Журнал клинических случаев

Placenta accreta is an obstetrical complication that can result in life threatening hemorrhage if not managed with adequate care and cause high maternal morbidity. Caesarean hysterectomy is an effective method to control intra-operative bleeding; however, we present a case of placenta accreta that was diagnosed intra-operatively in our secondary set-up hospital. Owing to the lack of multidisciplinary team, bleeding was temporarily controlled by tying a tourniquet using a Foley’s catheter around the lower uterine segment with the tourniquet left in-situ and patient was shifted to a tertiary care hospital. This novel tourniquet technique bought time to transport the patient, arrange for a multidisciplinary team needed for this patient’s management, and reduce hemorrhage which directly determined maternal outcome.

Background: Accessory Hepatic Lobe (AHL) is a rare congenital anomaly that consists of the presence of a supernumerary lobe of hepatic parenchyma. The incidence of AHL is less than 1%, with only 27 cases having been reported in the paediatric population to date.

Aim: To identify studies in the literature on accessory hepatic lobe and present our experience with this condition.

Material and methods: We report the case of a patient who underwent surgery for intestinal occlusion and was found to have an accessory liver lobe with an embedded gallbladder. We reviewed published articles on accessory hepatic lobes accessed via PubMed, Google Scholar, Science Direct and Web of Science. Keywords included accessory hepatic lobe, ectopic liver tissue, ectopic liver lobe, accessory liver lobe. The search included articles published before August 2021 in English.

Results: We identified 27 published cases of paediatric accessory hepatic lobe. Of these 27, 14 were female and 13 were male, and the age range was 1 day to 19 years. We report the case of a female patient with intestinal occlusion found to have an accessory hepatic lobe with an embedded gallbladder. Of the 28 published cases, including ours, 11 are associated with abdominal wall defects including Umbilical Hernia, Omphalocele, Cloacal Exstrophy and Beckwith Wiedemann syndrome.

Conclusion: Accessory hepatic lobe is a rare entity usually detected incidentally. A total of 28 cases were reported, including our own. Paediatric surgeons should be aware of this condition in children with a history of abdominal wall defects.

Streptomycin associated nephrotoxicity can manifest either as nonoliguric acute kidney injury, tubular dysfunction or electrolyte abnormalities including Fanconi-like syndrome or Bartter syndrome. We report a case of Streptomycin-induced renal electrolyte wasting mimicking Bartter’s syndrome.

Purpose: Individuals diagnosed with End-Stage Kidney Disease (ESKD) have multiple comorbidities and require many medications. Alterations in renal function, coupled with pharmacokinetic and pharmacodynamic changes in individuals with increasing age, can result in adverse drug effects. The purpose of this case is to demonstrate how interventions recommended by a clinical pharmacist improved medication safety for a patient with ESKD.

Case: A 55-year-old male with a past medical history of ESKD, peripheral artery disease, chronic heart failure, cirrhosis, and major depressive disorder had a clinical pharmacist-led medication review. During the review, the clinical pharmacist identified several medications (i.e., bumetanide, metolazone, spironolactone, rivaroxaban) that should be discontinued since the patient had no urinary flow output and was on dialysis. Before the recommendations were addressed, the patient experienced retinal hemorrhaging, which may have been a rivaroxaban-associated adverse drug reaction. After addressing the retinal hemorrhaging, the physician discontinued the rivaroxaban and initiated clopidogrel. Additionally, both bumetanide and metolazone were discontinued.

Conclusion: This case demonstrates that clinical pharmacists can have a significant role in medication therapy management and medication safety, especially in patients with ESKD. Healthcare providers with patients with ESKD on dialysis can greatly benefit from consulting with a clinical pharmacist who can evaluate all medications for safety and efficacy.

Transverse myelitis is an uncommon neurological condition characterized by the inflammation of the spinal cord causing destruction to the myelin sheath. Acquired immunodeficiency syndrome can be a risk factor for this unusual disease. In later stages of AIDS, HIV myelopathy can be presented with diminished CD4 counts. We report the case of a 47-year-old male patient with H/O HIV and Hypertension presented with the complaints of asymmetrical limb weakness, followed by involuntary bowel and bladder habits, decreased bladder sensation, and intermittent fever. At the time of admission, the patient was found to have features of myelopathy and after various modalities of evaluation the patient was initiated on the treatment for the same. Being a rare case, this case report has great importance. Also, treatment of multiple diseases with multiple drug therapy remains a major challenge for physicians.

Background: Visual hallucinations are disturbances of perception present in various pathologies. Peduncular hallucinosis is complex visual hallucinations involving animals or often terrifying people that occur after pontine injuries. In this case report we present the clinical history of a middle-age man who reported peduncular hallucinosis due to mild but numerous ischemic lesions in the pontine region. This is a peculiar condition as the literature reports PH for much more severe injuries. Case presentation: A 55-year-old Caucasian man with hypertension, dyslipidemia, carotid atheromatosis and a previous diagnosis of bipolar disorder was admitted to the psychiatry ward of the Sant'Andrea Hospital due to the appearance of a mixed mood state with psychomotor agitation, ideic acceleration, anguish, auditory hallucinations, severe anxiety, panic attacks, total insomnia, disturbances in concentration and suicidal ideation. During hospitalization, he had complex visual hallucinations. On MRI of the brain, there were numerous ischemic areas in the pontine paramedian ventral region. On audiometric examination, there was bilateral sensorineural hearing loss. The patient was discharged with Valproic Acid 1000 mg/day, Quetiapine 200 mg/day. After discharge he underwent a neuropsychological evaluation that showed a cognitive decline. Conclusion: There are various cases in the literature of pontine ischemias that have given simple and complex, terrifying and beautiful visual hallucinations. Patients generally had a normal state of consciousness, no delusions, and had sleep disturbances. Lesions of the pons involving the dorsal raphe nucleus result in the loss of ascending serotonin inhibition to the dorsal lateral geniculate nucleus. Consequently, an over-excited geniculate can generate visual hallucinations at the cortical level. These ischemias in the paramedian ventral pontine region may have damaged the nucleus of the acoustic nerve causing a bilateral sensorineural hearing loss and the nuclei of the lenticular formation which, through the serotinenrgic and dopaminergic dysregulation, gave rise to visual hallucinations. These visual hallucinations can be considered PH. Considering the cognitive impairment, assessed through neuropsychological assessment, and the cardiometabolic risk factors, we can also affirm that the previous psychiatric diagnosis of bipolar disorder could have delayed the neurological diagnostic investigations.