Indian Journal of Case Reports

Diode laser in the excision of intraoral fibroma: A safe tool for minimally invasive dentistry

Madhuri Alankar Sawai — 2021-04-03

Intraoral fibroma is a common lesion that develops in the oral cavity following trauma or tissue injury. It has a strong female predilection and is more frequently seen in the third and fourth decades of life. The most common site of traumatic fibroma is buccal mucosa along the plane of occlusion. The conventional method for excision of fibromas is using surgical blades. However, this method has certain disadvantages such as excessive bleeding and pain to the patient during the excision. Postoperatively, there can be delayed wound healing with occasional scarring. With the introduction of diode lasers for soft-tissue excisions in dentistry, we can now overcome these limitations. Here, we present the case series of two cases of intraoral fibroma. In this case series, intraoral fibroma was excised using a diode laser. It was observed that in both cases, the healing was much faster. There was minimal intraoperative bleeding. Furthermore, the surgical time reduced substantially and the patient was more comfortable during the procedure as well as in the postoperative phase. Thus, the diode laser has been found to be safe, less painful, and with better post-operative outcomes.

CT chest with pulmonary angiography as a diagnostic tool in clinically suspected RT-PCR-negative COVID-19 pneumonia with pulmonary artery aneurysm

Aniket Agarwal — 2021-04-03

COVID-19 caused by the SARS-CoV-2 strain of coronavirus was officially recognized as a pandemic by the World Health Organization on March 11, 2020. Most patients present with mild disease. However, elderly patients and those with coexisting comorbid conditions such as diabetes and hypertension are more likely to develop severe disease. Definitive diagnosis is by RT-PCR test and CT scan is an adjunct modality. By virtue of being a hypercoagulable state with cytokine storm and microthrombosis as key components in pathogenesis, additional finding of pulmonary thrombosis in such patients should increase diagnostic accuracy. We report an interesting case with clinical and radiological features supporting COVID-19 pneumonia such as patchy ground-glass opacities with consolidation in bilateral peripheral lung fields along with segmental pulmonary thrombosis. The conundrum in the case arises from the negative RT-PCR test and presence of pulmonary artery aneurysm which could be an incidental finding or sequelae of COVID-19, which remains to be studied.

Metastatic malignant PEComa of the brain: An unusual entity with rare presentation

Reena Bharadwaj — 2021-04-03

Perivascular epithelioid cell tumor (PEComa) is an unusual mesenchymal tumor comprised histological and immunohistochemically distinctive perivascular epithelioid cells exhibiting myomelanocytic phenotype. We hereby report the case of a 59-year-old female who presented with sudden headache, vomiting, and transient decreased vision with contrast MRI suggestive of the right occipital mass. Biopsy from the right occipital craniotomy mass was reported as metastatic malignant melanoma. The case was referred to our hospital for review. We considered a differential diagnosis of metastasis from malignant melanoma, poorly differentiated carcinoma, high-grade glioma, PEComa, hemangioblastoma, and high-grade sarcoma. A post-operative whole-body PET/CT scan revealed a metabolically active lesion in the endometrium that seems to be primary. It is suggested to consider PEComa as a differential diagnosis in poorly differentiated malignancy and to evaluate accordingly with appropriate immunohistochemistry markers. This is the third reported case of metastatic malignant PEComa to the brain as per the English literature.

Adult atrial septal defect device closure with floppy rims

Debasish Das — 2021-04-03

Floppy rims of atrial septal defect (ASD) preclude device closure as those rims do not hold the device with a high risk of device dislodgement and embolization. In spite of the floppiness if the margins have an adequate length (>5 mm), sometimes it may also hold the oversized device obviating the need for surgical closure. We report a successful closure of an adult 30 mm ostium secundum ASD with floppy posterosuperior and inferior vena cava rim with Amplatzer 34 mm device. “Oversize the device in floppy rims” is the only clue to get success in those cases. Sometimes, a fair trial against nature’s negativity can also result in a successful outcome.

Navigating through tortuosity: “A S-shaped abdominal aorta”

Debasish Das — 2021-04-03

Tortuosity of the abdominal aorta is common to encounter during transfemoral intervention in the elderly cohort but an extreme form of abdominal tortuosity assuming S-shape has not been reported so far. We report a case of an extreme form of abdominal aorta tortuosity in 65-year-old male in whom successful coronary intervention was performed with Amplatzer extra stiff (0.038) wire and larger guide catheter (EBU 7F 3.5) for good back up support. Rare to encounter, this extreme S-shaped tortuosity in a young-old patient remembers us the fact that “arteries and aorta can also kink early.”

Valproate-induced reactive lymphoid hyperplasia in pediatric population: A rare case report

Kanwardeep Kaur — 2021-04-03

Certain drugs may give rise to lymph node enlargement, predominantly in the neck known as drug-induced lymphadenopathy which may be associated with the involvement of DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) of drug reaction with eosinophilia and systemic symptoms also known as drug-induced hypersensitivity syndrome. It can also resemble lymphoma morphologically and this condition is known as pseudolymphoma. Valproate, a broad-spectrum antiepileptic, also used in bipolar disorders and migraine prophylaxis, is generally well tolerated. To date, very few cases of valproate monotherapy-induced lymphoid hyperplasia have been reported worldwide. Here, we are reporting one such rare case in a 13-year-old Indian male child who developed cervical lymphoid hyperplasia following the use of sodium valproate for 5 months for a seizure disorder.

Giant cell ependymoma: Cytology of a rare entity with unusual presentation

Kavita Sahai — 2021-04-03

Giant cell ependymoma (GCE) is a slow-growing tumor that accounts for 9–13% of all ependymoma and occurs preferably at conus medullaris, cauda equina, and filum terminate. Squash cytology is a fast, simple, and reliable technique for intraoperative diagnosis. We present a case of GCE arising at the L5-S2 level and suprasellar region in a 17-year-old male who initially presented with low backache followed by headache and double vision. Intraoperative squash smears of the lumbosacral lesion were suggestive of high-grade glioma. Histomorphological and immunohistochemical profile favors the diagnosis of giant cell variant of myxopapillary ependymoma. He received craniospinal irradiation followed by a boost to the sellar-suprasellar and lumbosacral region through IGMT. After sometime, he developed papilledema and decreased vision, the suprasellar lesion was decompressed which on histopathology revealed similar features. GCE remains a diagnostic challenge on intraoperative squash smears due to its rarity. It has a good prognosis with a 5-year survival of 98.4% after total resection; however, our patient succumbed to illness due to post-operative residual lumbosacral mass and effects of the suprasellar lesion.

A Rare Case of Intramuscular Schwannoma of Dorsal Ramus Nerve: A Case Report

Jainam K Shah — 2021-04-03

Schwannoma is a benign, expansile neoplasm that originates from nerve sheaths. Intramuscular schwannoma is a rare tumor presenting as a slow-growing soft-tissue mass that may or may not has associated neurological symptoms. We present a rare case of intramuscular schwannoma of the dorsal ramus nerve in a 50-year-old female patient who presented with a single, firm, and well-defined swelling over the back region. On magnetic resonance imaging, a 54 mm × 23 mm × 20 mm, well-defined altered signal intensity lesion at the left posterior paraspinal region extending from the superior endplate of D12 to the inferior endplate of L1 vertebral bodies was noted which was suggestive of neurogenic tumor/ hemangioma. The swelling was excised and sent for histopathological examination (HPE). A diagnosis of intramuscular schwannoma was confirmed on HPE. Hence, all soft-tissue tumors should be sent for HPE for confirmation of the diagnosis and its further management.

Knee cap bursitis/housemaid’s knee role of magnetic resonance imaging: A case report

Amandeep Singh — 2021-04-03

Pre-patellar bursitis is one of the major causes of anterior knee pain affecting people between 40 and 60 years of age. It occurs secondary to trauma, infection, overuse, systemic illness, and inflammatory arthropathy. Bursitis can be associated with certain occupations and named accordingly such as pre-patellar bursitis is also known as housemaid knee. Here, we present the case of a 65-year-old female who presented with visible palpable swelling in the pre-patellar region for 6–7 months which was gradual in onset. Magnetic resonance imaging (MRI) reveals well-defined collection in the pre-patellar bursa along with mild joint effusion. MRI is the modality of choice in this case as it shows high signal intensity on T2 W images and low signal intensity on T1-weighted images. Heterogeneity of the signal is altered when hemorrhage, thickened inflamed synovium, calcification, or loose bodies

Lepidopterism: A report from South India

S Daniel Sundar Singh — 2021-04-03

Lepidopterism is a term that refers to a spectrum of medical conditions in humans that usually involve the skin and result from worm-like contact with an adult or larval form of specific butterflies and moths. Lepidopterism is isolated but certain people may be more prone to exposure to moths. Caterpillar’s sting is not an everyday diagnosis; however, the physician should be alert and make awareness regarding caterpillar envenomation. Herein, we present the case of a 31-year-old man who presented to the hospital with a history of a caterpillar’s sting associated with unilateral rashes and prickly sensation on his left thigh and lower extremity. On examination, his vitals were stable and he does not develop systemic manifestations or anaphylaxis. In view of his present compliance, he was successfully managed with antihistamines and steroids. This case is being presented not only as the event is rare but also to create awareness and it will help the clinicians to manage the case appropriately.

Cerebral venous sinus thrombosis with venous hemorrhagic infarct in a patient with high-grade glioma of the left thalamus

Nithisha Thatikonda — 2021-04-03

Cerebral venous sinus thrombosis (CVST) is an uncommon type of venous thromboembolism whose diagnosis is often difficult due to its vague and non-specific clinical findings. Sometimes, the diagnosis is delayed as the symptoms were considered to be attributable to the underlying etiology, especially in patients with brain tumors such as high-grade glioma (HGG). We described the case of a 60-year-old male patient who presented with headache, generalized seizures, and right hemiparesis soon after receiving brain radiation and temozolomide therapy for HGG of the left thalamus. Initially, his symptoms were considered to be due to his underlying tumor but the subsequent imaging revealed left transverse, left sigmoid, and superior sagittal sinus thrombosis with venous hemorrhagic infarct of the left occipitoparietal lobe. The patient was started on anticoagulant therapy and symptoms resolved completely within a month. Clinicians should always consider CVST in the differential diagnosis of non-specific neurological symptoms, especially in patients with underlying brain tumors.

Development of acute ischemic stroke and seizure in a patient with COVID-19 disease: A case report

Henil Upadhyay — 2021-04-03

Acute ischemic stroke (AIS) is a life-threatening central nervous system (CNS) complication of coronavirus disease 2019 (COVID-19) infection. Here, we present the case of a 50-year-old COVID-19-positive male who developed AIS with hemorrhagic conversion during treatment in intensive care. He was managed with conservative treatment consisting of deep vein thrombosis prophylaxis and physiotherapy. We delayed oral aspirin and atorvastatin therapy due to hemorrhagic conversion. After 1 month of discharge, the patient presented with a seizure episode. He was observed for 24 h and discharged with prophylactic antiepileptic. Patients with COVID-19 may present with seizure episodes due to viral invasion into CNS, metabolic factors, and other systemic illnesses. Hence, seizures must be considered both as a presenting feature and long-term sequelae of COVID-19 infection. Physicians should take into consideration AIS as a possible complication of COVID-19 infection and should look out for clinical features suggestive of stroke for early diagnosis and improved clinical outcome.

Breast adenomyoepithelioma with ductal carcinoma in situ: An unusual entity

Gaurav Pratap Singh Gahlot — 2021-04-03

Adenomyoepithelioma is a rare biphasic tumor characterized by the proliferation of inner glandular epithelial cells and outer myoepithelial cells. These tumors have a low-grade potential for local recurrence and malignant transformation. Here, we present the case of a 51-year-old female who presented with a right breast lump for 1 month. Mammography was suggestive of BIRADS 4/5 for the right breast while BIRADS 1 for the left breast. FNAC was reported as benign breast disease, whereas, trucut biopsy of the same lesion was suggestive of invasive ductal carcinoma with ductal carcinoma in situ (DCIS). A final diagnosis of adenomyoepithelioma with DCIS component was confirmed on the right modified radical mastectomy. We, hereby, describe an extremely unusual case of biphasic breast adenomyoepithelioma that depicted benign features on FNAC and features of an invasive ductal carcinoma on trucut biopsy. Its distinct histomorphology with a characteristic epithelial-myoepithelial immunohistochemical profile on modified radical mastectomy specimen led to a definitive diagnosis of adenomyoepithelioma with DCIS.

Floating thrombus in the arch of the aorta: A diagnostic dilemma in coronavirus disease 2019

Ruchi Kapoor — 2021-04-03

Coronavirus disease 2019 (COVID-19) primarily involves the respiratory system, however, hypercoagulability and thromboembolism are its unique and common association. COVID-19 may predispose patients to an increased risk of thrombotic complications through various pathophysiologic mechanisms, such as inflammation, immobilization, endothelial dysfunction, and a hypercoagulable state. Therefore, a high index of clinical suspicion is needed for diagnosing thrombotic complications such as floating thrombus in the arch of the aorta as described in this case report and prompt anticoagulation should be started to prevent life-threatening complications. We describe a rare presentation of a patient who presented to intensive care unit of our hospital with respiratory symptoms and was being treated for COVID-19 and despite the management as per COVID protocol was difficult to wean off from the non-invasive ventilation. We will focus on how we arrived at this rare diagnosis “floating thrombus in the arch of aorta” and further management of the case.

Multimodal ayurvedic approach in the management of type 2 diabetes mellitus in insulin therapy: a case report

Mythri H S — 2021-04-03

In the literature of Ayurveda, Prameha (diabetes mellitus [DM]) is a disease where derangement is seen in urine with respect to its quantity and quality. The basic pathology involved in the disease is the Bahu, Abaddha Medas, and Kleda. Prameha can be well correlated to DM with respect to its pathology and symptoms. Here, we present the case of a 44-year-old male who came with complaints of restlessness, generalized weakness, giddiness, and pain in bilateral calf muscles for the past 4 months. Based on Ayurvedic examinations, he was diagnosed to have Margavarnajnya Madhumeha (~obese diabetic), suitable food, lifestyle, and medications were advised after assessing Prakriti, Dosha, etc. By Ayurvedic therapy, considerable improvement was seen in the quality of life. The case was followed up for 4 years and the patient’s condition was maintained well throughout, without any complications. This article reports a case of Type 2 DM on insulin therapy which was completely managed by Ayurvedic therapeutic modalities and all the oral hypoglycemic drugs along with insulin were withdrawn gradually during the course of the treatment.