Mani Khorsand Askari, Basil Akpunonu, Margaret Hoogland and Hoda Shabpiray
Background: Rhabdomyolysis is a syndrome of muscle breakdown with the release of intramuscular components intothe bloodstream. It has various causes, and recognizing rare causes is of utmost importance.
Methods: We completed three searches in the PubMed (Medline) database for articles on Rhabdomyolysis. Specifically, each retrieved article included Rhabdomyolysis, and one of the following terms appeared in both the title and the abstract: atypical presentations, diagnosis, barriers, and challenges.
Discussion: COVID-19 infection-induced Rhabdomyolysis is an initial or late presentation of the disease recognized during the pandemic. Viral illness-induced Isolated myositis can cause severe Rhabdomyolysis. Myositis secondary to Crohn’s disease can manifest as Rhabdomyolysis despite being a rare presentation. Baking Soda-induced severe hypokalemia is recognized as a cause of Rhabdomyolysis. Eating Quail as the cause should be thought of in the proper context. The proposed additional treatment for rhabdomyolysis, especially in recurrent forms, can consist of corticosteroids, which need further investigation.
Conclusion: It is of great importance for clinicians to recognize uncommon causes and presentations of Rhabdomyolysis tostart treatment earlier in the hope of curbing the dreaded complications like AKI. Newer additional therapies should be investigated.
Liyi Hu
Background: In the USA, there are approximately 17,730 new cases of Spinal Cord Injury (SCI) each year. Recent research highlights Spinal Cord Stimulation (SCS) as a promising avenue for functional recovery in chronic SCI patients. SCS complements intensive motor training, potentially enhancing spinal circuitry, particularly in cases of incomplete SCI. We describe the case of mild gain of function as a result of SCS in the setting of incomplete cervical SCI. Case Presentation: A 60-year-old patient with a history of traumatic SCI with C5 Asia Impairment Scale (AIS) grade D presented to the clinic with chronic right upper extremity pain, numbness and spasticity. On physical exam, the patient had significant right-sided upper extremity flexor tone with limited extension of the elbow. After a review of treatment options, the patient elected to trial a SCS. The SCS 8-contact leads were placed in the cervical region covering C3-C5 and the thoracic region covering T9-T11. The trial provided a 70% reduction in the patient’s neuropathic pain, leading to permanent implantation of the neurostimulation device. At two weeks post-op, the patient reported a 100% improvement in the right upper extremity pain and an additional 60% improvement in right arm spasticity. After multiple programming adjustments, the patient regained significant function of the right elbow extensor mechanism, improving their overall function and quality of life. Conclusion: Spinal cord stimulation is a promising treatment modality that can improve spasticity and motor function after spinal cord injury.
Boccardo Francesco*, Pozzo Silvia and Dessalvi Sara
Rauno J Harvima*, David E. Laaksonen, Minna Lonka and Ilkka T. Harvima
Isotretinoin has been used in the treatment of acne for decades.We report a young male at 17 years of age who developed gynecomastia after using isotretinoin after 2.5 months at dose of 20 mg bid. It resolved within 1.5 months after stopping isotretinoin.
Sriram Shanmugam, Anjana V Dinesh and Krishna Shankar G
Pyoderma gangrenous is a rare, distinctive cutaneous ulceration which is usually idiopathic but may be associated with many systemic diseases. Currently many aspects of the underlying pathophysiology are not well understood and the etiology still remains unknown. The multiple clinical variants (classic ulcerative, pustular, bullous and superficial granulomatous) makes the diagnosis even more difficult and treating the condition is challenging as there is no clinically accepted gold standard available. Here we present the case of an unusual association of Pyoderma gangrenous and cyclical Cushing’s syndrome in a 35 year old morbidly obese female patient admitted with symptoms of breathing difficulty and bilateral all limb blisters. Her past medication history included Tab. Hydrocortisone 10 mg OD and Tab. Ketoconazole 200 mg BD. On laboratory investigation abnormal parameters found were-Haemoglobin (6.5 g/dl), vitamin D (<8.00 ng/ml), ionized calcium (3.6 mg/dl), plasma urea (53 mg/dl), AST (69 U/L), GGT (118 U/L) and serum cortisol (1.43 mcg/dl). Antibiotic therapy with injection piperacillin/tazobactam 4.5 g 3 times a day was continued for 13 days and was changed to injection meropenem 1 g 3 times a day for the next 6 days. The patient was administered with injection hydrocortisone 50 mg 4 times a day, Colchicine 0.5 g 2 times a day, Ketoconazole 200 mg 2 times a day and injection enoxaparin 60 mg/0.6 ml once daily throughout the course of stay in hospital.
Sajad Wani
Anaemia is a condition of multifactorial basis that affects about 25% of world population. Sudden loss of 50% of blood leads to death due to hypovolemic shock, but chronic longstanding non-significant bleeding without rapid decrease in haemoglobin level can be tolerated and compensated for a very long period. In this case report we present a 40-year-old fully conscious female with abdominal pain which was manifested with haemoglobin level of 1.8 g/dl.
Raghad Aljishi
Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly characterized by triad of uterus didelphys, obstructed hemi vagina, and ipsilateral renal agenesis. The most common presentation is abdominal pain, dysmenorrhea, and abdominal mass secondary to hemi-hematometrocolpos. We report an emergency presentation of this syndrome during the pandemic of COVID-19 in Qatif Central Hospital, Saudi Arabia, April 2020. An 11-year-old Saudi girl presented to the emergency room with three months history of cyclical lower abdominal pain. The pain was progressive, continuous and not relieved by analgesics. Abdominal examination revealed a tender abdominal mass mainly in the left iliac fossa, Ultrasound evaluation showed two uterine bodies. The left uterus was distended with complex fluid. Pelvic MRI findings consistent with Herlyn-Werner-Wunderlich (HWW) syndrome were found with uterine didelphys and left sidedhematometra resulting from obstructed Hemi-vagina and ipsilateral agenesis of the left kidney. Resection of the vaginal septum and drainage of hematometra was done. The patient recovered with normal cyclical menstruation. Cyclical or continuous lower abdominal pain with or without amenorrhea is the usual presentation of HWW syndrome during adolescence. Diagnosis is made by ultrasonography and MRI. Early diagnosis and accurate management can provide pain relief, prevent future complications, and preserve fertility.
Armand Kamga Talom*, Florent Fouelifack Ymele, Edmond Mesumbe Nzene, Jeanne Fouedjio, Pascal Foumane
Objectives: The objective of this work was to determine the epidemiological, clinical and prognostic aspects of maternal mortality (MM) in the city of Yaounde. Methods: We conducted a descriptive cross-sectional study with retrospective data collection of maternal deaths according to the World Health Organization (WHO) definition, from January 1, 2017 to December 31, 2019, in two tertiary centers of Yaounde: The Yaounde Gyneco-Obstetric and Pediatric Hospital (YGOPH) and the Yaounde Central Hospital (YCH). Results: During the study period, 208 maternal deaths were identified, with 4/5 (78.4%) from referred cases. The MM ratio was 1532.8 per 100,000 live births (LB) vs. 609.5 per 100,000 live births at YCH and YGOPH respectively. The Main causes where hemorrhage (49%) followed by hypertensive diseases and their complications (21.2%), maternal mortality was associated with 50% of cases of foetal or neonatal deaths (57.4% in YCH vs 28.3% in YGOPH, P < 0.001). Health service systems were related to MM. Conclusion: Our study shows a large increase in maternal mortality ratios in YCH and YGOPH maternities since 2017. The main causes of MM found were hemorrhage followed by hypertensive diseases. These causes can be prevented. Our health systems should be improved if we want to significantly reduce the maternal mortality ratio
Kavya
Gonadal dysgenesis refers to various clinical conditions in which abnormal development of the fetal gonad is present. It consists of 46 XY gonadal dysgenesis, mixed gonadal dysgenesis, and 45 X turner syndrome. Mixed gonadal dysgenesis is a condition of unusual and asymmetrical gonadal development leading to unassigned sex differentiation. A number of differences have been reported in the karyotype, most commonly a mosaicism 45 X / 46 XY.1 We herein report an interesting and rare case of mixed gonadal dysgenesis in a 23-year-old nulliparous unmarried woman. Case: A 23-year-old nulliparous unmarried woman with primary amenorrhea with short stature, webbed neck, breast developed according to Tanner’s stage was presented to our clinic. She had normal external genitalia with axillary and absence of pubic hair. The evaluation of her uterus on ultrasound revealed a hypoplastic uterus measuring 2.6 x 1.4 x 0.9 cm with poorly formed endometrium and myometrium with bilateral ovaries being small and hypoplastic. Her follicle-stimulating hormone (FSH), testosterone, luteinizing hormone, and anti-mulleins hormone levels was 120 IU/L, 15 ng/dL, 24.5 IU/L and 0.02 ng/Ml respectively. Karyotype test showed mosaicism mixed gonadal dysgenesis, i.e., 45 X0 and 46 XY. She underwent laparoscopic bilateral salpingectomy (gonadectomy and salpingectomy).The postoperative period was uneventful. Intraoperatively streak gonads with elongated tubes were visualized. An infantile uterus with no pelvic abnormality was also observed intraoperatively. The histopathology report showed a cut dissection of ovaries. Discussion: Mixed gonadal dysgenesis (MCG) is a rare intersexual disorder, characterized by the presence of a testis and a contralateral streak gonad; in some cases the contralateral gonad may be rudimentary not having differentiated into an ovary or into a testis and in other cases it may be absent. On evaluation of 23-year-old nulliparous unmarried women’s uterus on ultrasound revealed a hypoplastic uterus measuring 2.6 x 1.4 x 0.9 cm with poorly formed endometrium and myometrium with bilateral ovaries being small and hypoplastic. Karyotype investigation revealed mosaicism mixed gonadal dysgenesis, i.e., 45 X0 and 46 XY. Johansen and coworkers reported structural rearrangement of the Y chromosome in 63% of mixed gonadal dysgenesis patients.2,3 Arora R et al reported that in 16-year-old person, karyotype analysis revealed 46XY karyotype and diagnosed with 46XY mixed gonadal dysgenesis.4 With this study, treatment recommended was laparoscopic bilateral salpingectomy (gonadectomy and salpingectomy). Sheela S et al also found similar kind of presentation where right sided gonads and adjacent tubal structures were visualized laparoscopically and performed gonadectomy.5 Similarly, Yadav P et al reported right streak ovary, left sided fallopian tube and streak ovary were noted in exploratory laparoscopy and later it was excised by doing gonadectomy.6. Conclusion: Gonadectomy was done as a prophylaxis measure in a 23-year-old nulliparous unmarried woman presented with gonadoblastoma or dysgerminoma. It was learned from the experience of the present study that patients with mixed gonadal dysgenesis have a different presentation and variant of chromosomal abnormalities. A multidisciplinary approach is essential for early diagnosis and proper management of patients diagnosed with rare mixed gonadal dysgenesis in order to prevent mental and social sequels
Hawa Obeid
Background: Diagnosis of ectopic pregnancy prior to rupture is an arduous task even with the availability of many new investigative methods and imaging modalities. Above all, a high index of suspicion is necessary when dealing with woman who present in early pregnancy with abdominal pain and vaginal bleeding. The use of transvaginal ultrasonography (TVS) will help in earlier diagnosis because of it is advantages over transabdominal ultrasosnography (TAS). Case presentation: A 36 years old woman, G2P0+1 presented at POA of 5 weeks and 5 days with history of an acute abdominal pain for 3 days’ duration and PV bleeding for 1 day. She has a history of primary infertility due to female factors and a laparoscopic ovarian drilling was performed 5 years back. A 2cm uterine fibroid was also noted during that laparoscopy. Subsequently, 3 IUI were performed the following two years but all were failed. She was also diagnosed with Diabetes Mellites one month ago and it is currently well controlled with diet, Metformin and Glibencarmide. Upon examination, she had tenderness of left iliac fossa. There was no palpable abdominal mass. A transvaginal scan done and revealed an empty uterus, no free fluid, no adnexal mass, complex mass at Pouch of Douglas size of 3.3?3.6cm. On review the next day, transvaginal scan repeated with finding of right ovarian cyst with solid cystic component and left adnexal mass size of 3.5?3.5cm. An laparpscopic was done, with operative finding of left tubal pregnancy over the lenght of fallopian tube (4?2cm), left fimbriae cyst of 1?1cm, subserosal fibroid at fundus (8?5cm) and intramural fibroid (3?3cm), right paratubal cyst (3?1cm) containing strawed coloured fluid, minimal adhesion seen over right pelvic wall with bowel, both ovaries were normal, bowel and liver were normal. A left sulphingectomy was carried out. Postoperative period was uneventful. Conclusion: Ectopic pregnancy carries a high morbidity and mortality partly due to the difficulty in establishing and early diagnosis prior to the rupture of the ectopic gestation. A high index of suspicion is necessary. With the recent advances in ultrasonography particularly transvaginal sonogram, diagnosis is made easier and more accurate.
Kristyna Helenicka
It is well known that the incidence of Adenomyosis and uterine fibroids increases significantly with age. In times when the first pregnancy is postponed into the fourth or even fifth decade, there is a growing demand for fertility saving procedures for these uterine diseases. To date, the literature contains a limited number of reports describing the reproductive outcomes of patients after adenomyomectomy for severe diffuse adenomyosis, and no report has compared the reproductive, obstetrical, and surgical outcomesbetween the two different uterus-sparing surgical procedures, namely, adenomyomectomy and intramural myomectomy. Therefore,we have tried to investigate it. Two groups of women who underwent different fertility-saving procedures were compared. Thepregnancy and delivery rates were 52.0% and 43.5%, respectively, in adenomyosis group versus 96.0% and 70.8%, respectively, infibroid group, with no significant differences between the two groups, except for pregnancy rate. The perinatal outcomes of the groupswere also comparable, including the low frequency of severe peripartum complications, such as the abruption or abnormal invasion ofthe placenta. The pregnancy rate was significantly lower in the group with severe form of adenomyosis. It appears, that the severity ofthe disease and the extent of the surgical resection of the uterus may influence the likelihood of a successful gestation. The clinicaloutcomes of women after cytoreductive resection of adenomyosis seems to be comparable with the different types of fertility sparingsurgery on uterine muscularity, namely myomectomy. Despite the technical challenges resulting in longer operation times and a higheconversion rate in comparison witmyomectomy, cytoreductive resection of adenomyosis seems to be feasible option for women withsevere adenomyosis and reproductive plans.
Evgeniya V Kirakosyan*, Tatyana A. Nazarenko, Stanislav V. Pavlovich
Introduction: The continuous development of assisted reproductive technologies (ART) has led to the fact that now all forms of male and female infertility have been overcome, however, the effectiveness of using ART methods remains limited and is considered to be approximately 30%. Why is this so? Purpose: Determine the possible role of genetic, immunological causes, disorders of intra-ovarian steroid?- and folliculogenesis, leading to the formation of an oocyte defect, mitochondrial dysfunction, which, in turn, can contribute to the disruption of early embryogenesis. Materials and methods: The review of world literature was conducted in the databases Scopus, Web of Science, MedLine, Cochrane CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), EMBASE, Global Health, CyberLeninka, RSCI for a comprehensive study of the contribution of various factors to the development of reproductive system disorders. Results: The findings are promising, but further research is needed to study the etiopathogenesis of reproductive system disorders in order to optimize the algorithm of diagnosis and treatment. Particular attention is paid to the most demonstrative clinical model of reproductive system disorders – infertility of unknown origin when the reproductive system appears anatomically and functionally normal, but conception does not occur. Conclusion: We present the algorithm that is currently relevant from a clinical point of view for the diagnosis and treatment of patients with infertility of unknown origin.
Deresse Daka
Aquatic environments close to cities are frequently used as sources for water and at the same time overloaded with a variety of pollutants either through direct or indirect discharges of untreated wastes and sew¬age. This condition is also worsened by the indiscriminate disposal of untreated wastes and sewage vigorously into used water. Sewage contaminated waters are known to carry microorganisms, some of which are pathogenic to humans. The aim of this study was to assess the extent of temporal and spatial levels of microbial pollution and sources of pollution in Lake Hawassa. A cross-sectional study was conducted at Lake Hawassa, which was sampled twice during 2017. A total of 26 samples of lake water were collected from 14 stations using a boat. Entry points of incoming streams, waste receiving sites, and areas upstream of anthropogenic impact, recreational and bathing sites were considered. Microbiological characterisation was performed using selective media and basic biochemical tests. Antibiotic sensitivity was tested with different antibiotics using the Kirby-Bauer agar disk diffusion method. All samples were positive for pathogenic bacteria, including Gram-positive and Gram-negative bacteria. Enterobacteriaceae were the most common bacteria identified from the samples, including Escherichia coli, Salmonella spp, Shigella spp, Proteus spp and Gram-positive bacteria, such as Staphylococcus aureus. The pre¬dominant bacteria found in the samples include E. coli, which constituted 22/26 (84.6%) of the total samples, followed by Salmonella and Shigella spp. All bacterial isolates were resistant to penicillin and ampicillin. The Salmonella spp were sensitive only to norfloxacin and gentamicin. A spatial variation with the occurrence of bacterial isolates has been observed. High concentrations and many different species were found in areas of human activities and in areas receiving direct pollutants from the city. This study revealed that multidrug resistant (MDR) pathogenic bacteria are found in Lake Hawassa. There is a possibility of outbreak of diseases associated with the isolated antibiotic-resistant pathogens for which the antibiotic resistance genes are transportable within aquatic bacterial communities. We recommend that the city administration take care of the municipal wastewater or effluents from healthcare facilities that enter the lake. It is also recommended that the government take steps to control anthropogenic activities near the water body.
Han Yu*, Lian Hu
Gastrointestinal glomus tumors are rare and almost always occur in the stomach. Up to now, only a very few cases have been reported in small intestine. Here, we present the ninth case of small intestinal glomus tumor in English literature. The 30-year-old female was referred to our hospital with chief complaints of melena and fatigue. Oral balloon-assisted enteroscopy revealed a 2.0*2.0 cm mass in the jejunum. Partial enterectomy was then performed and postoperative pathology reported a benign glomus tumor. No further melena was observed and also no malignant transformation or recurrence was detected after surgery. In conclusion, together with the literature review, small intestinal glomus tumor is an extremely rare cause of gastrointestinal hemorrhage. Early diagnosis and treatment are important to improve the prognosis since the potential risk of malignancy.
In late December 2020, vaccination for the coronavirus disease 2019 (COVID-19) started among the personnel of the United States Forces Korea and related units, including the medical team. Because its usage was approved based on emergency circumstances, sufficient research on the possible side effects has not been conducted yet. We experienced an unusual neurologic side effect after injection of the SARS-CoV-2 mRNA-1273 vaccine. A 32-year-old U.S Army male soldier with headache, blurred vision, and cramping chest pain after second-dose injection visited the emergency room. Subsequently, left-sided weakness developed during the observation. Imaging of the cervical lesion for the diagnosis of acute intracranial disease was performed but revealed no definite disease. While under close observation, the patient’s symptoms progressed to nearly hemiplegic but then improved gradually in an ascending and peripheral-to-center manner with only supportive care. We report this case as the first unilateral neurologic side effect of the SARS-CoV-2 mRNA-1273 vaccine.
Rahaf Alhabbab*
Ossifying fasciitis is a very rare benign tumor of reactive character that can mimic malignant lesions, especially osteosarcoma. We report a
case of a 19-months-old boy, who experienced a rapidly growing hard painless swelling at the right side of the mandible. Resection of the
mass, and a detailed correlation with a clinicopathological and radiological analysis led to the final diagnosis of ossifying fasciitis of the
submandibular region at the lower boarder of the mandible.
Gideon K. Kurigamba*, Vivian V. Akello, Asaph Owamukama, Irene Nanyanga
Juvenile polyps may also present with prolapse of the polyp from the anus, abdominal pain due to intussusception or may even be asymptomatic. All such polyps should be removed by colonoscopy or transanal resection.
Objective: To share the experience of Juvenile polyposis, at Bwindi community hospital Uganda.
Design and methods: These are case reports of two children second degree relatives, who presented with recurrent rectal bleeding for 4 months after every passage of stool, with prolapse of a mass and were managed at Bwindi community hospital
Results: These patients were all admitted for a total of two days in Hospital. Average hemoglobin was 11.5 mg/dl. Both had a preoperative colonoscopy that revealed a solitary polyp in the rectal canal. They both underwent Examination Under Anesthesia (EUA) and transanal polypectomy.
Conclusion: Juvenile Polyps (JP) are rare, but a key cause of rectal bleeding in children and in low resource settings, transanal polypectomy remains the treatment of choice.
Osamah Tahir Muslim* and Hasan Osamah Al-Obaidi
Background: Colonoscopy is considered to be the procedure of choice for both the diagnosis and treatment of large bowel diseases. Inspection of the whole colonic and distal portion of terminal ilial mucosa is usually feasible during colonoscopy.Colonoscopy is the best diagnostic tool to evaluate the large intestine and distal Ilium in patients complaining from bowel symptoms, anemia resulting from malabsorption, those with radiographic abnormalities of the colon, screening for colorectal carcinoma, after both polypectomy and cancer resection surveillance, surveillance in Ulcerative Colitis, and in those with suspicion of neoplastic masses. Quality examination of large bowel includes intubation of the whole colon and a thorough mucosal visualization. The investigators demonstrate that terminal ilium intubation is possible in endoscopy practice and at many times yields additional clinical details. Furthermore, it may be used as an indicator of colonoscopy completion.
Objectives: Is to estimate the rate of Cecal and Ilial Intubation in by a single well trained endoscopist as quality Indicator of colonoscopy and compare it with the same rates of heterogeneous group of endoscopists.
Patients and Method: This is a retrospective comparative study that estimate the rate of Cecal and Ilial Intubation in a Private Endoscopy Center in which all endoscopic procedures conducted by a single endoscopist who has fellowship in gastroenterology and compare it with the rates of a governmental center in which colonoscopy is done by five endoscopists including general surgeons, general physicians and trained in endoscopy as well as gastroenterologists who has gastroenterology fellowship. The study population included (442 patients); 245 males (55.42%) and 197 females (44.58%); ranging from 14 up to 85 years age.
Results: Overall Cecal and Ilial intubation rates were 88% and 47.5% Respectively; After considering cases of anatomic colonic obstruction and when the clinical indications don’t justify total colonic intubation; the adjusted rates were 49.2% & 50.8% for cecal & Ilial intubations respectively; and these figures were superior in comparison to the results of multioperator study in which the cecal intubation rate was 51.81% and the ilila intubation rate was 30.69%.
Conclusions: Cecal and Ilial intubation are important quality indicators for colonoscopy and in this study they are found to be superior in qualified gastroenterologist than in general surgeons & physicians; this result points to the importance of providing endoscopy units in Iraq with qualified well trained endoscopy personnel.
Journal of Clinical Case Reports received 1295 citations as per Google Scholar report
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