Журнал клинических случаев

A 65-year-old man presented for evaluation of altered mental status, preceded by several months of sleep abnormalities, excessive salivation, and paroxysms of drenching sweats. Despite having no history of diabetes mellitus, he was severely hyperglycemic with a hemoglobin A1C of 11%. Serum tests revealed hyponatremia as well as positive Voltage-Gated Potassium Channel (VGKC) serum antibodies, and EEG showed frequent epileptic discharges originating from the left temporal lobe. He was ultimately diagnosed with VGKC antibody encephalitis and was treated with antiepileptic, anti-diabetic and corticosteroid agents with improvement in his mental status. One year following treatment, he was seizure-free, had returned to his baseline level of function, and had been weaned off both corticosteroids and anti-diabetic medications.

Background: The association between intracranial Dural Arteriovenous Fistulas (dAVF) and psychiatric disorders has been reported in a few anecdoctal reports Case presentation: A case of severe depression with dAVF is presented. The patient with depression showed poor response to antidepressants, and after a severe headache she was investigated and was found to have a dAVF. The DAVF was successfully treated withmcoil embolization. After this treatment, his depression was improved and the quantity of the antidepressants decreased. Conclusions: The findings in our case suggest a probable association between dAVF and treatment resistant depression caused by cerebral hypoperfusion especially of the left cerebral hemisphere. It may be necessary to evaluate cerebral vessels in patients suffering from depression by using MRA.

Infusion-related reactions resulting from administration of monoclonal antibodies targeting the epidermal growth factor receptor (EGFR) are well defined in the literature. Although these reactions occur more frequently with earlier generation antibodies such as cetuximab, which contains 34% murine protein, the risk of immunogenicity is still present with fully human and humanized antibodies. Panitumumab is the first fully human monoclonal antibody approved by the US Food and Drug Administration for the treatment of patients with metastatic colorectal cancer. It is associated with a lower risk of hypersensitivity reactions and premedications are not routinely required. Because of the inherent differences in protein sequence between the two agents, patients who experience infusion reactions with cetuximab may tolerate panitumumab administration. There are however limited data on the safety of panitumumab in patients with prior infusion reactions to cetuximab. We report a case of a 62-year-old patient with metastatic colorectal cancer who was treated successfully with panitumumab and irinotecan after developing a grade 4 infusion reaction to cetuximab therapy. Treatment with panitumumab was initiated approximately five weeks after the single dose of cetuximab resulted in respiratory failure, cardiac arrest and intensive care management. The patient was premedicated prior to first and all subsequent doses. To date, the patient has not experienced any hypersensitivity reactions and continues to receive panitumumab in combination with chemotherapy with objective improvement in his overall condition. This case suggests that panitumumab maybe safely administered in patients with prior infusion reactions to cetuximab.

Erlotinib is a human epidermal growth factor receptor type 1 tyrosine kinase inhibitor which is used for non-small cell lung cancer treatment. Interstitial lung disease has been reported as an adverse event of erlotinib. We report the case of a 39-year-old man with erlotinib-induced interstitial lung disease in a non-small cell lung cancer patient. Although interstitial lung disease had improved by steroid therapy, palliative radiotherapy recalled the pneumonitis beyond the radiation fields. After the pneumonitis was well controlled, the patient was started on irinotecan, but the interstitial lung disease recurred shortly thereafter. We may have to abandon further cytotoxic therapies to avoid the recurrence of interstitial lung disease in patients who develop erlotinib-induced interstitial lung disease once.

5-15% of patients with undiagnosed Fever of Unknown Origin have a chronic course, especially in long term care settings. It is important to identify the underlying cause as it may be secondary to more sinister underlying causes that often require an intensive and advanced diagnostic evaluation. Acute non-tuberculous retropharyngeal abscess is an infection in one of the deep spaces of the neck; it is rate in adults and usually results from local trauma, such as foreign body ingestion, or following instrumental procedures (laryngoscopy, endotracheal intubation, feeding tube placement, etc.). An esophageal perforation after anterior cervical surgery is also an uncommon but well recognized complication. Esophageal perforation and neck abscess formation are a rare complication of anterior cervical spine surgery. The causes include: (a) Oppression of the esophagus during surgery, due to a clasp held for too long causing a necrosis of the esophagus; (b) Esophagus injured by loose plates and screws. Therefore, after anterior cervical spine surgery if patients have a high fever, sore throat, swelling incision, and food sediment is was found in the incision, esophageal cutaneous fistula should be considered. The final diagnosis could be done by esophageal radiography. CT scan helps in delineating the location and condition of the implant, extent of an underlying abscess and possible extension of the abscess along the prevertebral space. We report a 31-year-old, Indian male patient who developed non-tuberculous retropharyngeal abscess during his hospital stay. The retropharyngeal abscess occurred in the context of unknown blunt trauma to esophagus and led to bilateral lower lung collapse and consolidation with secondary bronchiectasis that ultimately proved fatal. This case report describes an unusual but important cause for fever of unknown origin especially in cases where patients have Polymicrobial infections with rare offending agents particularly in patients in acute medical setting.

Background: Intractable diarrhoea of childhood is one of the most life-threatening chronic conditions and its management is always intriguing even in highly advanced critical care set-up. Objective: To describe the clinical course of a 3 months old baby suffering from intractable diarrhoea and recurrent hypernatremia. This case focuses difficulties due to diagnostic limitation as well as management constrains of young children with intractable diarrhoea in the context of limited resources. Case brief: The young infant was admitted in the Intensive Care Unit (ICU) of Dhaka Hospital in the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) with the complaints of watery diarrhoea since birth, hypernatremic (serum sodium:168 mmol/L) seizure, and severe acute malnutrition. Hypernatremia was corrected within 5 days of admission (corrected serum sodium: 147 mmol/L) by using only Oral Rehydration Salts solution (ORS). To assess any possible structural damage of the brain as a result of hypernatremia, we performed Magnetic Resonance Imaging Scan of the brain. The scan revealed right sided bleeding in choroid plexus. Although, the diarrhoea was initially improved by diet as per world health organization dietary algorithm (beginning with low lactose followed by lactose-free chicken-based diet), it relapsed later. Subsequently the infant developed nosocomial infection, worsening of diarrhoea and recurrent hypernatremia. For the management of intractable diarrhoea, the patient had to stay in hospital for a prolonged period that may have led to nosocomial infection. It was difficult to manage due to severe malnutrition, young age and on-going diarrhoea. The patient finally expired on 39th day of admission due to septic shock. Conclusion: Patient with intractable diarrhoea may present with other co-morbidities like malnutrition, hypernatremia and sepsis that make the management very difficult. In low income countries, where total parental nutrition facility is unavailable, a systematic approach needs to develop to reduce intractable diarrhoea related mortality.

A Urinary Tract Infection (UTI) is an infection of the urinary system including the urethra, bladder, ureters, and kidneys. UTIs are typically caused by flora from the colon, most commonly E. coli. Infants typically present with non-specific symptoms of fever, poor feeding, and irritability, while older children may have more classic symptoms. Boys are more likely to develop a UTI in the first year of life, while after the first year they are more common in girls. In boys, circumcision decreases the risk of UTI at all ages. Overall 3-5% of girls experience a UTI, usually within the first 5 years of life.

A 28-month-old boy presented with a 3-week history of intermittent left esotropia with a 48 hour cycle. The decision to perform surgery was made after treatment with patching and full refractive correction of the hyperopia. Bilateral medial recession with recession of both inferior oblique muscles was performed. Follow up examination postoperatively showed that the cyclic pattern resolved but a constant esotropia occurred.

Isolated tubal torsion is rare event during pregnancy. The clinical symptoms are often nonspecific and the diagnosis is difficult, especially in the pregnant abdomen. The diagnosis is usually established during the operation performed for acute abdomen. Early diagnosis and treatment is necessary and early gestationel weeks laparoscopy may be a considerable diagnostic tool in these cases. We report a case of isolated tubal torsion in the third trimester of the pregnancy with pararectal incision.

Acute massive pulmonary embolism is a life-threatening emergency with a very high mortality. A 34 year old man, presented in our emergency department with complaints of NYHA class-III dyspnoea, cough, palpitation, and left sided chest pain. The clinical findings and investigations suggest diagnosis of pulmonary embolism followed by confirmation with CT angiography. The patient was taken to the operation theatre with supported hemodynamically with dobutamine infusion. Using required monitors, anesthetic induction was done with etomidate and fentanyl followed by the tracheal intubation with rocuronium. During induction, there was sudden hypotension which was managed with fluid boluses and norepinephrine boluses and continuing infusion of dobutamine. Anaesthesia was maintained with 50% oxygen with air, pancuronium, fentanyl and midazolam. After midline sternotomy, using Cardiopulmonary Bypass (CPB), thromboembolectomy was done on warm beating heart without aortic cross-clamping or cardioplegia. Partially organized thrombi were removed from left and right pulmonary arteries and their distal branches. The patient was weaned successfully from CPB with inotropic supports. The patient was extubated in the surgical ICU. The patient was discharged on the 5th postoperative day uneventfully. The management of pulmonary embolism tests the skills of the anesthetist with respect to rapid haemodynamic management, management during CPB and difficulty in weaning successfully off CPB, using appropriate combination of inotropes and vasodilators.

Vitamin B12 deficiency is common. Pernicious anemia is the most common cause of severe vitamin B12 deficiency worldwide [1]. Clinical spectrum of vitamin B12 deficiency may range from asymptomatic subclinical state to megaloblastic anemia to demyelination of the cervical and thoracic dorsal and lateral columns of the spinal cord and demyelination of the white matter in the brain.

Stafne cyst, also known as the stafne bone cavity is a concavity in the lingual cortex of mandible containing salivary gland tissue. These radiolucent areas are usually cortical defects occurred as a result of extension of the submandibular gland. This cyst is incidentally detected on the radiographs ordered for the other reasons. Our case report is on a male patient aged 44 years admitted to another center with the complaints of the pain in the jaw and left side of the face, and who underwent panoramic radiographic examination of the mandible, in addition to dental and mandible tomographies. Radiological findings correlate with Stafne cyst. Tegretol was commenced with the provisional diagnosis of atypical facial pain and trigeminal neuralgia. Panoramic radiography of the mandible was scheduled 6 months later for the follow up of the cyst.