Журнал клинических случаев

Abscesses and cellulitis represent the leading causes for emergency department visits and hospital admissions for intravenous drug addicts’ patients. Since these patients frequently use the neck for vascular access, neck abscesses are also commonly developed causing serious airway problems. A 28-year old Intravenous Drug Addict (IVDA) Caucasian male patient, presented to the casualty Department due to progressive neck swelling and pain after self-administered, unsterile, deep-cervical intravenous injection of heroin. Emergency contrast computed tomography scan revealed a large abscess causing significant dislocation of the trachea. The patient was urgently treated by percutaneous neck abscess drainage, via an 8Fr catheter, under ultrasound guidance Emergency computed tomography scan of the affected area and ultrasound scan of the major vascular supply are helpful in designing the therapeutic approach in terms of percutaneous drainage or surgery in cases of neck abscess that may cause airway obstruction in intravenous drug addicts. Percutaneous drainage under ultrasound guidance represents an effective treatment option relieving the life threatening trachea dislocation and eliminating the need for surgical intervention.

Aims: To report of a case with non-traumatic distal ulnar artery aneurism leading to ulnar nerve neuropathy at level of wrist in the ulnar tunnel. Ulnar nerve impingement has been mostly reported to be a result of posttraumatic false aneurysms, thrombosis, or anomalies distal ulnar artery in ulnar tunnel (Guyon’s canal). Methods: A 33 year-old woman with sever continuous pain which was gradual in onset over the last 9 months associated with intermittent burning sensation and continuous numbness on the ulnar side of her left hand was presented to causality unit. EMG examination showed an ulnar neuropathy in the ulnar tunnel and an ipsilateral carpal tunnel syndrome. Results: An operation was performed and exploration of the right ulnar nerve in the ulnar tunnel at the wrist showed that an ulnar artery aneurysm had pulsatile pressure like effect on the ulnar nerve. Ulnar nerve decompression by ulnar artery ligation was performed after ensuring of distal circulation, the carpal ligament was excised at the same session. After the operation, pain was improved completely in the first day postoperatively but numbness lasted for about 6 months post operatively. Conclusion: Peripheral nerve neuropathies are results of a variety of causes most of which are post traumatic, non-traumatic peripheral artery aneurism are very unlikely seen to be a leading cause to the neuropathy. Although the exact etiology is unknown but mostly it might be the pulsatile pressure like affect that predispose to the upcoming neuropathy which explains the disappearance of the pain first day postoperatively after the ligation of the aneurysm was performed.

Hypothyrodisim associated with different neuromuscular manifestations. Rarely patient with hypothyroidism may develop muscular pseudohypertrophy a condition called Hoffmann’s syndrome in adults. We report a patient present mainly with myelgia, cramps, calf pseudohypertrophy and persistently elevated Creatine Kinase (CK) with absence of other systemic symptoms of hypothyroidism. His laboratory works revealed severe hypothyroidism. Treatment with L-thyroxine resulted into disappearance of symptoms, normalization of CK and return of calf size to normal. Hypothyrodism should be considered when evaluating patients with neuromuscular complaints even in absence of systemic symptoms.

Nephroblastoma (Wilms’ tumor) the most common malignant renal tumor in childhood, is extremely rare in adults. The diagnostic is usually made by pathologic examination of a surgical specimen. Despite its aggressive treatment, such as radical surgery, chemo and radiotherapy; prognosis of nephroblastoma in adults is worse than in children. The authors report the clinical manifestations, complementary explorations, treatment, and results of two cases of nephroblastoma incidentally diagnosed in adult age. We conclude that the possibility of an adult Wilms’ tumor should be considered when a patient presents with pain in the flank and a renal mass.

Introduction: Lamivudine is a potent inhibitor of hepatitis B virus (HBV) replication via suppression of the RNAdependent DNA polymerase. However, patients with prolonged therapy were previously detected harboring drugresistant mutants. Such mutants though partially replication defective, confer resistance to lamivudine and can elicit exacerbation of hepatonecro-inflammation. Cases presentation: In this case series, we examined mutations in the YMDD motif gene in five lamivudinetreated patients (60 yr male, 50 yr female, 46 yr male, 36 yr male and 42 yr male) and in four untreated patients (34 yr female, 29 yr male, 29 female and 37 yr male). Rare mutational patterns of rtM204L in conjunction with rtL108M were recognized conferring resistance to lamivudine. The rtL180M compensatory mutation was identified in conjunction with rtM204V/I/L; among which three patients had viral and biochemical breakthrough associated with serum HBV DNA levels exceeding 106 copies/mL. Conclusions: These results indicate that; (i) lamivudine resistant HBV strains are naturally occurring mutants as detected in lamivudine untreated patients and; (ii) New mutational patterns (rtM204L: YLDD and rtL180M) were identified conferring resistance to lamivudine and resulted in biochemical and virological breakthrough. Based on these findings, we propose that such mutations can be used as a marker to predict development of viral breakthrough in the HBV patients whether or not treated with lamivudine.

Rasmussen encephalitis (RE) is a rare and progressive disease of childhood. We report the case of 14-year-old girl who presented with recurrent partial and generalized epileptic seizures with mental impairment and progressive left sided hemiplegia. EEG showed slowing of the background activity and paroxysmal discharges of slow waves in the right hemisphere. Serial MRI brain scans revealed an important atrophy of the right hemisphere with dilatation of the ipsilateral lateral ventricle. The residual phase, characterized by decrease in seizure frequency and stabilization in the hemiparesis, constitute the ultimate stage of RE.