Clin. Pract., Volume 11, Issue 1 (March 2021) – 24 articles

Secondary organizing pneumonia refers to a disease process caused by pulmonary tissue injury. Various insults can cause secondary organizing pneumonia, including multiple types of infections and cancer. The mainstay of diagnosis is a combination of imaging and lung biopsy showing inflammatory changes, specifically plugs with granulated tissue and fibrosis. Clinical suspicion needs to be raised for secondary organizing pneumonia when a patient is requiring increasing amounts of oxygen in the presence of treatment for pneumonia or another underlying lung disease. Here, we present the case of a 65-year-old male who presented with acute hypoxemic respiratory failure in the setting of previously having been tested positive for influenza B. Aggressive steroids with eventual tapering of his O₂ requirements led to a successful outcome. While influenza has been reported as a cause of secondary organizing pneumonia after proceeding infection, these cases are usually represented by type A, rather than B. Full article

Viral infections, alcohol, hepatic steatosis, autoimmunity medications and herbal supplements are common etiologies of hepatitis. Khat (Catha Edulis) is a commonly used recreational substance in East African and Middle Eastern countries. Khat has been reported in the literature to be associated with hepatotoxicity, which can present in several forms, including chronic liver disease. The possible pathogenesis of liver injury could be secondary to biochemical components of Khat itself or additives such as pesticides or preservatives. An autoimmune mechanism of liver injury has also been postulated, supported by sparse evidence. We present a case of a Yemeni immigrant with acute hepatitis whose fear about social norms and breaching confidentiality made it challenging to identify Khat as being the underlying cause. A 34-year-old man from Yemen presented with right upper quadrant pain of one day duration. He had predominantly elevated transaminases with mild elevation in bilirubin. His investigations were negative for the viral, metabolic or biliary etiology. A persistent focus on clinical history and the well-established physician–patient relationship revealed a history of Khat use. The liver biopsy finding of lobular hepatitis was compatible with drug-induced liver injury and established the finding of Khat hepatotoxicity. Subsequently, the patient improved with conservative management. Full article

Abiotrophia defectiva is a rare agent of endocarditis and subacute presentation may delay the diagnosis. We present the case of a 41-year-old male who was admitted to the hospital for further investigation regarding a consumptive syndrome with microcytic anaemia. Past medical history included new-onset mitral insufficiency followed by an ischaemic stroke due to small vessel disease. Thoraco-abdominal computed tomography revealed a splenic infarction. In the presence of two ischaemic events associated with mitral valve disease of unknown aetiology, we considered the possibility of subacute endocarditis. Blood cultures were positive for Abiotrophia defectiva, and transoesophageal echocardiography confirmed the diagnosis. As a subacute presentation of endocarditis, the paucity of symptoms caused a five-month delay in diagnosis. New-onset valvular disease and a stroke in an otherwise healthy young patient should always prompt proper investigation. This case highlights several complications caused by septic emboli of undiagnosed and untreated endocarditis. Full article

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread throughout the world. This disease has a spectrum of different clinical pictures with different outcomes. Herein, we report all the data from three paucisymptomatic patients during a hospital stay that might represent a paradigmatic example of the method by which SARS-CoV-2 is shed. We demonstrated the lack of an adequate qualitative and quantitative immune response by multiparametric flow cytometry analysis. Our data can provide a new perspective about the method by which SARS-CoV-2 is shed and the clinical weight of viral persistence. In all three cases, the long persistence of the virus and the consistent reduction in both innate and adaptative immune cells are not associated with greater disease severity. These patients might represent at least part of the population. In particular, one patient oscillated between positive and negative swab tests several times without presenting any immune response. In all three cases, the immune response failure was not associated with a clinically significant involvement, indicating that it is not the virus’s ability to impair the immune system, as well as its presence and persistence the fundamental mechanism that might causally lead to death. Finally, this kind of immune response in paucisymptomatic patients could pose a considerable danger to public health that questions the quarantine period. It is urgent to quantify the phenomenon with a large sample study. Full article

(1) Background: This study investigated the introduction of pediatric robot-assisted pyeloplasty in a low-volume centre with reference to open pyeloplasty with regards to operative times, length of stay (LOS) and outcomes and cost analysis. (2) Methods: Data from 10 consecutive robot-assisted pyeloplasties was compared retrospectively to an age and weight matched cohort of open pyeloplasties operated on during two previous years. Operative times were analyzed in conjunction with LOS, outcomes and cost-analysis from patient records. (3) Results: Operative times remain longer in robot-assisted pyeloplasties (168 (IQR 68) vs. 141 (IQR 51) min), but patients are discharged from the hospital earlier and may return to daily activities earlier. In our hospital, the difference in LOS levels to some degree the cost difference between operations. (4) Conclusions: Robot-assisted pyeloplasty can be safely and economically introduced and maintained in a low-volume centre. Full article

End-stage kidney disease patients who require hemodialysis for more than 3 months have a small chance of leaving dialysis unless they have a kidney transplant. Educating the patient about lifestyle changes can play a major role in improving kidney function. Therefore, we created a patient education program according to our nephrology experiences. Herein, we show an end-stage kidney disease patient who underwent hemodialysis for 6 months. Afterwards, dialysis was terminated with patient care, and the patient was then followed up for 9 years without dialysis. To date, there have been no reports regarding the termination of long-term dialysis with a kidney care program and the ensuing 9-year follow-up without renal replacement therapy. Full article

Multiple myeloma (MM) is a B cell malignancy resulting in osteolytic lesions. Pathological fracture of the vertebral body resulting in spinal cord compression is a common complication and accounts for approximately 5% of patients with MM. To date, there are no definitive guidelines for the treatment of spinal cord compression as a consequence of MM. Radiotherapy has frequently been the preferred form of treatment. Some surgeons, however, feel that spinal lesions in multiple myeloma should be treated in the same manner as spinal metastases from solid organs. I report the management of a 46-year-old gentleman with multiple myeloma that had resulted in neural compression in the lumbar and thoracic areas. Initial emergent treatment in this patient consisted of spinal decompression and stabilisation. Full article

A broad spectrum of lesions, including hyperplastic, metaplastic, inflammatory, infectious, and reactive, may mimic cancer all along the urinary tract. This narrative collects most of them from a clinical and pathologic perspective, offering urologists and general pathologists their most salient definitory features. Together with classical, well-known, entities such as urothelial papillomas (conventional (UP) and inverted (IUP)), nephrogenic adenoma (NA), polypoid cystitis (PC), fibroepithelial polyp (FP), prostatic-type polyp (PP), verumontanum cyst (VC), xanthogranulomatous inflammation (XI), reactive changes secondary to BCG instillations (BCGitis), schistosomiasis (SC), keratinizing desquamative squamous metaplasia (KSM), post-radiation changes (PRC), vaginal-type metaplasia (VM), endocervicosis (EC)/endometriosis (EM) (müllerianosis), malakoplakia (MK), florid von Brunn nest proliferation (VB), cystitis/ureteritis cystica (CC), and glandularis (CG), among others, still other cellular proliferations with concerning histological features and poorly understood etiopathogenesis like IgG4-related disease (IGG4), PEComa (PEC), and pseudosarcomatous myofibroblastic proliferations (post-operative spindle cell nodule (POS), inflammatory myofibroblastic tumor (IMT)), are reviewed. Some of these diagnoses are problematic for urologists, other for pathologists, and still others for both. Interestingly, the right identification of their definitory features will allow their correct diagnoses, thus, avoiding overtreatment. The literature selected for this review also focuses on the immunohistochemical and/or molecular data useful to delineate prognosis. Full article

Fusion is a congenital disturbance affecting primary dentition mostly during morpho differentiation of the primary tooth germs. Fusion leads to the union of two or more primary teeth by the enamel and dentin while the pulp and roots remain separate. These abnormalities may be unilateral or bilateral. Prompt diagnosis and a treatment plan in such anomalies may help to overcome problems concerning aesthetics, caries susceptibility and space management. This report describes a case of unilateral fusion of the primary mandibular lateral incisor and canine and aims to evaluate any associated pathology. Full article

There are several classes of medications that can cause prolongation of the corrected QT (QTc) interval and potentially Torsades de Pointes (TdP). Most of these medications are commonly used in the emergency department, and interaction between these medications increases the risk of this iatrogenic complication. We describe a patient on methadone therapy who developed TdP after she received metoclopramide and metronidazole. Interaction between different classes of medications can increase the risk of QTc prolongation and TdP. Awareness of this condition and its risk factors need continuous reinforcement among all hospital personnel to reduce the risk of this life-threatening complication. Full article

Patient centeredness in planning treatment and research has become paramount. The goal of this report was to describe a complex case in which untreated chronic pain was not properly addressed to reflect on the need to establish alternative protocols for controlling chronic orofacial pain. When a female underwent orthognathic surgery to correct her occlusion, she not only ended up with a worse occlusion, she developed chronic orofacial pain that could not be treated by opioids and only improved after the use of neuropathic medication, and finally disappeared after the use of low-level laser therapy. There is a need to incorporate alternative nonpharmacological approaches to manage chronic pain. Further, what the patient’s goals are for their treatments should be given priority in case of elective procedures. Full article

The virus that causes COVID-19 is rapidly spreading across the globe. Elderly patients with multiple pre-existing conditions are at a higher risk. This case study describes acute inpatient treatment of a COVID-19 patient with uncontrolled diabetes mellitus, kidney complications, heart failure, chronic pain, depression, and other comorbidities in an isolation ward without mechanical ventilation. Full article

Simpson-Golabi-Behmel syndrome (SGBS) is a rare x-linked overgrowth syndrome with distinct clinical features, which is difficult to diagnose prenatally. We report the diagnosis of SGBS in dichorionic-diamniotic twin pregnancies in the first trimester by ultrasound and genetic testing. The affected fetus developed polyhydramnios and the cervical length of the mother decreased significantly. To save the unaffected twin, a selective feticide of the affected fetus was performed. Finally, the patient underwent preterm caesarean section due to premature rupture of membranes in the dead twin, and also intrauterine infection. While SGBS has been reported, this was the first case in a multiple pregnancy, with possible consequences for the healthy twin. In conclusion, SGBS is a rare condition, which should be considered in the differential diagnosis of prenatal overgrowth syndromes and associated malformation. Full article

The skin is the largest, and arguably, the most vulnerable organ in the human body. Scratches and scrapes, bites and puncture wounds, impetigo and erysipelas—all these disruptions can lead to pain, swelling, and/or systemic symptoms. In this article, which is based on the Infectious Diseases Society of America’s 2014 guidelines and the World Society of Emergency Surgery and Surgical Infection Society of Europe’s 2018 consensus statement, a structured approach to skin and soft tissue infections (SSTIs) is reviewed, comparing treatment for suppurative and non-suppurative infections, and then discussing specific conditions commonly seen in Primary Care and Urgent Care facilities. Full article

Metastatic tumors to the oral cavity are uncommon, representing approximately 1% of all cases of oral malignant lesions even when a metastatic disease is present. The 53-year-old female is presented complaining of abdominal pain, weight loss, and a loose stool recurring not more than three times per day. A computed tomography (CT) scan of the abdomen showed a retroperitoneal mass expanding along the body of the pancreas. Colonoscopy and gastroscopy with a gastric mucosa biopsy showed a normal result. After laparoscopic surgery, the primary site of adenocarcinoma was not confirmed. The patient was referred to the Maxillofacial Surgery Clinic with pain, swelling, and occasional bleeding around the lower right second mollar. Immunohistochemicaly, the tumor cells were positive for Cytokeratin (CK) 19, Cytokeratin (CK) 7, and homebox protein (CDX-2), which are highly sensitive markers of pancreatobiliar cancer. Therefore, the patient was diagnosed with pancreatic carcinoma. This report describes a rare metastasis of malignant pancreatic tumor to the lower right gingiva and highlights the importance of immunohistochemical examination and how it helped identify both the origin and the nature of gingival neoplasm. Full article

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the “off-label” character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing. Full article

A case of nasopharyngeal tuberculosis with cervical lymph node tuberculosis is reported. The patient was a 20-year-old female immigrant from Vietnam and cook apprentice. Her chief complaint was left neck swelling with pain for three months. She was diagnosed with left neck lymphadenitis at a previous hospital, which suspected malignant lymphoma and referred her to our hospital. At the time of the first visit, she had left lymph swelling with tenderness and granuloma-like masses in the nasopharynx. PET-CT showed accumulations in both the swollen left neck lymph and nasopharynx. The diagnosis of this case would appear to be nasopharyngeal cancer with left and neck lymph node metastasis or nasopharyngeal tuberculosis with cervical lymph node tuberculosis in addition to malignant lymphoma. Based on some examinations (biopsy, bacteria culture, and imaging), it was diagnosed as nasopharyngeal tuberculosis with cervical lymph node tuberculosis. Therefore, she was treated with anti-tuberculosis agent in respiratory medicine. Full article

Pulmonary hyalinizing granuloma (PHG) is a rare, benign lung disease of unknown etiology. It usually manifests as solitary and sometimes as multiple pulmonary nodules. It may have irregular margins, cavitation, or calcifications mimicking metastasis or primary lung neoplasm. It should be considered in the differential diagnosis of pulmonary nodules or masses. In this report, we present an unusual case of incidental slow-growing lung mass in a patient with 30 pack-year smoking history, construction-based occupation. The pleural-based calcified nodule in the left upper lobe gradually increased in size over ten years without any hilar or mediastinal lymphadenopathy. For an accurate diagnosis, PET-scan and histopathological analysis through wedge resection by video-assisted thoracoscopic surgery (VATS) were done. The biopsy findings were consistent with pulmonary hyalinizing granuloma, a rare benign cause of lung mass with an excellent long-term prognosis. Full article

Pleural involvement in Non-Hodgkin Lymphoma (NHL) is well documented, but primary pleural lymphomas are extremely rare, occurring mostly in immunosuppressed patients or associated with chronic pleural inflammation. Nevertheless, the pathogenesis and therapeutic approaches to counteract primary pleural lymphomas are still matter of debate. The authors present the clinical case of an 81-year-old female with respiratory and constitutional symptoms. A valvular heart disease and bilateral pleural effusion were known. The study carried out showed a large right pleural effusion; the fluid analysis was compatible with Diffuse Large B-cell Lymphoma (DLBCL), and two lymphomatous masses with pleural origin were found at the ipsilateral hemithorax. Primary pleural lymphoma was considered and chemotherapy was initiated with a good response and evolution. The authors report this remarkable clinical case because of its rarity, its excellent clinical evolution and the absence of an immunodeficiency context. Full article

There is an increasing consensus that the treatment of Hidradenitis suppurativa (HS) significantly varies with the degree of inflammation and that treatment according to guidelines is not always successful. Here, we report the case of a 31-year-old male with widespread, highly inflammatory Hurley Stage II HS in multiple locations who failed to respond to any kind of established medical treatment, including biologics. As an alternative approach, Ustekinumab was maintained, and additionally the patient was treated with LAight therapy, a combination of intense pulsed light and radiofrequency. After 10 sessions, deroofing of multiple lesions was performed in a two-step process. After a few weeks of healing time accompanied by specialized wound experts, the patient continued with LAight therapy to control and prevent recurrence. This case shows that the combination of LAight therapy and deroofing is a promising treatment plan for the long-term symptom control of mild and moderate HS. Full article

Pregnancy is a period of continuous change in the maternal cardiovascular system, partly mediated by the autonomic nervous system. Insufficient autonomic adaptation to increasing gestation is associated with pregnancy complications, such as hypertensive disorders of pregnancy and preterm birth (both major causes of perinatal morbidity and mortality). Consequently, maternal heart rate variability (mHRV), which is a proxy measure for autonomic activity, is increasingly assessed in these cohorts to investigate the pathophysiology of their complications. A better pathophysiological understanding could facilitate the early detection of these complications, which remains challenging. However, such studies (typically performed in pregnancies leading to hospitalization) have generated conflicting findings. A probable reason for these conflicting findings is that these study cohorts were likely administered routine obstetric medications during the study period of which the effects on mHRV are largely unknown. Subsequently, we design a longitudinal, observational study to quantifying the effect of these medications—particularly corticosteroids, which are known to affect fetal HRV—on mHRV to improve the interpretation of past and future studies. We will enroll 61 women admitted to a tertiary obstetric unit with an indication to receive corticosteroids antenatally. Participants’ mHRV will be continuously acquired throughout their hospitalization with wrist-worn photoplethysmography to facilitate a within-patient comparison of the effect of corticosteroids on mHRV. Full article

PET/CT scans are frequently used in the initial workup of suspicious lesions but not all that lights up on a PET is cancerous. We wish to discuss a case of silicone-induced granuloma mimicking malignancy and the role of other imaging modalities for further workup. Full article

Superior mesenteric artery (SMA) syndrome is an uncommon phenomenon caused by the compression of the third portion of the duodenum between the aorta and the SMA. Here, we present a previously healthy 15-year-old male who presented with early satiety and 20 kg weight loss. Computed tomography (CT) demonstrated a massive retroperitoneal liposarcoma displacing the entire small intestine into the right upper quadrant. Following resection of the large mass, the patient was intolerant of oral intake despite evidence of bowel function. Abdominal CT revealed a narrowing of the duodenum at the location of the SMA. A nasojejunal feeding tube was placed past this area, and enteral nutrition was initiated before slowly resuming oral intake. Post-operative SMA syndrome is an uncommon complication but should be considered in patients intolerant of oral intake following resection of large abdominal tumors associated with extensive retroperitoneal fat loss, even in the absence of concomitant major visceral resection. Full article