Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report

Rationale:The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention.Patient concerns:A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain.Diagnoses:The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing.Interventions:The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed.Outcomes:The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery.Lessons:Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.     

Carbohydrate metabolism in women with metabolic syndrome with multimodal non-drug correction of menopausal disorders

Purpose of workTo study the effect of non-pharmacological correction on carbohydrate metabolism in women with menopausal disorders against the background of metabolic syndrome.Materials and methods330 women 45–50 years old with menopausal disorders during the menopausal transition and metabolic syndrome (MS) are ranked in 5 groups. Group I used: basic treatment, physiotherapy, balneotherapy, multivitamins and minerals, as well as physiotherapeutic factors (vibration therapy, chromotherapy, melotherapy, aromatherapy, aeroionotherapy). In group II, chromotherapy was excluded from the above methods, in group III - vibration therapy, in group IV physiotherapy was not used, in group V only basic treatment was used. The levels of glucose, serum insulin, and the HOMA-IR index (Homeostasis Model Assessment-Insulin Resistance) were determined.ResultsThe inclusion of physical factors in the treatment complex significantly improved carbohydrate metabolism. The simultaneous use of all these physical factors allowed the most significant decrease in the HOMA-IR index after 6 months of therapy in patients with mild climacteric syndrome by 56,2 %, in patients with moderate climacteric syndrome by 57,2 %, respectively (p < 0,0001). The decrease in the total Green test score was 55,3 % and 39,9 %, respectively (p < 0,0001).ConclusionNon-drug complex programs with physiotherapy improve carbohydrate metabolism and contribute to the regression of menopausal disorders in women with metabolic syndrome during the menopausal transition. The priority is the simultaneous use of vibration therapy, chromotherapy, melotherapy, aromatherapy and aeroionotherapy.     

Conservative management of avascular necrosis of the metacarpal head: A case report and brief review

Rationale:Avascular necrosis (AVN) of the metacarpal head is rare, and there is no clear consensus on treatment. The main aim of this study was to discuss the possible pathologic-mechanics of its development, epidemiology, radiographic features, and outcome after conservative treatment.Patient concerns:A 14-year-old male with a history of fractures in little finger complained of right-hand pain with a limited range of motion for 1 month. Diagnosis: Imaging examination confirmed the diagnosis of AVN in the long metacarpal finger and ring finger.Interventions:The patient was treated using non-surgical management, such as splint immobilization, non-steroidal anti-inflammatory drugs, and physiotherapy.Outcomes:At the last follow-up 26 months later, the patient was in complete remission with no residual symptoms. Magnetic resonance imaging (MRI) confirmed excellent remodeling and regeneration in the metacarpal head.Lessons:Metacarpal head necrosis typically occurs in adolescent patients with a history of trauma. Conservative treatment may sometimes have an excellent prognosis.     

Acute HIV infection with presentations mimicking acalculous cholecystitis: A case report

Rationale:Acute retroviral syndrome is the symptomatic presentation of acute human immunodeficiency virus (HIV) infection, which often manifests as a self-limited infectious mononucleosis-like syndrome and occurs 2 to 6 weeks after exposure to HIV. Atypical manifestations including hepatitis, meningitis, or hemophagocytic lymphohistiocytosis have been reported. However, manifestations of acute acalculous cholecystitis during acute HIV infection are rarely reported.Patient concerns:A 30-year-old man with nausea and loose stools, followed by fever and abdominal pain at the right upper quadrant for 10 days.Diagnosis:Acute retroviral syndrome, complicated with acute acalculous cholecystitis.Interventions:Percutaneous transhepatic gallbladder drainage was performed and treatment with co-formulated bictegravir/emtricitabine/tenofovir alafenamide was initiated upon HIV diagnosis.Outcomes:The patient''s symptoms improved after the drainage. The levels of liver enzyme including aspartate transaminase alanine aminotransferase decreased to a level within normal limits 1 month after initiation of antiretroviral therapy.Conclusion:Acalculous cholecystitis in combination with acute hepatitis could be manifestations of acute HIV infection. For individuals at risk of acquiring HIV infection who present with manifestations of acute acalculous cholecystitis, HIV testing should be considered.     

Effectiveness of two modalities of physiotherapy in the treatment of haemophilic arthropathy of the ankle: a randomized pilot study

Although different techniques of physiotherapy have been described for the treatment of haemophilic arthropathy (HA) of ankle, hardly any studies have been applied manual therapy or educational physiotherapy and home exercises. The aim of this study was to assess the effectiveness of manual therapy and educational physiotherapy in the treatment of HA of the ankle. Thirty‐one patients with HA of the ankle with a mean age of 35.29 (SD: 12.877) years randomized to manual therapy group (n = 11), educational group (n = 10) and a control group (n = 10). The two physiotherapy programmes were one with manual therapy articular traction, passive stretching of the gastrocnemius muscles, and exercises for muscle strength and proprioception (MT group) and the other with educational sessions and home exercises (E group). The study lasted for 12 weeks. The treatment with manual therapy improved the gastrocnemius muscle circumference, and the pain of ankle (P < 0.05). Six months later, MT group still enjoyed improvement. In the educational group there were improvements, but not significant, in the measured variables. No patient had ankle haemarthrosis during the study. The treatment with manual therapy improved the circumference of gastrocnemius and lessened pain in the patients with haemophilic arthropathy of the ankle.     

A case report of refractory otalgia after Ramsay Hunt syndrome successfully treated by applying pulsed radiofrequency to the great auricular nerve: A CARE-compliant article

Rationale:Ramsay Hunt syndrome is a type of herpes zoster infection involving geniculate ganglion and facial nerve. Unilateral facial palsy, otalgia, and painful vesicular rash on the auricle and external auditory canal are the typical symptoms. Although postherpetic neuralgia (PHN) is a devastating complication of herpes zoster infection, PHN following Ramsay Hunt syndrome has rarely been reported.Patient concerns:A 55-year-old immunocompetent female patient visited our pain clinic, for left-sided refractory otalgia (PHN) that persisted for 3 months after she was diagnosed with Ramsay Hunt syndrome. Although facial palsy and tinnitus had recovered within 2 to 4 weeks after symptom onset, the patient had been experiencing a persistent and severe otalgia radiating to mandibular angle, temporal and upper cervical area of neuropathic nature.Diagnoses:The patient''s pain persisted despite conservative medication and administration of ultrasound-guided stellate ganglion block, facial nerve block, and great auricular nerve block several times.Interventions:The patient was treated with the application of ultrasound-guided pulsed radiofrequency (PRF) to the great auricular nerve.Outcomes:The patient experienced significant pain reduction more than 50% on a numeric rating scale after 2 weeks of PRF treatment.Lessons:Chronic otalgia might be a type of PHN after Ramsay Hunt syndrome with cervical nerve involvement. PRF treatment to the great auricular nerve can be a therapeutic option for refractory otalgia following Ramsay Hunt syndrome.     

Pharmacopuncture and joint movement manual therapy for post-traumatic phalangeal osteoarthritis: A case report

Introduction:Post-traumatic osteoarthritis (PTOA) is a type of osteoarthritis that develops after ligament injury, meniscus injury, or fracture. Currently, there is no specific treatment approved for PTOA. This report describes the case of a 38-year-old man who suffered from PTOA of the right second distal interphalangeal (DIP) joint after practicing judo.Patient concerns:He visited the author''s clinic at 3 months after the onset of symptoms. Symptoms included pain, limited motion, and joint enlargement of the right second DIP joint.Diagnosis:Partial tear of the ulnar collateral ligament of the DIP was revealed by magnetic resonance imaging. As the symptoms appeared after the traumatic event, PTOA was diagnosed.Interventions:Intra-articular hominis placenta pharmacopuncture and joint movement manual therapy were performed on each visit. Altogether, 10 sessions were performed until the symptoms improved remarkably.Outcomes:Visual analogue scale score (VAS) for pain; Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH); joint circumference; and range of motion showed improvements at the end of the treatment. VAS decreased from 8.4 to 0.4, QuickDASH decreased from 44 to 13, joint circumference decreased from 5.5 to 5.4 cm, and range of motion was almost recovered, which was measured by the photographs.Lessons:There are not enough studies on phalangeal joint PTOA and its treatment. This case suggests pharmacopuncture and joint movement manual therapy as treatment options for phalangeal PTOA.     

Rheumatoid arthritis patients with peripheral blood cell reduction should be evaluated for latent Felty syndrome: A case report

Rationale:Felty syndrome is a rare and life-threatening type of rheumatoid arthritis (RA).Patient concerns:A patient with RA had skin rash and subcutaneous hemorrhage, with a significant decrease in blood hemoglobin (Hb), white blood cell count (WBC), and blood platelet count (BPC).Diagnoses:The patient had a history of RA, splenomegaly, decreased Hb, WBC, BPC, and normal immunological indexes, combined with a series of bone marrow related tests and genetic tests.Interventions:She was given high-doses of glucocorticoids intravenously, followed by oral prednisone and cyclosporine maintenance therapy.Outcomes:Her symptoms were resolved within 2 weeks after the start of immunosuppression. After 2 weeks of discharge, the Hb, WBC, BPC basically returned to normal, and prednisone gradually decreased.Lessons:Felty syndrome is a rare complication of RA. Reductions in Hb, WBC, BPC, and subcutaneous hemorrhage should be considered strongly as the possibility of Felty syndrome. Multi-disciplinary diagnosis and related tests of bone marrow and genes are helpful for diagnosis and correct treatment.     

Use of N-butyl cyanoacrylate in the successful transcatheter arterial embolization of an arteriovenous fistula caused by blunt pelvic fracture: A case report and review of literature

Rationale:Traumatic arteriovenous fistulas (AVFs) of the pelvis are uncommon and present with a variety of clinical manifestations; their detection may be difficult. An endovascular approach is usually the first choice of treatment, because surgical intervention is complicated due to the location of the lesions.Patient concerns:A 68-year-old man was admitted with severe pelvic pain following a fall.Diagnosis:A pelvic bone fracture (Young and Burgess Classification, lateral compression type II) was revealed on pelvic computed tomography (CT), while a pelvic sidewall hematoma, unaccompanied by any vascular injury, was detected on multidetector CT.Interventions:Pelvic angiography revealed an AVF between the internal iliac artery and vein, which was undetected by MDCT. The AVF was successfully treated using transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate (NBCA).Outcomes:The patient recovered well and was discharged 4 weeks later. No complications were noted at the 8-month follow-up.Lessons:AVF may occur as a complication of blunt pelvic bone fracture. A high index of suspicion, angiography, and prompt diagnosis resulted in the successful management of our patient who presented with risk factors. Furthermore, TAE using NBCA enables a minimally invasive and effective treatment of traumatic pelvic AVF.     

Importance of early detection of juvenile polyposis syndrome: A case report and literature review

Rationale:Juvenile polyposis syndrome (JPS) is a rare genetic gastrointestinal disorder with hidden and variable clinical features. Early detection is crucial for good prognosis.Patient concerns:A 20-year-old female went to hospital for fever, and was unexpectedly diagnosed as JPS during treatment. She reported no clinical signs or family history of JPS.Diagnosis:Blood routine examination on hospital admission suggested a moderate anemia. Bone marrow cytology and leukemia fusion gene test were performed to rule out leukemia. Other examinations including ultrasound and computed tomography were also conducted for differential diagnosis. Further electronic colonoscopy identified more than 20 pedicle polyps located at her ileocecum and rectum. Mutation analysis detected a novel de novo pathogenic variant, c.910C>T (p.Gln304Ter) within bone morphogenetic protein receptor type 1A gene, establishing the diagnosis of JPS.Interventions:The patient was treated with endoscopic interventions. We also provided a genetic counseling for this family.Outcomes:The patient''s polyps were removed, some of which already had adenomatous changes. The patient received surveillance of hereditary colorectal cancer according to guidelines.Lessons:Variable features and lack of family history probably lead to a great underestimation of potential JPS population. It is recommended to perform genetic testing by a multigene panel in individuals who have suspected symptoms of polyposis.     

Traumatic atlanto-axial rotatory subluxation and dens fracture with subaxial SCIWORA of Brown-Sequard syndrome: A case report

Rationale:A case of traumatic atlanto-axial rotatory subluxation (AARS), dens fracture, rupture of transverse atlantal ligament (TAL), and subaxial spinal cord injury without radiographic abnormality (SCIWORA) of Brown-Sequard syndrome has never been reported in a child.Patient concerns:A 7-year-old boy presented to hospital with torticollis, neck pain, and limited neck rotation after a seat-belt injury sustained during a car accident. Neurologic examination revealed right-side motor weakness and left-side sensory abnormality, known as Brown-Sequard syndrome.Diagnosis:Radiologic examinations revealed type II AARS (Fielding and Hawkins classification), increased atlanto-dental interval (ADI) of 4.5 mm due to a type 1B TAL rupture (Dickman classification), a displaced transverse dens fracture along with an ossiculum terminale, and an intramedullary hemorrhage on the right side of the spinal cord at C3–4.Interventions:The patient immediately received methylprednisolone, and his motor weakness and sensory abnormality gradually improved. At the same time, the patient underwent initial halter traction for 2 weeks, but he failed to achieve successful reduction and required manual reduction under general anesthesia.Outcomes:At the 7-month follow-up visit, radiologic examinations showed a corrected type II AARS that was well maintained and normalization of the ADI to 2 mm. The reduced transverse dens fracture was well maintained but still not united. All clinical symptoms were significantly improved, except the remaining motor weakness of the right upper extremity.Lessons:To the best of our knowledge, this is the first report of traumatic AARS, dens fracture, TAL rupture, and subaxial SCIWORA of Brown-Sequard syndrome in a child. Appropriate diagnosis and careful treatment strategy are required for successful management of complex cervical injuries in a child.     

Total uterine prolapse complicated with vesicovaginal fistula: A case report

Rationale:Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used.Patient concerns:A 63-year-old postmenopausal woman, para 3 (all spontaneous vaginal deliveries), complained of vaginal bulging sensation and involuntary urinary leakage for 3 years.Diagnosis:Stage IV uterine prolapse with VVF.Interventions:She underwent transvaginal VVF repair combined with total vaginal hysterectomy and sacrospinous ligament fixation. The postoperative course was uncomplicated.Outcomes:The patient remained free of complications during the 1-year follow-up.Lessons:This case illustrates the point that patients with pelvic organ prolapse (POP) should be treated promptly and careful follow-up should be conducted. Clinicians should be aware of the symptoms of VVF to ensure its early diagnosis and treatment.     

Development and implementation of a physiotherapy intervention for use in a pragmatic randomized controlled trial in primary care for shoulder pain

Objective: To develop a package of physiotherapy treatment for a randomized controlled trial in primary care for shoulder pain and audit its use within the trial. Methods: A survey of current physiotherapy approaches to the management of shoulder pain was conducted. The most frequently reported treatments were proposed as a package of care for a physiotherapy intervention in a trial of shoulder pain. The package was refined by a subgroup of 13 physiotherapists. For patients receiving the physiotherapy intervention in the main trial (n = 98), the frequency of use of modalities over the treatment period was calculated by percentages of modality usage per number of patient contacts. Treatment details were recorded by the physiotherapist at each patient visit. Results: The physiotherapy intervention included passive movements/mobilizations, active movement/mobilizations, a home exercise programme, education and advice, and ultrasound. The most frequently used modality at the assessment visit was the standardized education and advice leaflet for shoulder pain (85%) followed by the home exercise programme (79%), which was reinforced throughout the trial treatment course. The most frequently used modalities over the treatment period were ultrasound (42%), active mobilizations (41%) and passive mobilizations (41%). The mean number of trial treatment visits was 6.2 (SD: 2.1; range 1–8). Additional trial treatments (1–8) were delivered to 12 patients. Eighty‐five patients were given only one therapeutic diagnosis, and 13 were given two. The most common diagnoses were tendonitis (32%) and capsulitis (25%). Pain was the major problem in 78% of patients, 15% had stiffness and 7% of patients reported both pain and stiffness. Conclusions: Physiotherapists complied well with the trial protocol. Few treatments were used in isolation. This report demonstrates how physiotherapists can agree and deliver a standardized package of treatment, which reflects current practice, as part of a randomized controlled trial. Copyright © 2009 John Wiley & Sons, Ltd.     

Healing of partial tear of the supraspinatus tendon after atelocollagen injection confirmed by MRI: A case report

Rationale:Recently, collagen therapy has been made available for treating rotator cuff tendon injuries. However, to our knowledge, there are no clinical studies objectively investigating the effect of collagen therapy.Patient concerns:A 53-year-old female patient visited our pain clinic because of pain in the right shoulder. Although she had never experienced trauma and had not overused her shoulder and arm, the patient showed limited range of motion with painful arc syndrome. Moreover, the Neer test and Hawkins–Kennedy test were positive with subacromial tenderness.Diagnoses:The MRI findings revealed partial tears on the articular surface of the anterior supraspinatus tendon in the rotator cuff.Interventions:The patient was treated with injections of exogenous collagen at the site of the partial tear under ultrasound guidance.Outcomes:Follow-up MRI after injection of collagen revealed healing of the previous partial rupture of the tendon without any complications. Moreover, the patient reported reduction in pain and improvement in the movement of her shoulder during the follow-up period.Lessons:In this report, we demonstrate healing of a partial tear of the supraspinatus tendon in the rotator cuff after injection of exogenous collagen, as confirmed by MRI.     

Giant cell tumor of the cervical spine treated by carbon ion radiotherapy: A case report

Introduction:Giant cell tumor (GCT) of the bone is a benign–malignant intermediate tumor with locally destructive growth and a relatively high local recurrence rate. Neurological symptoms may develop in patients with GCT of the spine, and surgical treatment is prioritized in cases where resection is possible. However, the local recurrence rate of GCT of the bone is higher than that of GCT at other sites owing to the associated surgical challenges, and treatment is often difficult. No study to date has reported long-term remission of recurrent tumors for more than 5 years by treatment with carbon ion beam radiotherapy after resection of GCT of the cervical spine.Patient concerns:A 14-year-old boy who experienced recurrence after surgery for GCT of the cervical spine.Diagnosis:The patient presented with cervical pain, and computed tomography revealed a mass of the C2 vertebral body. He underwent surgery for tumor resection and autologous bone grafting, and the final pathological diagnosis was GCT. The transplanted bone exhibited gradual progression of resorption, and recurrent tumors were observed on computed tomography and magnetic resonance imaging 1 year and 4 months after surgery.Interventions:The patient was started on denosumab at 15 years of age and received carbon ion beam therapy with 70.4 Gy administered in 32 sessions over 7 weeks.Outcomes:No progressive tumor growth was observed, there were no neurological symptoms such as paralysis or pain were noted, and the patient was in remission for 5 years after irradiation.Conclusion:These findings suggest that carbon ion radiotherapy is a safe and effective therapeutic option for patients with recurrent GCT of the cervical spine.     

Conservative physiotherapeutic management of chronic haematomata and haemophilic pseudotumours: case study and comparison to historical management

Summary.  A conservative, non-operative physiotherapeutic regime for the management of chronic haematomata and pseudotumours in patients suffering from haemophilia is described in this article. Two cases are described where physiotherapy treatment is applied to large masses at the shoulder and femur respectively, where therapy commenced within the first 6 months following onset. These are presented relative to a case that was managed over a much longer period without early physiotherapy input, and the relative outcomes are examined. While both the early physiotherapy-managed cases showed a complete resolution at follow-up examination, the more established chronic pseudotumour required surgical excision, with significant residual muscle contractility, length and strength issues noted on clinical and magnetic resonance imaging reviews. No adverse symptoms or haemostatic issues were reported in response to this less invasive treatment regime by either patient in the two conservative physiotherapy cases.     

Effect of the stellate ganglion block on symptoms of ulcerative colitis: A case report

Rationale:Chronic ulcerative colitis is an autoimmune disease in which epithelial injury continuously occurs in the colonic mucosa. While mesalazine (5-aminosalicylic acid) is used to treat ulcerative colitis, it can also cause liver failure, headaches, and abdominal pain; therefore, an alternative treatment is required. The purpose of this study was to evaluate the effectiveness of 80 stellate ganglion blocks in reducing pain and other symptoms in a patient with chronic ulcerative colitis.Patient concerns:A 54-year-old female patient with a history of ulcerative colitis was concerned with worsening symptoms, such as abdominal discomfort and bloody-mucous stools, over the past 3 years.Diagnoses:Oozing mucosal bleeding and a small amount of exudate were observed on colonoscopy; a diagnosis of ulcerative colitis was made upon histologic examination.Interventions and outcomes:A total of 80 stellate ganglion blocks were administered, after which the patient''s symptom and pain level was decreased from 6 to 4 points on the numeric rating scale (11-point, 0 = no pain, 10 = worst pain imaginable). Improved clinical signs were observed on colonoscopy at a follow-up assessment.Lessons:The stellate ganglion block may be effective for the reduction of pain and other symptoms in patients with chronic ulcerative colitis.     

Tacrolimus-induced epilepsy with primary membranous nephropathy: A case report

Rationale:Tacrolimus-associated neurologic disorders can be found in some cases, mainly in organ transplantation patients. However, epilepsy induced by tacrolimus in primary membranous nephropathy (PMN) patient is scare.Patient concerns:A 63-year-old man experienced 1-year history of foamy urine, and edema of lower extremity.Diagnosis:The patient had proteinuria, hypoalbuminemia, which indicated nephrotic syndrome. Further, we performed renal biopsy for this patient. Combined with the renal biopsy result, the diagnosis of primary membranous nephropathy was established.Intervention:At first, irbesartan was administrated for 6 months. However, the proteinuria had no obvious improvement. Tacrolimus was administrated afterwards.Outcomes:Twenty-two days after tacrolimus treatment, epilepsy occurred. Sodium valproate and carbamazepine were successively given to control epilepsy. However, the epileptic symptoms were not effectively controlled. During the treatment, the concentration of tacrolimus fluctuated greatly. At last, levetiracetam was given to maintain the curative effect. Fortunately, the patient did not suffer from epilepsy again. The concentration of temporary tacrolimus was stable, whereas proteinuria gradually decreased.Lessons:Tacrolimus-induced epilepsy should be considered in patients exhibiting acute neurological symptoms. Early diagnosis and effective treatment play a vital role for favorable prognosis.