Bone metastases from renal cell carcinoma: A case report and literature review

Management of bone metastases from Renal Cell Carcinoma (RCC) has significantly changed after the era of targeted therapy that improved the overall survival. This has sucked the different interveners in their management to push the surgical indications in order to improve outcome and quality of life for these patients. In case of a solitary metastasis or a limited number of resectable metastases wide resections have to be considered according to patient profile, comorbidities, localization, heaviness of the surgery and to benefit –risk balance. However such surgeries are highly demanding procedures that must be carefully planned and discussed in multidisciplinary team and with patient. Thus, surgical decision-making for a second metastasis and according to what criteria remains a subject of controversy. We report a case of an aggressive metastatic renal cell carcinoma with good functional and oncologic outcomes 3 years after surgery coupled with anti-angiogenic treatment. A review of the literature concerning recent attitudes in the management of bony metastatic renal carcinoma was carried out. Keywords: renal cell carcinoma; bone metastases; surgery; targeted therapy.

Acute pulmonary embolism: Tell tale signs

Acute Pulmonary embolism is one of the major preventable causes of in hospital mortality. It is commonly seen in ICU setting in chronic bed ridden patients [1]. It has wide spectrum of clinical presentation ranging from asymptomatic stage to severe hemodynamic decompensation so diagnosis requires high degree of suspicion. In majority of cases detailed history and physical examination along with ECG and 2D transthoracic echocardiography is enough the diagnosis. CT pulmonary angiography is done to confirm the diagnosis or when diagnosis is not possible by other non-invasive tests. A 45-year-old army person presented to ER with breathlessness for 3 days. There was no complaint of chest pain, giddiness, palpitation, swelling or pain of legs. Patient does not have any other comorbidities.

Breaking the dry ice: A case of accidental carbon dioxide poisoning due to dry ice inhalation

Background: Solid dry ice undergoes sublimation to gaseous carbondioxide (CO2 ) at room temperature. Symptoms of exposure include headache, dizziness, unconsciousness, seizures, even coma and death based on concentrations of CO2 inhaled. We present a case of accidental poisoning due to dry ice inhalation. Case: 35-year-old Caucasian male with a history of depression and tobacco use was brought into the emergency department after he was found unconscious in the walk-in freezer at the fast-food center he was working at. On contacting his coworkers, we were told that the walk-in freezer was out of order, and they had packed it with dry ice. On examination, the patient was tachypneic, tachycardic and was saturating at 89% on room air. Physical examination was normal. Blood work showed acute hypoxic respiratory failure with metabolic acidosis with lactic acid 13.1 mmol/l. Carboxyhemoglobin level was elevated at 5.3% (normal level and smokers 3 to 5%). The patient significantly improved with supplemental oxygen and fluid boluses and was discharged in the next 24 hours. Conclusion: Exposure to dry ice in confined spaces and warm temperatures can lead to carbon dioxide poisoning. Accurate and detailed history taking helps recognize this potentially fatal medical emergency Keywords: dry ice poisoning; carbon dioxide poisoning; accidental poisoning; inhalation toxicity.

Unilateral colonization of fungal infection presenting as renal mass in young patient: A case report

Fungal ball or fungal bezoar is the saprophytic colonization of a preformed cavity by a conglomerate of fungal mycelia without invasion of the adjacent tissue. Fungal bezoar is seen commonly in immunocompromised individuals. We present a case of urinary tract infection, complicated by unliateral fungus balls in a 25-year old female whose imaging findings (USG and CT scan), laboratory investigation and histopathological findings are consistent with renal fungal ball. Keywords: fungal ball; urinary tract infection.

Loratadine syrup is successfully used to fix Covid-19 induced respiratory distress and chest pain

COVID-19 disease is a highly transmissible viral infection caused by the SARS-CoV-2 coronavirus. This virus can cause lung damage, acute respiratory distress syndrome and death. In this case, How Covid-19 in a pregnant patient which didn’t respond well to Vancomyci + Caftazidime + Dexamethasone + Heparin for 7 days was finally responded to Loratadine syrup, and the patient was cured is going to be presented.

Saber sheath trachea: A radiological sign of severe airway obstruction

A middle-aged man, chronic smoker, presented with complaints of productive cough & exertional breathlessness (mMRC grade III) for 3 years with frequent episodes of exacerbation in the past. There was no other comorbidity or significant past history. His chest radiograph showed narrowing of trachea. Evaluation with computerized tomography of thorax showed normal extra-thoracic trachea with narrowing of the coronal diameter with increase in the sagittal diameter of the trachea along with thickening and calcification of the tracheal wall seen in saber sheath trachea. Keywords: forced expiratory volume; tracheal narrowing; saber sheath trachea.

A rare entity of malignant insulinoma diagnosed after 30 years of clinical manifestation of hypoglycemia: A case report and literature review

Malignant insulinomas, a rare life threatening pathology, exists in literature as an entity that constitutes 10% of all insulinomas and often present as multi-centric macro nodules with multiple lymph nodes or liver metastases before diagnosis. We report a rather rare case of a 68 year old male with a 30 years history of uninvestigated severe hypoglycemic attacks that improved on glucose intake. Blood tests showed a decreased value of glycemia (45 mg/dL) associated with increased insulin level (54 μU/ml) and an increased glycemia/ insulinemia ratio of 0.83 supporting the diagnosis of insulinoma. Abdominal CT showed a 4 cm mass localized in the head of the pancreas with atrophic body and tail, no signs of distant metastatic disease. A concomitant diagnosis of primary hyperparathyroidism raised, based on elevation of calcium associated and high level of PTH. The coexistence of the two endocrinopathies suggested the presence of type 1 multiple endocrine neoplasia (MEN I). Based on the workup suggesting a benign insulinoma with no signs of metastatic disease, co-existing with debilitating symptoms of hypoglycemia, pancreatectomy with lymph node dissection was performed. Histo-pathological examination returned surprisingly positive for malignant neuro-endocrine tumor with positive lymph nodes. In that domain, we summarized the literature discussion of neuroendocrine tumors, elaborating on malignant insulinoma diagnosis and management. Furthermore, what our article is trying to lay upon existing literature is a case of a long standing existent MEN 1 malignant insulinoma manifesting as a remarkably slow progressive disease of 30 years’ timeline versus a less likely chance of a transformation from benign insulinoma to malignant Keywords: neuroendocrine neoplasm; pancreatectomy; MENI; malignant insulinoma; chronic hypoglycemia.

Endocarditis following an unsuccessful attempt to remove a gastric GI stromal tumor by laparoscopic endoscopic cooperative surgery

Gastrointestinal Stromal Tumors (GIST) are the most common subepithelial lesions of the gastrointestinal tract. Treatment of lesions greater than 2 cm in diameter is by laparoscopic wedge resection. We report a 77-year-old man who was diagnosed with a 2.3 cm diameter gastric GIST. He had a thickened mitral valve, severe mitral annular calcification, mild mitral regurgitation and moderate aortic stenosis. One week after undergoing an unsuccessful attempt at Laparoscopic Endoscopic Cooperative Surgery (LECS), he was admitted with a fever of 40.2o C. Blood cultures grew Staphylococcus lugdunensis. Transthoracic and transesophageal echocardiography revealed moderate mitral regurgitation and an 8 X 5 mm vegetation on the mitral valve and posterior annulus. This is the first report of endocarditis following LECS. Physicians need to be aware of this possible complication. Keywords: endocarditis; GI stromal tumor; endocarditis; endoscopic tumor.

Vanishing hyperintensity in MRI: Vascular or epileptic origin?

Status Epilepticus and epilepsy-related MRI vanishing changes have been reported in the literature since the 1980s; hypoxia and hypoperfusion have been related to these image modifications. These alterations and their disappearing characteristics can cause trouble among work up and their diagnosis, especially if there is no exact etiology of what is causing seizures. We present a case of a 37-year-old righthanded man with a 6-year history followed up after seizure debut, with no exact etiology at the first event, considering an ischemic event as etiology. After a six-year follow-up seizure-free and no sequels, the patient newly developed aphasia, seizures, and status epilepticus, with a now evident vascular abnormality (cavernous cerebral malformation) etiology in MRI imaging. The cumbersomeness of the clinical picture in its presentation, the seriousness to which it reached, and the complete resolution of the problem with medical treatment make this clinical case especially attractive.

Intracavernosal ephedrine for management of intraoperative penile erection during urological procedure under general anesthesia

Intraoperative penile tumescence during urological procedure can occur after regional or general anesthesia. It is a rare event but can cause delay or defer of the surgery. Pathophysiology of intraoperative erection is mainly due to autonomic imbalance during anesthesia. Various physical and pharmacological management of tumescence have been tried with variable success and complication. We injected ephedrine 15 mg intracavernous resulting immediate de-tumescence and minimum complication.