and healing by secondary intention may leave a large scar. Suspicious skin lesions should not be subjected to immediate wide surgical debridement leaving a large uncovered area with subsequent extensive scarring and failure to respond to skin grafting.
by Mohamed Shoukry, Jose De Lafunte and Muhammad S. Choudhry

Differentiation between disorders of consciousness and disorders of movement using functional MRI

18 Jul 2011

The differential diagnosis between disorders of consciousness (DoC), on the one hand, and conditions of severe immobility with aphasia, on the other hand, is extremely difficult. A patient is described whose morphology of brain lesions permitted both kinds of disorder. A battery of functional magnetic resonance imaging (fMRI) examinations was applied indicating that severe DoC was implausible. The following clinical course confirmed this conclusion, resulting in a severe tetraparesis/aphasia, however with clear awareness. The data suggest that fMRI can be very useful in differentiating between severe motor disorders, including a locked-in syndrome, and DoC such as the vegetative state and the minimally conscious state.
by Boris Kotchoubey, Tao Yu, Alexandra Markl, Friedemann MÃ¼ller, Niels Birbaumer and Simone Lang

Amyloid light-chain amyloidosis, myeloma and autonomic neuropathy

18 Jul 2011

Systemic amyloidosis secondary to myeloma is an uncommon condition that often has an insidious onset and poses as a diagnostic challenge due to the lack of typical presenting symptoms and signs. Prompt diagnosis of amyloidosis and appropriate referral have the potential to improve outcome for these patients. Here, we report the unusual case of a man whose primary presenting complaint was of long-standing orthostatic hypotension.
by John Chan, Arvind Sangwaiya and Jayantha Arnold

Hypokalaemia in a woman with eating disorder

18 Jul 2011

Chronic hypokalaemia often remains a diagnostic challenge, especially in young women without hypertension. A concealed diuretic abuse should be suspected, especially in young women with eating disorders. This case describes a woman with chronic hypokalaemia in whom a thorough medical history and proper laboratory tests were essential to early and accurate diagnosis.
by Zachary Z. Brener, Boris Medvedovsky, James F. Winchester and Michael Bergman

Fatal very late stent thrombosis in a paclitaxel-eluting stent after treatment of gastrointestinal bleeding: a case report

18 Jul 2011

We describe a case of very late stent thrombosis (ST) in a patient presenting with hematemesis while taking aspirin and oral anticoagulation therapy (OAC). This case shows that the management of patients with an indication for OAC who undergo percutaneous coronary intervention with drug-eluting stent (DES) implantation is challenging because of the need to balance the risk of bleeding against the ongoing risk of ST. The use of DES should be discouraged in those patients because of the available treatment modalities in which major bleeding can occur. Close management between the gastroenterologist and cardiologist is advocated in patients with previous DES implantation and major gastrointestinal bleeding.
by Miranda C.A. Kramer, Marcel A. Beijk, Allard C. van der Wal and Robbert J. de Winter

Waxing and waning of joint motion

14 Jun 2011

Knee pain, stiffness and swelling are common complaints. Trauma and osteoarthritis are the most common diagnoses. However, benign and malignant tumours may also present around the knee. These tumours require characterization prior to definitive treatment. Here we describe a rare cause of knee stiffness with a popliteal mass.
by Matthew L. Broadhead, Sina Babazadeh, Miron Goldwasser and Peter F.M. Choong

Vestiphobia in a military conscript: a case report

14 Jun 2011

The case presented is a 21-year-old male conscript with vestiphobia and panic attacks triggered from donning his military vest. This case report highlights a common but largely under recognized anxiety disorder, and it is hoped to encourage improved diagnosis of patients suffering from such conditions in future.
by Jason Yongsheng Chan

Pure red cell aplasia in a patient with lupus-like disease and thymoma

14 Jun 2011

Pure red cell aplasia (PRCA) is a rare complication of autoimmune rheumatic diseases such as systemic lupus erythematosus (SLE). Thymoma occurs in 5â��13&percnt; of patients with PRCA and in 2&percnt; of patients with SLE. The simultaneous occurrence, however, of all 3 disorders is rare. We report a patient with lupus-like disease who developed PRCA in association with a thymoma and explore the management challenges that ensued.
by Satveer Mankia and Ian P. Giles

Burkitt lymphoma presenting as cardiac tamponade in a patient infected with HIV: a case report

6 Apr 2011

Febrile illness has a broad differential diagnosis, particularly among persons infected with human immunodeficiency virus (HIV). Infectious complications of immunodeficiency must always be high on this differential, but clinicians must also consider HIV-associated malignancies as an explanation for fever in this population. We present the case of a 48-year-old man with HIV initially thought to have osteomyelitis who was subsequently diagnosed with Burkitt lymphoma presenting as cardiac tamponade.
by Goldis Chami, Samantha MacLean, Evan Wood, Mark W. Hull and Christopher R. Thompson

Sensate free radial forearm flap reconstruction to the instep following recurrent plantar fibromatosis: a case report

6 Apr 2011

Plantar fibromatosis is a complex problem encountered by many surgeons in different specialties. Understanding the complexity of this debilitating disease and awareness of the concept of the reconstructive toolbox is crucial in achieving best surgical outcome. We present a case where an instep defect following an excision of recurrent plantar fibromatosis was reconstructed with a sensate free radial forearm flap. We selected this flap as it is thin and pliable therefore allowing restoration of the anatomic contour of the foot. It is relatively quick and easy to raise with a two team approach and can cover a large defect. It is also sensate hence providing protection to the foot. The use of a free radial forearm flap for instep defect has provided a good cosmetic and functional outcome in this case.
by Magelia Kitcat and Amer Durrani

Small bowel perforation: an unusual cause

26 Mar 2011

An 80-year-old lady with abdominal pain had a perforated terminal ileum at laparotomy 2 weeks after treatment for Campylobacter jejuni infective colitis. Histology of the excised bowel revealed transmucosal inflammation but no dysplasia or malignancy. Cases of bowel perforation secondary to Campylobacter are more common in children and HIV-positive individuals.
by S.S. Jassim, A. Malik and A. Aldridge

A new complication of adnexal transposition: isolated torsion of the Fallopian tube

26 Mar 2011

A woman with known adnexal transposition for carcinoma of the cervix presented with abdominopelvic pain. The previously known complications of adnexal transposition are discussed and the first description of isolated torsion of the fallopian tube is presented.
by CÃ©cile Muzelle, JÃ©rÃ´me Delotte, Babou Soilihi Karimdjee and AndrÃ© Bongain

Emphysematous pyelocystitis in a renal allograft secondary to sigmoid diverticular disease and colovesical fistula: a case report

26 Mar 2011

Pyelonephritis is a serious common complication of transplantation that can lead to either acute renal failure or graft loss. The occurrence of diverticulitis in a renal transplant recipient is a rare complication but may lead to major morbidity and mortality. The overall incidence of diverticular disease in patients over the age of 60 years is 30&percnt;. Intense immunosuppression plays a major role in the development of infection during the first 6 months after transplantation. This may take the form of emphysematous pyelonephritis due to gas-forming organisms, xanthogranulomatous nephritis and malacoplakia. The incidence of colonic perforation secondary to diverticulitis in renal transplant patients is 0.9&percnt;. Emphysematous cystitis and pyelitis affecting a renal transplant allograft is a rare but serious condition and patients with diabetes mellitus, neurogenic bladder, bladder outlet obstruction, and recurrent urinary tract infections (UTIs) are at increased risk for the disease. In this case, severe urinary sepsis culminated in disseminated intravascular coagulation involving the mesenteric vessels leading to ischaemic infarction of the midgut which proved fatal. In non-diabetic patients with pneumaturia and recurrent UTIs, inflammatory enterovesical communication should be suspected and investigation by computed tomography and the institution of appropriate treatment is indicated.
by H. Elenin, P. Brown and B. Shrestha

Treatment and follow-up using microscopy and polymerase chain reaction in East African sleeping sickness: a case report

26 Mar 2011

We report a case of East African trypanosomiasis in a 26-year-old traveler returning from Tanzania, including a series of pictures of the progression of the inoculation chancre. Trypanosoma brucei rhodesiense-specific DNA was detected in the blood until 8 days after treatment. We hypothesize that the previously observed suramin toxicity may be an immunological response to parasite debris, produced as they are killed by the treatment.
by L.M.A. Vingerhoets, M.P. Bauer, E.A. Hamminga, J.J. Verweij and L.G. Visser

Adult-onset cystic hygroma: a case report and review of management

26 Mar 2011

Cases of cystic hygroma are rare and this report highlights the need for further research into treatment options. A 24-year-old Lithuanian woman was referred for further investigation of a painless but restricting right-sided neck swelling. This case report discusses the differential diagnosis and up-to-date management of cystic hygroma in the adult.
by L. Gow, R. Gulati, A. Khan and F. Mihaimeed

Osseous pinch mechanism in traumatic rupture of aorta and the left main bronchus

25 Feb 2011

We report an unusual case of traumatic aortic rupture and lesion of the left main bronchus after blunt chest trauma in an 8-year-old otherwise healthy boy. The trauma mechanism was severe compression of the thoracic cavity underneath a heavy object without a deceleration component. The visceral lesions were disproportionally severe compared with the surface injury. This case shows the possibility of an osseous pinch after severe compression of the chest and the importance of meticulous examination and monitoring of the patient for complications afterwards.
by Maj Lesbo, Gratien Andersen, Per Hostrup Nielsen, Hans Kristian Pilegaard and Vibeke Elisabeth Hjortdal