pISSN: 2538-2683
eISSN: 2538-2691
Editor-in-Chief:
Shahin Akhondzadeh
Editor-in-charge:
Seyed Farshad Allameh
Current Issue
Vol 9 No 5 (2024): September -October
Case Report(s)
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Endogenous endophthalmitis is caused by the hematogenous dissemination of infectious organisms, resulting in intraocular infection. This entity is uncommon and accounts for 5–15% of all forms of endophthalmitis. Patients with compromised immune systems are most at risk for endogenous endophthalmitis. An immunocompetent 20-year-old man, following a recent hospitalization and ventilator-associated pneumonia (VAP), presented with blurred vision in the left eye. Fundoscopy revealed dense white-toyellow, pus-like subfoveal material originating from the choroid, breaking through the retina, and dispersing into the vitreous. According to polymerase chain reaction (PCR) findings, the infection had a bacterial origin and caused irreversible damage to the macula.
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Disseminated tuberculosis (TB) is rare, can affect any organ system, and predominantly presents in immunocompromised populations. While pulmonary tuberculosis (TB) is prevalent in developing countries, it is an uncommon cause of disseminated TB. In pediatric populations, particularly in the first and second decades of life, disseminated TB is often secondary to lung infections. However, there have been few reports of disseminated TB complicated by disseminated intravascular coagulation (DIC). Disseminated TB is defined as the involvement of two or more noncontiguous sites due to the lymphohematogenous spread of Mycobacterium tuberculosis. Extrapulmonary involvement occurs in one-fifth of all TB cases and may present
without histological or radiological evidence of pulmonary infection. An eleven-year-old girl presented to the emergency department (ED) with complaints of weight loss and abdominal pain. She had no history of immunodeficiency but had been in contact with TB patients. On admission, she exhibited refractory coagulopathy, necessitating transfer to the pediatric intensive care unit (PICU). In the PICU, intravenous vitamin K, fresh frozen plasma (FFP), and packed red blood cells (PRBCs) were administered on the 14th day of admission, following the initiation of antibiotics and a combination of standard anti-tuberculous drugs.
It can be speculated that many pediatric cases of TB-induced pneumonia leading to acute respiratory distress syndrome (ARDS) remain unreported in the literature. More robust data on the epidemiology of childhood TB are necessary to better understand its contribution to ARDS and to develop pediatric-specific therapeutic strategies. Some risk factors for disseminated TB include young age, recent measles infection, immunodeficiency, malnutrition, and malignancies. Children, especially infants and immunocompromised patients, are at higher risk of developing miliary and disseminated TB. However, none of these contributing factors were identified in this child. In the present case, the patient had no HIV infection or immunodeficiency but was an immigrant from an endemic country and had a history of contact with TB patients. The onset
of her symptoms closely resembled those of inflammatory bowel disease (IBD), and she later developed coagulation disorders and DIC. We successfully treated disseminated TB complicated by DIC using antibiotics, FFP, PC, vitamin K, and anti-tuberculous therapy. The follow-up indicated an improvement in her condition and the resolution of symptoms. -
Leiomyomas are most commonly encountered in the genitourinary and gastrointestinal systems, with primary hepatic leiomyomas (PHL) being a rare occurrence. We present the case of a 62-year-old man with an incidentally discovered voluminous lesion in the left lobe of the liver, initially suspected to be a hemangioma. The patient was referred for further evaluation, during which advanced imaging modalities were utilized for
accurate diagnosis, and tissue biopsies were obtained. A definitive diagnosis of PHL was established through immunohistochemistry based on pathological findings. -
Inguinal hernia repair is a common surgery that can result in incarceration in some cases. Catastrophic events may be encountered in specialized circumstances, such as Fournier’s gangrene, which is an emergent condition. Treatment of debrided skin of the abdominal wall is always challenging, particularly in large defects.
A 69-year-old man suffered from complications following inguinal hernia repair, which included laparoscopic mesh repair, subsequent right hemicolectomy with anastomosis, leading to ileostomy, Fournier’s gangrene, and eventually a large skin defect in the lower abdomen and perineal area. After multiple sessions of wound
therapy, he underwent abdominal wall reconstruction with two large pedicled anterolateral thigh flaps.
Anterolateral thigh flaps, with their robust blood supply, can easily reach the lower abdomen and cover extensive abdominal skin defects when transferred bilaterally. Level of Evidence: Level V, therapeutic study -
Silent thyroiditis during pregnancy is an under-recognized clinical condition and a rare case, often manifesting as transient hypothyroidism. We report a 23-year-old woman at 8 weeks of gestation who presented with newly diagnosed hypothyroidism [TSH = 85 mIU/L (0.4–4.5), FT4 = 0.4 ng/dL (0.7–2.5), and anti-TPO = 78 IU/mL (up
to 16)]. Thyroid function tests had been normal eight months prior. Levothyroxine (LT4) therapy was initiated, restoring euthyroidism. Treatment was discontinued postpartum, and the patient maintained normal thyroid function for over one year. Our case is unique in that silent thyroiditis occurred unusually early in pregnancy
and differed from the more common postpartum cases. Silent thyroiditis should be considered in pregnancy-related hypothyroidism, particularly when prior thyroid function was normal. Prompt diagnosis and treatment can prevent adverse maternal and fetal outcomes. -
Cervicocranial arterial dissection is not a common disease (2.5% of total brain infarction), and its pathogenesis is still not fully understood. However, it appears to be multifactorial and is rarely seen in the postpartum period. A 40-year-old woman presented to the emergency department with sudden right lower limb paresis 10 days after vaginal delivery. She had no history of DM, HTN, preeclampsia, or underlying cerebrovascular disease. Upon evaluation, left extracranial carotid artery dissection was found on cervical MRA. The likelihood of postpartum dissection is rare, but it could be due to vascular damage associated with the Valsalva maneuver during labor; hemodynamic and hormonal changes due to pregnancy may also play a role.
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Unusual Presentation of Clostridium Difficile Infection in a Patient with Inflammatory Bowel Disease
Clostridium difficile infection (CDI) is commonly associated with nosocomial diarrhea; however, certain atypical presentations can challenge its diagnosis. We report a case of CDI in a 25-year-old male with inflammatory bowel disease (IBD), presenting with unusual clinical features, including abdominal distension, lower extremity edema, and persistent non-bloody diarrhea. Diagnostic uncertainty arose due to the patient’s prior IBD diagnosis and atypical symptoms. Nevertheless, CDI was confirmed through stool toxin assay and colonoscopy findings of pseudomembranes. Treatment with oral vancomycin resulted in complete symptom resolution, underscoring the importance of considering CDI in cases with atypical symptoms. Prompt diagnosis is essential for effective management and prevention of complications.
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SARS-CoV-2 causes an inflammatory disease characterized by symptoms such as fever, cough, shortness of breath, and myalgia, along with leukopenia, lymphopenia, elevated serum aspartate aminotransferase levels, and abnormal chest computed tomography findings. It may also lead to respiratory distress, unilateral complications, and secondary infections. COVID-19 infection can result in severe neurological complications, including viral encephalitis, cerebrovascular disorders, acute diffuse encephalomyelitis, and acute necrotizing encephalopathy. Here, we report a case of hemorrhagic encephalitis due to SARS-CoV-2 in a 27-year-old patient with a history of type 1 diabetes.
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A Calcified Amorphous Tumor (CAT) consists of calcified nodules embedded within an amorphous fibrous material and represents an uncommon non-neoplastic intracavitary cardiac mass. In this article, we present the case of a 38-year-old Iranian gentleman who experienced a sudden loss of consciousness and right hemiparesis. Brain imaging revealed acute infarction in the left basal ganglia. Echocardiography identified a large heterogeneous echodensity in the posterior AV groove, with central echolucency extending to the base of the posterior left ventricular (LV) wall and the basal posterior mitral valve leaflet (PMVL), findings consistent with CAT. Cardiac Magnetic Resonance Imaging (CMR) demonstrated an intramural calcified mass with a necrotic core located in the lateral annulus of the mitral valve, extending into the left atrium and ventricle. The mass was deemed responsible for the cerebral infarction, which was classified as cardioembolic. This case report highlights Calcified Amorphous Tumor (CAT) as a potential embolic source, underscoring the importance
of early recognition through multimodality imaging. Comprehensive management, which may include regular follow-ups or surgical intervention, is crucial for patients diagnosed with CAT. -
Ankylosing spondylitis (AS) is a progressive inflammatory disease characterized by spinal rigidity, kyphotic deformities, and significant challenges in airway management during surgery. We report the case of a 50-year-old male with severe kyphosis caused by long-standing AS, scheduled for corrective spinal surgery. Preoperative assessment revealed restricted cervical mobility, a “chin-on-chest” deformity, and a high risk of
difficult intubation. Awake video-laryngoscopy-assisted intubation, combined with regional airway blocks, was successfully performed to minimize complications. Intraoperative neuromonitoring, strategic positioning, and meticulous hemodynamic management were implemented to ensure patient safety. The surgery was completedwithout neurological deficits, and the patient was discharged in stable condition. This case underscores the importance of thorough airway planning, neuromonitoring, and intraoperative vigilance in AS patients undergoing spinal correction. It highlights the critical role of a multidisciplinary approach in achieving successful surgical outcomes.
