Indian Journal of Case Reports

Asymptomatic coronavirus disease followed by symptomatic reinfection in a patient with monoclonal gammopathy of undetermined significance: A case report

Varsha Narayanan — 2021-06-03

Coronavirus disease (COVID-19) pandemic has been present for over a year and has been seen to behave unpredictably in different
people especially those with other underlying health conditions. Monoclonal Gammopathy of Undetermined Significance (MGUS) is
a rare condition that can alter immune responses. There are few case reports of COVID in people with MGUS and most of these are in
elderly people often with associated comorbidities. The mutual impact of COVID and MGUS in younger people (<50 years) has been
far less explored, and therefore, this case report would add to such data. Although there is no conclusive evidence to suggest that MGUS
increases predisposition or significantly impacts the clinical course and outcomes of COVID-19, it can have some bearing on serological
assessment in both COVID infected or vaccinated individuals.

Severe angioedema induced by tomato soup with alprazolam and muscle relaxant drug: A rare and complex drug-food interaction

Deep Inder — 2021-06-03

Molecular interactions at the level of drug and food may lead to the reduced or enhanced effect of a concomitantly given drug or food nutrient. The resultant effects of such interactions may sometimes be severe to life-threatening. Here, we present a rare case of a 40-year-old male patient who developed severe angioedema secondary to drug-food interaction. The patient presented in emergency with complaints of angioedema face, rashes, and difficulty in breathing. History revealed that the patient had been prescribed analgesic muscle relaxant Flexon MR (t.i.d) for severe backache 1 day before. On day 2, the patient self-medicated with tablet alprazolam for inducing sleep followed by intake of hot concentrated tomato soup (350 ml). Within ½ h, the patient took Flexon MR. Following Flexon MR, the patient went drowsy and developed angioedema face and rashes on the whole body with difficulty in breathing. The patient was given injection adrenaline (i.m) injection followed by an injection of chlorpheniramine (i/m) stat. After stabilization of vitals, the patient was discharged.

With a pinch of salt: The importance of history in evaluation of hyponatremia

Rashmi Prakash — 2021-06-03

Fatigue, a non-specific symptom, is often dismissed as trivial or functional, however, an underlying malignant, endocrine, or metabolic disorder may be the cause of fatigue. We present the case of an elderly lady who presented with tiredness, anorexia, and vomiting for a month. Physical examination revealed pallor, facial puffiness, and coarse crackles in the left mammary area. Investigations revealed hyponatremia and hypokalemia. The patient denied a history of amenorrhea and lactation failure, but further questioning revealed that she had severe post-partum hemorrhage necessitating a hysterectomy. Investigations revealed normal TSH, low normal fT4, inappropriately low FSH, and LH. The patient was treated with thyroid and adrenal hormone replacement. We present this case to emphasize the importance of detailed history taking for a medical diagnosis, especially in conditions like Sheehan’s syndrome with relatively non-specific presenting complaints.

A case report of sporadic Creutzfeldt-Jakob disease in an Asian origin coronavirus disease-19 patient: An enigma

Suman Choudhary — 2021-06-03

Creutzfeldt-Jakob disease (CJD) is a rare, degenerative, and fatal brain disorder affecting about one in every 1 million persons/year worldwide, with a typical duration from onset to death is only 7 months. In our case report, we describe a patient of Sporadic CJD (sCJD) who presented to the hospital during the coronavirus disease (COVID-19) pandemic and the intensive care unit experience and precautions taken to prevent the iatrogenic spread of the disease. This case was diagnosed following confirmation of all the typical clinical, radiological, and laboratory features of this condition. From all recent data on the pathogenesis of the sub-category of prion disease and the immune responses to severe acute respiratory syndrome coronavirus-2, we can suggest that coronavirus disease can lead to exaggerated and accelerated pathogenesis and manifestations of neurodegenerative disorders such as of our patient’s sCJD. We have tried to highlight the challenges in managing patients with a rare disease such as sCJD and how its progression can be intensified by COVID-19.

Subclavian venoplasty: A second life to the upper limb

Debasish Das — 2021-06-03

Venoplasty, a forgotten art now rescued the upper limb circulation and made the left brachial arteriovenous fistula for hemodialysis functional avoiding the long-time need of a femoral arteriovenous fistula for hemodialysis. We report a rare case of successful left subclavian venoplasty in a 43-year-old male with end-stage chronic kidney disease on alternate day hemodialysis therapy with critical chronic total occlusion of the left subclavian vein secondary to traumatic central line insertion 8 months back presenting with gross wet edema of the left upper limb with visible venous collaterals over the left neck and the left anterior chest wall. Due to acquired left subclavian stenosis, the left brachial arteriovenous fistula for hemodialysis became non-functional and the patient was on alternate day hemodialysis with right femoral arteriovenous fistula.

A rare case of isolated cervical intramedullary neurosarcoidosis, successfully treated using a combination of prednisolone and mycophenolate mofetil

V Shyam Gopal — 2021-06-03

Isolated spinal cord intramedullary neurosarcoidosis (NS) in the absence of systemic involvement is exceptionally rare, and the diagnosis can be challenging. A 41-year-old female presenting with bilateral limb weakness was referred to us with a clinical and radiological diagnosis of an intramedullary spinal cord tumor. A biopsy done from the mass was suggestive of an inflammatory lesion with no evidence of neoplasia. Following the report, she was treated with steroids that resulted in an initial symptomatic relief followed by worsening without regression of the mass. Hence, a laminotomy and decompression of the mass were done. The intraoperative smear examination showed a granulomatous lesion that was characterized on histopathology as a non-necrotizing chronic granulomatous meningomyelitis. A final diagnosis of isolated intramedullary NS was considered based on clinical features of waxing and waning response to steroids, intramedullary and leptomeningeal enhancement on radio imaging, histopathological findings of non-necrotizing granulomatous lesion, and exclusion of systemic disease. She was treated with steroids along with mycophenolate mofetil. On follow-up, there was a significant improvement in clinical symptoms.

Mediastinal and subcutaneous emphysema after manual strangulation

Onur Bayrakçı — 2021-06-03

Pneumomediastinum is a disease characterized by the presence of air in the mediastinum. The disease is examined in two categories as spontaneous and secondary and frequently seen as a result of traumatic causes. In our study, we present a case of diffuse mediastinal and subcutaneous emphysema after strangulation, unrelated to penetrating injury. After detailed anamnesis, it was understood that it was not a simple penetrating injury but a complicated trauma. Anamnesis, clinical findings, and radiology should be compatible with each other. When necessary, detailed anamnesis should be insisted and the etiology of blunt trauma should be investigated, especially if mediastinal emphysema is detected. Complications such as tension pneumomediastinum, pneumopericardium, and mediastinitis can be seen which complicates the disease and can result in death.

Management of a case of acute bacterial cholangitis with septic shock in a surgical intensive care unit: A case report

Ram Singh — 2021-06-03

Acute bacterial cholangitis is an emergency and needs prompt diagnosis and administration of appropriate therapy as soon as possible. The presentation of the condition may vary from case to case. As the mortality associated with this illness is huge, a thorough physical examination and high clinical suspicion may help in timely diagnosis and could be lifesaving. Our patient presented with sepsis and septic shock to the emergency department, on clinical examination, and point-of-care ultrasonography performed by a vigilant emergency team, and given high suspicion of cholangitis, the patient was redirected to surgical intensive care unit (SICU). In SICU, after initial resuscitation and stabilization, further diagnostic imaging studies were carried out and definitive interventional management was initiated by the multidisciplinary team of the hospital. The condition of the patient improved drastically on apt and targeted management. Hence, it is very important to rule out the possibility of acute cholangitis in patients presenting with septic shock with a suspected intra-abdominal source of infection. Acute bacterial cholangitis is a highly treatable condition with very encouraging outcomes on timely intervention and results in significantly reduced mortality, morbidity, length of hospital stay, and treatment cost of course.

Spontaneous pneumomediastinum and pneumothorax in a non-intubated patient with coronavirus disease 2019 pneumonia: A case report

Angela Iuorio — 2021-06-03

Coronavirus disease 2019 (COVID-19) has rapidly spread across the globe. Many studies have shown its typical and atypical clinical presentations. Pneumothorax and pneumomediastinum have both been noted to complicate cases of COVID-19 requiring hospital admission even in the absence of mechanical ventilation. The major described pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. Here, we describe a case of spontaneous pneumomediastinum and pneumothorax in a non-intubated patient after sixteen days of initial symptoms of COVID-19.

Left atrial myxoma swinging like a ball valve thrombus: “The wrecking ball effect”

Debasish Das — 2021-06-03

Left atrial myxoma is the most common benign primary tumor of the heart, more common in females, and often presents with non-specific symptoms with incidental detection in echocardiography. The bimodal mode of presentation of the left atrial myxoma is as follows: one group of patient’s presents with symptoms mimicking infective endocarditis and the other group of patient’s presents with symptoms of typical mitral stenosis. Large left atrial myxoma acting as a ball valve thrombus causing complete obstruction of the mitral valve and causing pulmonary venous hypertension with acute pulmonary edema has not been described in the literature so far. We report a rare case of large left atrial myxoma swinging like a ball valve thrombus across the mitral valve in a 76-year-old female presenting with acute pulmonary edema and desaturation. The patient underwent emergent surgical excision of the left atrial myxoma which relieved the pulmonary edema and desaturation as well. Left atrial myxoma being completely occlusive led to passive pulmonary venous hypertension and acute pulmonary edema: a rare phenomenon to be observed in a clinical scenario.

Acute myeloid leukemia along with Gaucher disease in a child

Priyanka Maity — 2021-06-03

There is sparse literature on the occurrence of acute leukemia in association with Gaucher disease in adults. Earlier, only two cases have been published describing acute leukemia in association with Gaucher disease in the pediatric age group. In this case report, we have described a case of acute myeloid leukemia along with Gaucher disease in an 8-year-old female child who presented with fever with hepatosplenomegaly. Measurement of ?-glucosidase activity was the key modality in diagnosis. The possibility that the reduction of the enzyme in Gaucher disease is related to the development of hematological malignancies needs to be explored.

Anesthetic management of craniosynostosis repair in a 13-month-old boy with Apert syndrome

Hardika Mangal — 2021-06-03

Apert syndrome is a congenital disorder characterized by malformations of the skull, face, hands, and feet. It is a form of acrocephalosyndactyly. It is classified as a branchial arch syndrome, affecting the first branchial (or pharyngeal) arch, the precursor of the maxilla and mandible. Presently described is a case of 13-month-old boy diagnosed with apert syndrome. French pediatrician Eugène Apert described Apert syndrome in 1906. The purpose of this report is anesthetic management of craniosynostosis repair in this child under general anesthesia. Craniosynostosis, the premature fusion of skull sutures, results in failure of normal bone growth perpendicular to the suture and the compensatory growth at other suture sites, which results in an abnormally shaped head. Anesthetic challenges include management of a difficult airway, airway hyperreactivity, possibility of raised intracranial pressure, blood loss, blood transfusion, and its associated complications.

Primary thyroid lymphoma with double expression of MYC and B-cell lymphoma-2 Gene

Ramesh Mundle — 2021-06-03

Primary lymphomas of the thyroid (PTLs) are rare entities. We report a case of high-grade B-cell lymphoma double hit (DH) of
the thyroid gland with dual expression of MYC and BCL-2 gene in a 55-year-old woman. Most PTLs have a good prognosis to
combined modality treatment but identification of DH lymphomas or double-expressor lymphomas is important as these are resistant to
chemotherapy and radiotherapy and pose a challenge for the treatment of the same.

Pseudotumor cerebri in carcinoma cervix: “A diagnostic dilemma”

Kiran Kumar B R — 2021-06-03

Pseudotumor cerebri, commonly known as idiopathic intracranial hypertension or benign intracranial hypertension, is a rare syndrome that presents mainly as a result of raised intracranial pressure (ICP). The diagnosis of this condition is established by the exclusion, with the aid of radiological imaging, and examination of cerebrospinal fluid. Due to the aggressive nature of this disease, both signs and symptoms may be intermittent, making definitive diagnosis difficult. Here, we present the case of a 60-year-old female with Stage III carcinoma cervix that was treated with concurrent chemoradiation with weekly cisplatin. She completed the concurrent chemoradiation and developed intermittent seizures, headache, weakness of lower limbs, and visual disturbances. A diagnosis of pseudotumor cerebri was entertained using the modified Dandy Criteria. Pseudotumor cerebri should be considered in cancer patients presenting with raised ICP of sudden onset in the absence of clinical and radiological evidence of brain metastases.

Cracking the Coronary Calcium with IntraVascular Lithotripsy

Debasish Das — 2021-06-03

Intervention in calcified coronaries remains a particular challenge as it is tough to crack the calcium with semi-compliant balloon dilatation. Coronary calcium is cracked with the non-compliant balloon, cutting balloon, scoring balloon, and rota ablation. Intravascular lithotripsy (IVL) has emerged now as a new modality to crack the coronary calcium and bring successful outcomes in coronary angioplasty. We present a case series of two cases where we cracked multi-vessel high dense coronary calcium with IVL and stented the coronary segments with drug-eluting stents to bring good angiographic results and Thrombolysis in Myocardial Infarction (TIMI) III flow.