Gangrenous Cholecystitis From Gallbladder Volvulus With a Hiatal Hernia

Gallbladder volvulus is a rare condition involving the rotation of the gallbladder about the cystic duct and vascular pedicle, compromising biliary drainage and blood flow. This report describes a case of gallbladder volvulus presenting in an 88-year-old female with acute onset of right upper quadrant abdominal pain, nausea, and vomiting. Complete work-up included a physical exam, laboratory studies, and computed tomography (CT), which was notable for a markedly distended gallbladder with circumferential wall thickening, pericholecystic fluid, a 12 mm common bile duct, and a hiatal hernia. Given that her initial presentation was consistent with acute cholecystitis, we elected to perform laparoscopic cholecystectomy. The definitive diagnosis of gallbladder volvulus was made intraoperatively after decompression of the gallbladder and visualization of counterclockwise rotation of the gallbladder around the hilum and the infundibulum. This case illustrates the challenge in preoperative diagnosis of gallbladder volvulus, which requires high clinical suspicion to provide prompt surgical intervention.

The impact of polymerase chain reaction (PCR) on diagnosis and management of infectious uveitis at a tertiary care facility

Background Polymerase Chain Reaction (PCR) is a well-accepted adjunct in the management of infectious uveitis. In turn, few reports in the literature have evaluated how PCR then impacts patient care. This study aims to evaluate the impact of PCR sampling on diagnosis and treatment of infectious uveitidies at a large tertiary care facility. Main body This is a retrospective, observational study of patients with aqueous and vitreous PCR samples obtained from 2014 to 2019. The study was undertaken at a single institution. At least one follow up visit following results of PCR testing was required for inclusion. If a patient had multiple PCR samples taken, only the first sample was included. The patients were divided into three categories based on pre-sampling diagnosis. A chi-square test was used to analyze the data. 108 cases were available for analysis. PCR did not change diagnosis or management in any of the cases where pre-sampling diagnosis carried a high clinical suspicion for negative PCR. Overall, the results of PCR testing had a more significant impact on diagnosis in those cases where pre-sampling diagnosis was unknown versus those where it was confirmatory in nature, thus presumed to be related to an infectious entity tested by PCR (74% vs. 29%, p = 0.00006). The rate of treatment change based on PCR was similar between those cases where there was a high clinical suspicion for positive PCR and those where pre-sampling diagnosis was unknown (32% vs. 33%, p = 0.95). Further analyzing specimens separately depending on source of sample, this pattern persisted for aqueous samples, with PCR showing a more significant impact on diagnosis in those cases where the diagnosis was unknown versus those where sampling was confirmatory (86% vs. 31%, p = 0.00004). The rate of change in treatment between the two groups was similar (35% vs. 31%, p = 0.79). Vitreous samples followed a similar pattern with a higher rate of diagnosis change for those cases where pre-sampling diagnosis was unknown and a similar rate in treatment change between the two groups, however this did not reach statistical signifigance (44% vs. 25%, p = 0.28; 27% vs. 33%, p = 0.74). Conclusion There is no well-defined algorithm as to when to employ PCR testing in uveitis. As expected, in our experience, it has the largest impact on diagnosis when the diagnosis is unknown, however even when confirmatory in nature, it continues to impact patient management.

Newly diagnosed type 1 diabetes in a 93 year old

Type 1 diabetes is typically a disease of young but can present at any age. We present a case of a 93-year-old woman who presented with 10 days history of feeling lethargic, polydipsia and decreased appetite. Her capillary blood glucose was raised at 25 mmol/L with significant ketonaemia and venous blood gas showing metabolic acidosis. She had a background of primary hypothyroidism and vitamin B12 deficiency with weakly positive parietal cell antibodies. Laboratory investigations confirmed diabetes with HbA1c of 117 mmol/mol (12.9%). In view of high clinical suspicion of type 1 diabetes, her diabetes autoantibodies were checked which showed strongly positive anti-GAD antibody with titre of >2000 IU/mL (range<10) confirming our diagnosis. She was treated with diabetic ketoacidosis protocol with intravenous fluids and intravenous insulin. On recovery, she was discharged home on once daily insulin with aim to self-manage diabetes with support from district nurses and to avoid hypoglycaemia.

Myocarditis in a Pediatric Patient with Campylobacter Enteritis: A Case Report and Literature Review

Myocarditis represents a potential complication of various infectious and noninfectious agents and a common diagnostic challenge for clinicians. Data regarding Campylobacter-associated myocarditis are limited. Here, a case of a 13-year-old female with Campylobacter jejuni gastroenteritis complicated by myocarditis is presented, followed by a literature review in order to retrieve information about Campylobacter-associated carditis in the pediatric population. A search on MEDLINE/PubMed yielded 7relevant cases in the last 20 years. Most of them (six/seven) were males and the mean age was 16.1 years. All patients presented with gastrointestinal symptoms followed in six/seven cases by chest pain within two to seven days. Campylobacter was isolated from stool cultures in six patients; abnormal electrocardiographic findings were detected in six; and abnormal echocardiographic findings in three of the cases. Five patients were treated with antibiotics. Full recovery was the clinical outcome in six patients, whereas one patient died. Concerning the nonspecific symptoms of patients with myocarditis, high clinical suspicion of this complication is necessary in cases where patients with a recent infection present with chest pain and elevated cardiac biomarkers.

Acute Suppurative Thyroiditis Secondary to Escherichia coli Infection

Infections of the thyroid gland are rare. Its innate resistance to infections can be attributed to its unique anatomical features and rich blood supply. High clinical suspicion is required as a delay in diagnosis can lead to significant morbidity and mortality. Major pathogens include the Gram-positive Staphylococcus aureus and Streptococcus species; however, Gram-negative organisms have been found especially in immunocompromised hosts. We present a rare case of acute suppurative thyroiditis (AST) secondary to Escherichia coli (E. coli) infection in a woman known to be infected with human immunodeficiency virus (HIV).

Choriocarcinoma (stage IV) despite two normal dilation and curettages: A case report

Choriocarcinoma is a highly metastatic subtype of gestational trophoblastic neoplasia (GTN) following pregnancy. It can arise from any type of pregnancy (50% occur after term pregnancies, 25% after molar pregnancies, and 25% after early pregnancy loss and ectopic pregnancies) (Soper, 2006). This case report describes an interesting diagnostic conundrum with normal histology findings on two separate endometrial dilation and curettages (D&C) and a unilateral oophorectomy in the context of high clinical suspicion for molar pregnancy that progressed to stage IV choriocarcinoma with brain and lung metastasis. The patient presented to our hospital nearly aphasic but would only say “molar pregnancy”. Due to her brain metastasis and worsening intraparenchymal hematoma, she underwent craniotomy confirming the diagnosis. After stabilization, she was transferred to a quaternary care center to complete chemotherapy with etoposide, methotrexate, actinomycin, cyclophosphamide, and vincristine and had a good response. At this time, there is no clear explanation for normal histology on two separate D&Cs and a unilateral oophorectomy in the context of a classic case of choriocarcinoma with progression from a molar pregnancy. It reminds us as providers that medicine remains an imperfect science and requires astute clinical judgement to properly treat patients when diagnostic data such as pathology findings and lab values appear to be incongruent with the larger clinical picture.

Primary Hepatic Neuroendocrine Tumor and its Metastasis to Breast; Case Report of an Unusual Malignancy

Introduction: Neuroendocrine tumors (NETs) are rare tumors with varied clinical presentations. Entero-pancreatic and respiratory systems are usually involved but it can also affect unusual sites like the liver. Purpose: This paper presents a case of a 45 years female who developed progressive and disabling symptoms of mass effect and carcinoid but remained undiagnosed for many years due to extremely low suspicion of such a tumor in liver. Methods: Diagnosis was made after extensive radiological, histopathological, and biochemical investigations. By that time, disease had spread to her breast which is also not a typical feature of NETs. Findings: Diagnosis of rare tumors at an unusual site is challenging and requires high clinical suspicion and appropriate workup.

PRIMARY ABDOMINAL TUBERCULOSIS, 2 CASE SERIES REPORT AND LITERATURE REVIEW

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is a disease that has affected human beings since antiquity and is still a global health problem. The main site of TB is usually in the lung, from where it can spread to other parts of the body. However, it can also present in extrapulmonary forms, the most common being the abdominal. Abdominal tuberculosis is dened as an infection of the gastrointestinal tract, peritoneum, abdominal solid organs, and/or abdominal lymphatics. Because its clinical symptoms are nonspecic, the diagnosis of abdominal tuberculosis requires a high clinical suspicion, especially in the predisposed population

Limited diagnostic utility of SARS-CoV-2 serologic testing in symptomatic PCR negative patients

Background Guidelines from the CDC and the IDSA suggest the use of serologic testing to support the diagnosis of COVID-19 in individuals with high clinical suspicion that repeatedly test negative by diagnostic methods. Given that variability in specimen type, collection technique, and time from symptoms all reduce the sensitivity of molecular methods for SARS-CoV-2. The routine use of serology to diagnose and manage patients with symptoms concerning COVID-19 is tempting, despite limited studies in the literature supporting this approach. Here, we assessed the utility of serology testing for diagnosing SARs-CoV-2 in symptomatic, PCR-negative patients. Methods Remnant EDTA plasma specimens were obtained from 393 patients with clinical suspicion for COVID-19 and a negative SARs-COV-2 RNA test by the nasopharyngeal swab. The specimens were analyzed for SARs-CoV-2 IgG on an Abbott Architect i2000 (Abbott diagnostic). Patient information and symptoms adjudication were obtained from patient electronic health records. Results 14 of 393 patients were positive for antibodies to SARS-CoV-2 (seropositivity rate of 3.6%), 6 of which were from patients with previous RT-PCR-confirmed COVID-19 infection. Among patients without previously diagnosed COVID-19, the seropositivity rate in symptomatic patients was 1.2% (2/171), in patients with altered mental status was 4.3% (2/46), and in asymptomatic patients with no known previous COVID-19 diagnoses was 2.6% (4/170). The seropositivity rate among symptomatic patients presenting ≥ 14 days after symptom onset was 0% (0/67), 7-13 days was 5% (1/20), and for patients &lt; 7 days, was 2.1% (1/47). Among the 4 patients with AMS that were serologically positive, 2 were previously diagnosed by PCR. Conclusion There is a low diagnostic utility of SARS-COV-2 serological testing for identifying novel cases of acute SARS-CoV-2 infections in the ED after a negative PCR test.