Acute midgut volvulus in a septuagenarian with secondary jejunoileal diverticulitis and undiagnosed congenital malrotation: an unusual presentation

Abstract A 79-year-old male presented with abdominal pain, incidental umbilical hernia and acute midgut volvulus that was not detected until surgical exploration. When he presented to hospital, computed tomography (CT) findings indicated perforated jejunoileal diverticulitis; however, in the operating room clockwise volvulization of the jejunum and ileum, secondarily inflamed jejunoileal diverticula, incomplete malrotation (right-sided duodenojejunal flexure), right retroperitoneal adhesions (Ladd’s bands) and numerous other congenital adhesive bands were found. A modified Ladd’s procedure and umbilical hernia repair were completed including detorsion, division of Ladd’s bands with medialization of the cecum and lysis of other congenital adhesions without appendectomy. The patient recovered to baseline function by 3 weeks postoperatively. Acute midgut volvulus is a life-threatening surgical emergency that is exceptionally rare in the elderly. CT is relatively insensitive, so misdiagnosis is common. A high index of suspicion is required, especially in patients with a history of congenital gastrointestinal abnormalities. Prompt surgical exploration for correction and prevention is crucial.

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A rare acute presentation of intestinal malrotation in the elderly

International Surgery Journal ◽

10.18203/2349-2902.isj20204149 ◽

2020 ◽

Vol 7 (10) ◽

pp. 3432

Author(s):

Abidemi A. Adesuyi ◽

Oladele O. Situ ◽

Cephas S. Batta

Keyword(s):

The Elderly ◽

Intestinal Malrotation ◽

Age Group ◽

Midgut Volvulus ◽

Diagnostic Challenge ◽

Rare Presentation ◽

Diagnostic Dilemma ◽

Acute Presentation ◽

History Of ◽

High Index Of Suspicion

Intestinal malrotation, a congenital anomaly of the midgut, typically presents in pediatrics age group with the most feared complication of midgut volvulus and its catastrophic sequelae. Midgut volvulus secondary to intestinal malrotation is a rare presentation in adults more so in the elderly. Its rarity portends a diagnostic dilemma for both the surgeon and radiologist. We report a 65-year-old man admitted following a referral with a 12-hour history of acute abdomen with an initial diagnosis of acute pancreatitis but later had laparotomy with intraoperative findings of a midgut volvulus and gangrenous ileal segment secondary to intestinal malrotation. This case emphasizes the importance of early diagnosis to prevent the disastrous complication of this disease. The rarity of this condition portends a formidable diagnostic challenge in adults hence the awareness of its possibility and a high index of suspicion is crucial in diagnosis.

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Intraorbital Abscess: A Rare Cause of Orbit Compression

FACE ◽

10.1177/27325016211005062 ◽

2021 ◽

pp. 273250162110050

Author(s):

Samuel Ruiz ◽

Rizal Lim

Keyword(s):

Pediatric Population ◽

Rare Complication ◽

Disease Process ◽

Rare Condition ◽

External Drainage ◽

Direct Extension ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion ◽

Prompt Diagnosis

Introduction: Intraorbital abscess is a rare complication of rhinosinusitis that affects most commonly the pediatric population. It is thought to be caused by direct extension or venous spread of infections from contiguous sites and can lead to life-threatening complications, like permanent visual loss and cerebral abscesses. Objectives: Intraorbital abscess is a rare condition that requires prompt diagnosis and treatment to avoid serious complications. Our objectives are to provide an overview of this rare disease process and its management including our successful treatment experience. Case Description: We present a 2 case report of a 13-year-old pediatric male and a 66-year-old male with history of chronic sinusitis who presented with a right intraorbital abscess successfully treated with external drainage with decompression of the orbit. Conclusion: When intraorbital abscess is encountered, a high index of suspicion is needed to allow prompt and accurate diagnosis for this infrequent condition. Timely surgical drainage of the abscess is needed to prevent the development of fatal complications.

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The “Fountain of Death”: A Case Series on Tracheo-innominate Artery Fistula

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v20i2.727 ◽

2021 ◽

Vol 20 (2) ◽

Author(s):

Jason Lo ◽

Marina Mat Baki ◽

Yeoh Xing Yi ◽

Nik Hisyam Amirul ◽

Zahirrudin Zakaria

Keyword(s):

Potential Role ◽

Rare Complication ◽

Case Series ◽

Innominate Artery ◽

Survival Outcomes ◽

Permissive Hypotension ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion

Tracheo-innominate artery fistula (TIF) is a very rare complication related to tracheostomy and has been reported in 0.7% of patients, but certainly is one of the most life-threatening conditions. It is of paramount importance to maintain a high index of suspicion in evaluating patients with TIF and to anticipate occurrence of massive haemorrhage even during simple procedures related to tracheostomy such as tube change. We report 3 cases of TIF, each with a unique and unsuspecting history of the condition and review the emergency protocol in arresting the bleeding. We’ve also highlighted the potential role of permissive hypotension with sedation in improving survival outcomes of patients with TIF.

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Abstract 14494: Once You 1c It, You Can’t Unsee It: A Case of Flecainide Toxicity

Circulation ◽

10.1161/circ.142.suppl_3.14494 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Balint Laczay ◽

Venu Menon

Keyword(s):

Ventricular Arrhythmias ◽

Mechanical Circulatory Support ◽

Structural Heart Disease ◽

Circulatory Support ◽

Simultaneous Evaluation ◽

Life Threatening ◽

History Of ◽

Cardiac Intensive Care ◽

High Index Of Suspicion ◽

Flecainide Overdose

Introduction: Flecainide is a class 1c antiarrhythmic commonly used for the treatment of atrial and ventricular arrhythmias in the absence of underlying structural heart disease. The significant proarrhythmic effects of the drug warrant familiarity with the drug and its toxicity. Flecainide overdose, whether intentional or iatrogenic, is a life threatening emergency with mortality rates as high as 22.5%. We present a case of intentional flecainide overdose and its management. Case: A 78-year-old man with a history of heart failure, paroxysmal atrial fibrillation on flecainide, presented to a local ED after a suicide attempt. He was initially hemodynamically stable and a 12-lead EKG revealed a wide-QRS bradyarrhythmia (See figure 1). Electrolyte panel showed normal potassium and pH. During transport to our tertiary cardiac intensive care unit, the patient declined and was critically ill on arrival. The diagnosis of flecainide toxicity was suspected and therapy was initiated on arrival. Despite therapy with sodium bicarbonate and fat emulsion, the patient continued to decline. Renal replacement therapy was started and the patient was evaluated for mechanical circulatory support. Ultimately, the patient’s family elected for palliative extubation. The patient’s flecainide level returned more than four times above the therapeutic range. Discussion: This case highlights the importance of a high index of suspicion when faced with a wide-QRS arrythmia in a patient with suspected antiarrhythmic overdose. The persistence of these rhythms after correction of acid-base abnormalities and electrolyte derangements should prompt aggressive, empiric treatment of potential overdose. The presence of electromechanical dyssynchrony in this context is an ominous sign and should prompt simultaneous evaluation for biventricular mechanical circulatory support concomitant with medical therapy for suspected overdose. Figure 1

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Post-COVID rhinocerebral mucormycosis: an otolaryngologists nightmare

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20212450 ◽

2021 ◽

Vol 7 (7) ◽

pp. 1144

Author(s):

Samir V. Joshi ◽

Nimita Dubey ◽

Rajesh R. Havaldar ◽

Amish Wakhlu

Keyword(s):

Vision Loss ◽

Fungal Infections ◽

Tertiary Care ◽

Positive Outcome ◽

Rhinocerebral Mucormycosis ◽

Facial Swelling ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion

Background: Rhinocerebral mucormycosis which was considered to be a rare occurrence in the pre-COVID era is currently emerging as a life-threatening disease with seemingly poor prognosis in post COVID recovered patients. Prompt diagnosis with urgent surgical and medical management is vital to a positive outcome.Methods: A retrospective observational study and analysis was done among patients of biopsy proven mucormycosis with preceding history of COVID 19 disease between March 2021 to April 2021 in a tertiary care state run hospital at Pune coinciding with the sudden surge and second COVID 19 wave.Results: 20 0ut of 23 patients were having a history of type 2 diabetes mellitus for a mean duration of 4±3.5 years. The most common presenting complaint was unilateral facial swelling, periorbital pain, swelling and oedema in 18 out of 23 patients. All patients had COVID infection within the last one month of presentation with mean duration of 18±8.4 days. Out of 23 patients 16 survived while 19 patients had permanent vision loss and ophthalmoplegia.Conclusions: Establishing the possibility of invasive secondary fungal infections in patients with history of COVID-19 infection especially in patients with pre-existing risk factors should raise high index of suspicion. Prompt early diagnosis and treatment should be started to reduce morbidity and mortality.

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Disseminated genitourinary histoplasmosis in a patient with AIDS with negative urine antigen testing

BMJ Case Reports ◽

10.1136/bcr-2021-243375 ◽

2021 ◽

Vol 14 (11) ◽

pp. e243375

Author(s):

Candice Theodora Joseph ◽

Michael Feely ◽

Nicole Iovine

Keyword(s):

Histoplasma Capsulatum ◽

Surgical Pathology ◽

Rare Presentation ◽

Persons Living With Hiv ◽

Pathological Evaluation ◽

Threatening Condition ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion ◽

Living With Hiv

Disseminated histoplasmosis is a life-threatening condition in immunocompromised patients. The majority of healthy persons have benign disease not requiring treatment. However, in persons living with HIV, mortality is high and accurate diagnosis is paramount. We present a case of a 48-year-old HIV-positive woman who presented with haematuria and flank pain. She had a history of recurrent urinary tract infection and nephrolithiasis with obstructive hydronephrosis. During cystoscopy, a bladder lesion was found. Pathological evaluation demonstrated abundant intracellular organisms with apparent budding. Subsequent urine histoplasma antigen was negative. Given the high index of suspicion for histoplasmosis based on the surgical pathology findings and epidemiological history, the patient was started immediately on antifungal therapy. One week later, PCR results of the bladder lesion confirmed the presence of Histoplasma capsulatum. This case highlights a rare presentation of genitourinary histoplasmosis and the utility of surgical pathology evaluation and PCR for diagnosis.

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An unusual presentation of acute gastric volvulus in the elderly patient: a case report and literature review

International Surgery Journal ◽

10.18203/2349-2902.isj20203282 ◽

2020 ◽

Vol 7 (8) ◽

pp. 2796

Author(s):

Aditya Prasad Padhy ◽

Inturi Pranay ◽

Sarvesh Biradar

Keyword(s):

Gastric Volvulus ◽

Longitudinal Axis ◽

The Elderly ◽

Radiologic Diagnosis ◽

Clinical Presentations ◽

Acute Gastric Volvulus ◽

Life Threatening ◽

History Of ◽

Timely Fashion ◽

High Level

Gastric volvulus is nothing but the torsion of stomach in thoracic cavity by more than 1800 along its transverse or longitudinal axis. A very rare case occurring both in male and female. The term first described by Berti after doing an autopsy of a female, in 1886. We found a case of 65 years old male with history of dyspepsia since, 1 year with history of vomiting and pain abdomen since, 1 day. On evaluation, clinically gurgling sound heard on left side chest and with investigations like USG and CT whole abdomen, we came to know about mesentrico axial volvulus which is more common in children. Acute gastric volvulus cases have high mortality rate also requires emergency surgery. Gastric volvulus is very rare with variable and non-specific clinical presentations, hence high level of suspicion for radiologic diagnosis may require. Acute gastric volvulus is a potentially life-threatening occurrence with a good outcome when treated in a timely fashion. Chronic volvulus may be more difficult to recognize. Timely diagnosis with proper treatment can potentially decreases morbidity and mortality of the patient.

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Silent primary ovarian ectopic pregnancy following ovulation induction: diagnostic dilemma

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20213509 ◽

2021 ◽

Vol 10 (9) ◽

pp. 3654

Author(s):

Kalyani Saidhandapani ◽

Yashaswi Pandey ◽

Priya Shaunthini

Keyword(s):

Ovulation Induction ◽

Diagnostic Challenge ◽

Diagnostic Dilemma ◽

Ovarian Pregnancy ◽

Threatening Condition ◽

Reproductive Techniques ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion ◽

Urine Pregnancy Test

Early diagnosis of an ovarian pregnancy, of all the diagnoses relating to extrauterine gestations, is perhaps a diagnostic challenge faced by an obstetrician and a radiologist. About 0.5% of extrauterine implantations occur in the ovary. Recent studies have demonstrated infertility and Assisted reproductive techniques (ARTs), multiparity, use of intrauterine devices as risk factors for ovarian ectopic. Knowledge pertaining to ovulation induction and risk of ovarian ectopic is even more scant. In this article, we report a case report of ovarian pregnancy following ovulation induction with letrozole. Patient visited with history of missed menstrual period, mild abdominal pain and a weakly positive urine pregnancy test. Provisional diagnosis of right tubal ectopic was made. Diagnosis of ruptured ovarian ectopic was made on explorative laparoscopy which was later confirmed histopathologically. Patient had normal intra and post-operative course. An ovarian ectopic can present as a life-threatening condition and a high index of suspicion can prevent morbidity as well as mortality. Ovarian pregnancy in a primigravida with ovulation induction without an alarming sign, as in this case, is the rarest entity came across till date.

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Amiodarone-induced myxoedema coma as a rare differential diagnosis of consciousness disturbance

Case Reports in Internal Medicine ◽

10.5430/crim.v4n1p42 ◽

2017 ◽

Vol 4 (1) ◽

pp. 42

Author(s):

Cláudio Martins ◽

Clara Rosa ◽

Ana Paula Oliveira

Keyword(s):

Differential Diagnosis ◽

Early Recognition ◽

Hormone Replacement ◽

Previous History ◽

Amiodarone Therapy ◽

Consciousness Disturbance ◽

Rare Differential Diagnosis ◽

Life Threatening ◽

History Of ◽

High Index Of Suspicion

Myxoedema coma is an uncommon and life-threatening endocrine emergency with a high mortality rate. This entity is the extreme expression of severe hypothyroidism and the cardinal features are decreased mental status and hypothermia. Diagnosis is challenging and a high index of suspicion is crucial because it allows an early recognition of this condition and prompt initiation of supportive measures along with adequate thyroid replacement therapy. Herein, we report an extremely rare case of myxoedema coma secondary to amiodarone in a 90-year-old female with no previous history of thyroid disease, which was successfully treated with thyroid hormone replacement. Although its rarity, we emphasize that myxoedema coma should be included in the differential diagnosis of consciousness disturbances, particularly in patients under amiodarone therapy.

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Left gastric artery pseudoaneurysm as a sequelae of chronic pancreatitis: recognizing a life-threatening complication

Open Medicine ◽

10.2478/s11536-013-0302-2 ◽

2014 ◽

Vol 9 (3) ◽

pp. 370-373

Author(s):

Deepak Pattanshetty ◽

Pradeep Bhat

Keyword(s):

Abdominal Pain ◽

Chronic Pancreatitis ◽

Early Recognition ◽

Left Gastric Artery ◽

Gastric Artery ◽

Artery Pseudoaneurysm ◽

Life Threatening ◽

History Of ◽

Life Threatening Complication ◽

High Index Of Suspicion

AbstractLeft gastric artery pseudoaneurysm is a rare but important life-threatening complication of chronic pancreatitis. We report a case of a 54-year-old male with chronic pancreatitis who presented with history of severe abdominal pain. Following an initial suspicion of acute pancreatitis, a computed tomography of abdomen was obtained that showed a large left gastric artery pseudoaneurysm (4×4 cm) with circumferential thrombosis. The patient then underwent successful angiographic coiling of the aneurysm, thus preventing a potentially life-threatening hemorrhage. In conclusion, in patients with a history of chronic pancreatitis who present with abdominal pain, a high index of suspicion should be maintained for alternate causes of abdominal pain such as visceral aneurysms involving left gastric artery. Early recognition is critical and consequences of missing these lesions can be catastrophic.

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