Журнал клинических случаев

Objective: The management of insomnia presents as a challenge for many Parkinson’s disease patients and their care teams. Insomnia in patients with Parkinson’s disease may be attributed to the side effect profile of several medications that are commonly used to treat Parkinson’s disease. Additionally, the progression of the disease is associated with disruption of circadian rhythms, nocturnal symptoms, blunted melatonin secretion, and late melatonin onset. This case report aims to demonstrate how a patient's Parkinson's medication profile could be optimized to control motor symptoms and reduce the occurrence of insomnia through the use of comprehensive medication review services.

Case report: A 71-year-old male with Parkinson’s disease was developing severe symptoms of tardive dyskinesia due to his chronic carbidopa/levodopa/entacapone therapy. In order to address the tardive dyskinesia, entacapone was discontinued and amantadine was initiated to offset the stiffness and bradykinesia. The addition of amantadine resulted in nightmares and poor sleep quality, even though the patient was already taking mirtazapine to treat his depressive status and insomnia. The patient’s healthcare team collaborated with a clinical pharmacist to adjust the Parkinson’s disease regimen and mirtazapine dosage, all of which resulted in notable improvements in his reported insomnia and quality of life.

Discussion and Conclusion: Optimizing motor control in patients with Parkinson’s disease, while mitigating insomnia side effects of medications can be a very complex process. The main goal for patients who encounter this problem is to enhance their Parkinson's disease therapy by identifying medications that can contribute to insomnia while addressing the patient's symptoms and disease progression. Alternative treatments to manage insomnia in patients with Parkinson’s disease should also be considered, including the addition of melatonin and/or the use of bright light therapy.

Introduction: Glanzmann thrombasthenia is a rare inherited bleeding disorder, with a global prevalence of about one in one million. It is an autosomal recessive condition characterised by episodes of mucocutaneous bleeding. A defect in the membrane protein results in a defective platelet aggregation.

Case presentation: A fifteen-month-old female child presented to the emergency department with nosebleed for the last two days. The patient had two similar episodes of epistaxis in previous few months which were managed at home. There was an accompanying complaint of easy bruising since birth. After emergency management and anterior nasal packing, extensive blood tests were ordered to determine the cause for recurrent haemorrhages. Platelet aggregation study concluded a diagnosis of Glanzmann thrombasthenia and the patient was treated accordingly. Family members were thoroughly counselled, and safety netting was vigilantly done.

Conclusion: Many public tertiary cares set ups in Pakistan lack the adequate diagnostic and therapeutic facilities for bleeding disorders. This does not only result in delaying appropriate care but also causes patients to remain undetected. Through this report, we aim to encourage emergency physicians to have a high index of suspicion for haematological disorders in patients presenting early in life with recurrent bleeding episodes.

A young man with a history of pseudo-seizures was admitted after an episode of severe agitation and rigorous physical activity. The patient was febrile on admission with notable leukocytosis and lactic acidosis but a negative infectious workup. During the hospitalization, the patient developed severe Acute Kidney Injury (AKI) despite fluid hydration. Creatinine Phosphoryl Kinase (CPK) was minimally elevated at 693 U/l. Urine
microscopy was significant for many uric acid crystals. Subsequent lab studies revealed an elevated uric acid level of 13.4 mg/dl with fractional excretion of urate (Fe-Urate) of 13%. The patient was treated with rasburicase and allopurinol with the improvement of AKI that paralleled the improvement in hyperuricemia. AKI was likely due to acute urate nephropathy from a pseudo-seizure. AKI following an icteric activity or rigorous physical activity can occur via a mechanism that is independent of rhabdomyolysis. Acute Urate Nephropathy should be considered in cases with no significant elevations of CPK, with prompt initiation of rasburicase and potentially rapid resolution of AKI.

A 75-year-old female with history of a prior right renal artery stent (coronary bare metal stent, duration 3 years), stage IV CKD (baseline serum creatinine (Scr) 2.1-2.3 mg/dL (eGFR 20-23 ml/min/1.73 m²)), diastolic heart failure, and hypertension. She had multiple hospital admissions for acute decompensated heart failure, now presenting with worsening dyspnea, increased oxygen requirements of 4 L oxygen via nasal canula, increased from baseline 2 L. Despite treatment with up to nine anti-hypertensive medications, her systolic BP remained 180-200 mmHg. Her Scr also increased to 3.92. Work-up showed normal kidney sizes and urine protein/creatinine ratio 1.26 g/g. Renal artery duplex revealed right renalartery peak systolic velocity 267 cm/sec, renal-to-aortic ratio 2.68, and resistive index 0.7-0.9, suggestive of right renal artery re-stenosis and some intrinsic damage. Due to progressive volume overload and worsening respiratory status, she required temporary hemodialysis. As her volume status improved, she underwent CO₂ angiogram and was found to have 90% diffuse in-stent restenosis with marked deformity of the previous stent. She underwent re-stenting of the right renal artery with a proprietary FDA-approved Herculink Elite® renal stent with only 8 ml of contrast. Immediately post-intervention, her BP dramatically improved and after two months, hemodialysis was stopped, (new baseline SCr 1.5-1.9) and she only required two BP medications.

Venous Thromboembolism (VTE) is a vexing heterogeneous disease that, along with Myocardial Infarction (MI) and stroke, is among the top three cardiovascular killers. VTE's morbidity and mortality globally cause high social, health, and economic impacts. The modern diagnostic strategies of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) developed to aid physicians in diagnosing these presentations and using imaging resources effectively have shown limitations in several subgroups, including patients with recurrent VTE or those who are already on anticoagulation therapy. In the light of a previously reported breakthrough (recurrent) DVT while on rivaroxaban 20 mg PO daily in a 43-year-old Caucasian female, this review discusses the various etiologies, which contribute to anticoagulant's failure and VTE's recurrences in general to increase awareness among practicing physicians about these subgroups. The roles of imaging and D-dimer testing in these subgroups are also discussed, leading the author to cautiously conclude that diagnostic imaging plays a central role in identifying recurrence regardless of D-dimer testing and recommending baseline sonography upon completing DVT anticoagulation therapy for future references. Accurate diagnostic strategies are needed to ensure the best available care and treatment reaches the patient. Based on this review, the author constructs a hypothetical algorithm targeted to diagnose recurrent VTE or breakthrough VTE while on anticoagulants coupled with the possible causes for recurrent and breakthrough VTE. This algorithm should only be considered as hypothesis-generating for specifically designed prospective studies to assess and validate the algorithm's potential in decreasing the incidence of missed diagnosis of VTE and their underlying etiologies in these subgroups.

Aortic dissection is a critical cardiovascular disease with extremely high mortality. It has an acute onset and poor prognosis. Patients with uremic
hemodialysis have more risk factors for aortic dissection than ordinary patients. Early diagnosis and treatment have a positive impact on the
prognosis of aortic dissection. This article reports a case of uremic hemodialysis complicated with aortic dissection, aiming to further explore the
clinical diagnosis, treatment and distinguishing characteristics of uremic complicated with aortic dissection, and improve the early diagnosis rate
of the disease.

Periodic Thyrotoxic Hypokalemic Paralysis (PTHP) is a rare endocrinological complication characterized by hypokalemia, episodes of muscle weakness and thyrotoxic symptoms. The following is a case report of PHHP in a black patient diagnosed with hyperthyroidism during an episode of sudden and progressive weakness associated with hypokalemia. PHHP is often underdiagnosed and should be remembered as a diagnosis of acute muscle weakness in young patients, especially males, regardless of ethnicity, although it is frequent in Asians.

Pregnant women with coronavirus disease 2019 (COVID-19) show overall similar clinical features as that of non-pregnant adults with COVID-19, except perhaps for higher risk of admission to the Intensive Care Unit (ICU) and mechanical ventilation. Apart from the established therapeutic options used in COVID-19 like steroid, low molecular weight heparin role of COVID Convalescent Plasma (CCP) has never been evaluated. We present a case of a pregnant woman, treated with CP at the AMZ hospital, Dhaka, Bangladesh.

Ectopic teeth develop when displaced from their normal position. Any permanent tooth can be ectopic, and the cause may be both genetic and environmental. Orthodontic treatment is justifiable for aesthetic reasons. Subsequently a careful diagnosis along with a proper treatment plan for ectopically erupting permanent maxillary canines requires timely management by the orthodontist. The purpose of this case report is to illustrate
an approach involving management using HANT wire.

Paraganglioma is a very rare extra adrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56 mm paraganglioma in a 53-year-old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed.

Paraganglioma is a very rare extra adrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56 mm paraganglioma in a 53-year-old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed.

Since novel coronavirus pneumonia (novel coronavirus pneumonia) novel coronavirus outbreak, countries around the world have accelerated the development of a new coronavirus pneumonia vaccine (new crown vaccine). As of December 2020, 60 candidate new coronal vaccines have been approved for clinical trials, among which 7 vaccines (3 inactivated vaccines, 2 mRNA nucleic acid vaccines, and 2 vector vaccines) have been approved for emergency use or conditional marketing. In this paper, the development progress, advantages, and disadvantages of six new coronal vaccines including inactivated vaccine, nucleic acid vaccine, vector vaccine, protein subunit vaccine, live attenuated vaccine and virus-like particle vaccine was reviewed. The results of the novel coronavirus pneumonia in phase III clinical trials show that the new vaccine has good safety and immunogenicity. The approved vaccine has been proved to have good protective efficacy. However, attention should be paid to the adverse reactions of the vaccine and the long-term protective effect.

Purpura fulminans may have infectious, hereditary and idiopathic etiology. We came across a case of purpura fulminans in a 9-year-old boy who
had been healthy for first 4 years of his life and suddenly developed gangrenous lesions on extremities which proceeded to the detachment of
some digits. Laboratory evaluation revealed mild anemia, hypoalbuminemia, high platelet count, elevated aPTT, PT and INR, mild proteinuria and
high urinary protein to creatinine ratio. Child was managed by warfarin therapy.

Metastatic tumors to oral cavity are rare and represent approximately 1% off all cases of oral malignat lesions even though metastatic disease may be present. The 53-year-old female presented in March of 2017 complaining with abdominal pain, weight loss and loose stool not more than 3 times per day. CT scan of the abdomen in July showed retroperitoneal mass expanding along the body of the pancreas. Colonoscopy and gastroscopy with biopsy of mucosa of the stomach showed normal result. The tumor marker Ca 19-9 in July 2018 was 110.3 and in August 2018 350.6. The patient was referred in September of 2018 to the maxillofacial surgery Clinic for examination of the lesion in the oral cavity. She presented with a pain, swelling and occasional bleeding around the lower right second mollar. Immunohistochemical the tumor cells were positive for Cytokeratin (CK) 19, Cytokeratin (CK) 7, and homebox protein (CDX-2) which is highly sensitive markers of pancreatobiliar cancer. Therefore, the patient was diagnosed with pancreatic carcinoma. This report describes a rare metastasis of malignant pancreatic tumor in lower right gingiva and highlights the importance how immunohistochemical examination ped to identify both the origin and the nature of gingival neoplasm.

Purpose: The purpose of the study was to explore the impact of graded early mobilization on psychomotor status of patients with mechanical ventilation.

Objectives: To measure the effect of early mobilization on days first out of bed, other motor function, psychological status and length of ICU stay of mechanically ventilated patient.

Methodology: This was a single case study. Sample was selected from BRB Hospitals Limited of Dhaka using convenient sampling method and according to selection criteria. A precise semi structured questionnaire was used for data collection.

Graded early mobilization was provided as intervention to the participant by a Professional qualified physiotherapist for 10 sessions. Another senior physiotherapist was assigned as data collector. He assessed the participant’s Functional Independence Measure (FIM) score and Generalized Anxiety Disorder 7 point (GAD-7) score during discharge from ICU.

Results: It was found that Functional Independence Measure (FIM) score was 65 which means the participant was very much independent during discharge from ICU. The finding of GAD-7 was 04, which indicates that the participant was free from any psychological problems.

Conclusion: This study showed that graded early mobilization was effective to improve mechanically ventilated patients motor and psychological status.

Small lesions invading or compressing dural sinuses are frequent but secondary intracranial hypertension is not very common, with few examples reported in the literature. This event may be explained in the setting of anatomic variants in pattern of venous sinus circulation. We present the case of a patient who presented with papilledema and loss of visual acuity due to a small meningioma located inside the superior sagittal sinus (SSS). The patient underwent a lumboperitoneal shunt placement with recovery of symptoms. Literature available is also reviewed.

Fibroadenoma is a painless, unilateral, benign breast lesion that is a solid in consistency. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. This is a case report for a young twin who presented to the one stop clinic with a unilateral breast lump in the right upper quadrant of the breast. Both patients were assessed clinically by obtaining detailed history and clinical examination and further evaluation of the lump was done by ultrasound examination, which confirmed diagnosis and patients were reassured and treated conservatively.

We present a one clinical case of patient with metastasis of squamous cell non–small-cell lung cancer in pancreas. A 49-year-old Caucasian male patient presented to our Medical Oncology department with obstructive jaundice and severe abdominal pain, after the last course of chemotharapy. Six months prior to presentation the patient had undergone right bronchoscopy, due to stage IV, moderate-grade squamous cell lung carcinoma. After the bronchoscopy, the patient receives chemotherapy and radiotherapy. Abdominal computed tomography on admission after the last course of chemotharpy, revealed lesion located at the head of the pancreas, causing biliary obstruction. The abdominal computer tomography reveals also lesion in left adrenal gland. Histological examination reveals and changes in grade of the histology from moderate in primary foci in lung to low-grade in metastasis in pancreas. Due to the severe pain in the abdomen and jaudice of the metastatic disease, surgical resection was proposed and the patient underwent pancreaticoduodenectomy. Histological examination of the resected specimen from pancreas confirmed a low-grade squamous cell carcinoma form the lung.

Melioidosis is a granulomatous infectious disease caused by Burkholderia pseudomallei. It is a motile, aerobic, oxidase-positive, gramnegative,
non-spore forming soil saprophyte. It has gained a lot of importance in recent times as one of the most potent emerging
infections in India. The clinical presentation of Melioidosis is highly variable, ranging from benign skin and soft tissue infections to rapidly
fulminant and fatal septicaemia. It is because of this wide range of clinical diversity, it is called "Great mimicker" and poses diagnostic
challenges to clinicians. In this case report, we illustrate the diagnostic difficulties we faced and our management of infrequent complication
of disseminated Melioidosis presenting as broncho-oesophageal fistula with concomitant lung consolidation.

A 26-yr old army man of commandant rank posted in forest belt of district Mirzapur Uttarpradesh, presented to the medicine emergency department with a 4-day history of high grade fever which was associated with chills and rigor, vomiting and generalized abdominal pain. Peripheral blood smear stained with leishman demonstrated ring-form trophozoites of P. falciparum with high parasitaemia (62%) with rapid antigen test for P. falciparum was also positive. Chest X-ray was normal. Non contrast computed tomography (CT) scan of the abdomen showing a bulky pancreas with peripancreatic fat stranding suggestive of acute pancreatitis. A diagnosis of severe falciparum malaria with acute pancreatitis was made on basis of investigation. Treatment in form of intravenous quinine 1000 mg as loading dose in 10% dextrose solution followed by 500 mg in same solution and was monitored for hypoglycaemia. Oral quinine tab was started 8th day up to 15th day. The patient was discharged on 18th day and his condition was good on further follow up.

Heart failure affects more than 40 million people globally in a single year and is expected to increase in the coming time. In patients, who have associated co-morbidities are more likely to develop left ventricular dysfunction and subsequently heart failure. Left ventricular dysfunction increases cardiovascular mortality and morbidity in end stage renal disease patients on hemodialysis. Peritoneal dialysis has emerged as an alternative mode of renal replacement therapy for end stage renal disease patients. However the prevalence of left ventricular dysfunction in end stage renal disease patients is scarcely known. A 33.33% prevalence of left ventricular dysfunction has been observed in our study.

The purpose of the study was to explore the impact of graded early mobilization on psychomotor status of patients with mechanical ventilation. To measure the effect of early mobilization on days first out of bed, other motor function, psychological status and length of ICU stay of mechanically ventilated patient. This was a single case study. Sample was selected from BRB Hospitals Limited of Dhaka using convenient sampling method and according to selection criteria. A precise semi structured questionnaire was used for data collection. Graded early Mobilization was provided as intervention to the participant by a Professional qualified Physiotherapist for 10 sessions. Another Senior Physiotherapist was assigned as data collector. He assessed the participant’s Functional Independence Measure (FIM) score and Generalized Anxiety Disorder 7 point (GAD-7) score during discharge from ICU. It was found that Functional Independence Measure (FIM) score was 65 which means the participant was very much independent during discharge from ICU. The finding of GAD-7 was 04, which indicates that the participant was free from any psychological problems. This study showed that graded early mobilization was effective to improve mechanically ventilated patients motor and psychological status.