Journal of Clinical Case Reports

Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of Inosine Monophosphate Dehydrogenase (IMPDH) and Methylprednisolone are seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case presentation:A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusion: In symptomatic bradycardia or asymptomatic, however, significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Rosai-Dorfman Disease (RDD) also known as Sinus Histiocytosis With Massive Lymphadenopathy (SHML) is a rare and benign non- Langerhans histiocytosis. First described in 1965 by Destombes [1] then in 1969 by Rosai and Dorfman, this disease is characterized by benign histiocytic proliferation with frequent lymphophagocytosis (emperipolesis) [2]. All ages are affected but most of the patients present before age 20, with a slight male predominance [3]. Rosai-Dorfman disease usually presents as bilateral, massive and painless cervical lymphadenopathy [2]. Extra-nodal involvement is found in 30-40% of cases and is more common in the head and neck region [3]. The disease is often benign and self limiting requiring only observation. In some cases, the condition can be severe. Several treatments have been used with varying efficiency [4]. We report a case of RDD in a male Tunisian patient treated and followed up in our department.

The incidence of adverse reaction to isoniazid was estimated to be 3.4% in a study done in more than 3000 patients treated withthis drug. The most common adverse effect being rash (2%), fever(1.2%), jaundice (0.6%) and peripheral neuritis (0.6%). If pyridoxine is not given concurrently, the incidence of peripheral neuritis (mostcommonly parasthesias of hands and feet) is the most common adverse reaction to isoniazid and occurs in about 2% of patients receiving 5 mg/kg. Higher doses may result in peripheral neuropathy in around 10-20% of the patients. The prophylactic administration of pyridoxine prevents thedevelopment not only of peripheral neuritis, but also of other neurological adverse effects. Muscle twitching, dizziness, ataxia, parasthesias, stupor and toxic encephalopathy are other manifestationsof the neurotoxicity of isoniazid.

Anorectal sepsis is classified into perianal abscess which is the most common followed by Ischio Rectal Abscess. The incidence of ischio rectal abscess located around the anal canal in relation to the line joining both the ischeal tuberosity is 53% in posterior, 35% in lateral and 12% in anterior quadrant 2.

Background: Myelomeningocele is the most common open spinal dysraphism eligible for surgical repair. Traditionally, myelomeningocele patients that received no surgical intervention had a dismal prognosis. Before 1970, 80% of untreated infants were dead at 3 months, while after 1970 more untreated children survived infancy but usually did not live past adolescence. Adult presentation of myelomeningocele is exceedingly rare. Case presentation: We present a 74 years Caucasian female was transferred to our institution for evaluation of purulent drainage around an unrepaired myelomeningocele site. Per the patients report, she was offered no surgical treatment for her myelomeningocele as a newborn, but was instead treated with percutaneous needle drainage of the lumbar fluid collection on a weekly basis for several months. Examination of her back was notable for a large 6 cm×6 cm fluid filled mass in the lumbosacral region with an abnormal epithelialized covering and purulent drainage. Her brain MRI revealed arrested hydrocephalus and a Chiari II malformation. Due to the infection, she underwent surgical correction of the myelomeningocele. At 6 month follow up she had a well healed wound and no complications from the surgery. Conclusion: The present case adds to the small body of literature describing adult presentation of spinal dysraphism. To our knowledge, this is the oldest patient to undergo primary repair of a congenital myelomeningocele. Primary repair, even in the elderly, is possible and can be done safely.

Pulmonary barotrauma (PBT) is caused by overinflation of the lungs and the intrapulmonary gas enters into the surrounding tissues and blood vessels leading to mediastinal and subcutaneous emphysema, pneumothorax and Cerebral Arterial Gas Embolism (CAGE). Due to its specific prerequisite conditions, PBT is rare in comparison with other traumas and most physicians are inexperienced in its treatment. In this report, a fatal case of PBT complicated by CAGE and pneumothorax was presented and some experiences in treatment were introduced.

A-60 years old woman has been observed in our outpatient clinic for several years. She has been uncontrolled for her asthma despite multi-drug therapy; [Fluticazone (FP) 800 μg/day+Salmeterol(SM l00 μg+Montelukast 10 mg+Theophilline 200 mg/day], presenting asthma control test (ACT) score as 13. We added Ciclesonide (CIC) to her therapy and replaced FP and SM with BFC. As a result, her pulmonary function and ACT score improved. The counts of eosinophils in induced sputum decreased significantly. Furthermore, during an observation period of 9 months, she had neither had an emergency visit nor an asthma exacerbation. While some physicians previously reported efficacy of Inhaled corticosteroids (ICS) combination therapy of FP and Beclomethasone (BDP), there are no reports concerning the efficacy and tolerability of ICS combination therapy of Budesonide/Folmoterol combination (BFC) and Ciclesonide-hydrofluoroalkane (CIC-HFA). This is the first case report of a persistent asthma patient succesfully treated by the ICS combination therapy of BFC and CIC-HFA.

Vulval growths though rare, may be a cause of social withdrawal and emotional drain, apart from causing physical signs and symptoms. Treatment is excision and removal, recurrence is rare. We present an interesting case of a large pedunculated, fibroma of the labia majora in a middle aged woman. The tumor was excised and subjected to histopathological examination which revealed it to be a Fibroma.

Herpes zoster is caused by varicella zoster virus, a DNA virus. Post herpetic neuralgia is a common complaint in patients following resolution of the rash. We present the case of a patient who was initiated on acyclovir therapy within 48 hours of onset of the rash resulting in significant improvement in pain. The case illustrates the importanceof rapid initiation of acyclovir which helps reduce the chances of post herpetic neuralgia. Narcotic analgesics may be necessary in the acute phase to control the pain