Case Report. Cryoglobulin Hyaline-thrombi Associated Acute Jejunitis in A Patient with Type 2 Cryoglobulinemic Glomerulonephritis

Introduction/Objective Only one prior case report indicates that mixed positive cryoglobulin in serum can be associated with intestinal vasculitis (Annals of Internal Medicine, 1974). Methods/Case Report We report a 63-year old man with history of positive serum cryoglobulin and hepatitis-C 4 years ago and membranoproliferative pattern of glomerulonephritis with possible cryoglobulin type of deposits by electron microscopy on renal biopsy. After treatment, his hepatitis C became negative. But he was recently found to have monoclonal IgM-kappa and positive cryoglobulin in his serum, and the concurrent renal biopsy showed membranoproliferative pattern of glomerulopathy with many hyaline-thrombi (eosinophilic vascular occlusions with no lamination, inflammatory cells or nuclear debris) in the glomerular capillary loops (Figure, left panel). Both immunofluorescent and electron microscopy confirmed a mixed IgG polyclonal and IgM monoclonal type 2 cryglobulinemic glomerulonephritis. The patient also developed abdominal pain and underwent intestinal endoscopy with biopsy. His jejunal biopsy revealed neutrophil infiltration into glands and surface epithelium, with superficial sloughed epithelial cells, consistent with acute jejunitis with features of ischemic etiology. In addition, hyaline-thrombi were identified in the submucosal vessels with surrounding vasculitis (Figure, right panel); the central part of thrombi was morphologically similar to that found in glomerular capillary loops. Therefore, we conclude that cryoglobulin associated hyaline-thrombi were the most likely etiology to cause the acute ischemic jejunitis in this patient. Results (if a Case Study enter NA) NA Conclusion NA

Multimodal Imaging in Retinal Vascular Occlusions following Trauma – A Case of Sickle Cell Disease with Negative Sickling Test

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Trans-prosthetic recanalization of a collapsed iliac limb using the GoBack catheter: a case report

Background Recanalization of graft limb occlusion can prove challenging and the use of the GoBack crossing and reentry device may be a suitable option, especially when there is no other way to restore flow with an usual endovascular approach. The GoBack catheter is a novel device designed to enhance pushability, and to enable direction-change inside hard plaques and crossing of tough lesions, even when they involve graft fabric. Case presentation It’s reported a case of a 76-year-old male who presented with claudication, previous placement of an aorto-bi iliac graft by open surgery for a ruptured abdominal aneurysm 10 years ago that, over time, developed severe kinking on the left limb and a fabric occlusion on the right limb. After several unsuccessful attempts to cross the occlusion of the right common iliac artery, the GoBack™ was deployed to create a lumen through graft’s folds. After angioplasty and stenting a satisfactory result was achieved, restoring flowCT-scan at 1 month and duplex ultrasound (DUS) at 3 months confirmed the patency of ilio-femoral axis. Conclusions The advent of this new CTO crossing device has the potential to facilitate recanalization of some of the most challenging occlusions. Facilitating more consistent distal entry and allowing for a decrease in crossing time. Therefore, the GoBack catheter should be considered as a potential complementary tool to treat vascular occlusions via endovascular approaches, especially when classical endovascular techniques fail.

Bleeding Disorders in Primary Fibrinolysis

Fibrinolysis is a complex enzymatic process aimed at dissolving blood clots to prevent vascular occlusions. The fibrinolytic system is composed of a number of cofactors that, by regulating fibrin degradation, maintain the hemostatic balance. A dysregulation of fibrinolysis is associated with various pathological processes that result, depending on the type of abnormality, in prothrombotic or hemorrhagic states. This narrative review is focused on the congenital and acquired disorders of primary fibrinolysis in both adults and children characterized by a hyperfibrinolytic state with a bleeding phenotype.

An Unusual Case of Concurrent Central Retinal Vein and Cilioretinal Artery Occlusion in a Healthy Patient

It is rare for young, healthy patients to have retinal venous or arterial occlusions and even rarer for both to occur in concert. Such an occurrence should prompt a rapid and extensive workup to prevent further complications. We present our patient, a 37-year-old Lebanese male, who reported a 3-day history of blurring of vision in his left eye. He had no medical or ocular history and is a nonsmoker. Examination of the left fundus revealed inferior macular edema and retinal whitening associated with tortuous retinal veins. He was diagnosed with a combined central retinal vein and cilioretinal artery occlusion. Emergency treatment was done for an acute arterial occlusion. Embolic and thrombotic causes were excluded with investigations. The only positive result was homozygosity for 677C>T mutation of the 5,10 methylenetetrahydrofolate reductase (MTHFR) enzyme gene. MTHFR enzyme breaks down homocysteine, which is atherogenic and prothrombotic. This mutation can lead to a prothrombotic state, precipitating this occurrence. In fact, the Lebanese population is known to have the highest incidence of such mutations, but there are surprisingly few reports on retinal vascular occlusions attributed to this. He was promptly treated with antiplatelet therapy, possibly preventing a full-blown central retinal vein occlusion. After 4 weeks, his vision improved to 6/6 bilaterally. Examination showed less tortuous veins, no more retinal whitening, resolution of macula edema and visual field defect. Hyperhomocysteinemia can be significant in patients without ischemic risk factors. It is vital to manage these patients promptly, preventing future sight and life-threatening events.

Globe Perforation During Peribulbar Anesthesia: Experience of Half a Million Consecutive Injections

Aim: To evaluate the risk factors, clinical presentation, management and outcome of inadvertent globe perforation during peribulbar anaesthesia.Methods: This retrospective study evaluated the medical records of all the patients treated for globe perforation secondary to peribulbar block preceding ocular surgery from 2012 to 2020. The patients were divided into three groups; Group 1 - clear media with no retinal detachment (RD); group 2 - vitreous hemorrhage (VH) without RD; and group 3 - RD with/without VH.Results: Twenty-five patients (25 eyes) were identified. The incidence of globe perforation was 0.002 %. The mean axial length (AL) was 24.7±2.7mm (Range, 20.9-31.2mm). Eleven eyes (45.8%) had AL≥24mm. The most common presenting features were VH (n=14), ocular hypotony (n=7) and RD (n=7). The treatment included laser photocoagulation for the retinal break(s) (n=7) and vitrectomy (n=17). Retinal breaks were identified in all the patients (total breaks, 37). Other complications included full-thickness macular hole (n=5), subretinal haemorrhage (n=4) and retinal vascular occlusions (n=4). Mean presenting best-corrected visual acuity (BCVA) in group 1,2 and 3 were logMAR 0.79±0.73, 1.82±0.78 and 2.13±0.59 respectively. All the patients, except one who did not undergo surgery due to advanced proliferative vitreoretinopathy, had an attached retina at the time of last follow-up. The mean final BCVA was logMAR 0.59±0.79, 0.48±0.26 and 1.25±0.64 respectively. Conclusion: Early intervention can help manage the eyes with inadvertent perforation successfully. The presence of retinal detachment, as well as macular and vascular complications are risk factors for poor prognosis.