Treatment of severe mitral stenosis in pregnancy using multi-track mitral balloon dilatation: case report

A case of 31-year old pregnant lady with severe mitral stenosis who benefited tremendously from multi-track balloon valvotomy is presented. She had history of cardiorespiratory arrest during delivery in the previous pregnancy and presented to the obstetrician pregnant again and symptomatic. After detailed cardiac evaluation, she was managed medically up to end of second trimester and then percutaneous balloon mitral valvotomy was done under fluoroscopy with total abdominal and pelvic shielding. The results were dramatic both in terms of haemodynamic changes and in the clinical outcome. The patient went on to give birth to a normal healthy baby. This case illustrates current management approach of mitral stenosis in pregnancy.     

Central serous choroidopathy in pregnancy

Central serous choroidopathy is a spontaneous serous detachment of the sensory retina, usually affecting adults between 20 to 50 years of age but is also found in patients older than 60 years of age. This disease usually affects males with a male to female ratio of 8-10 to 1. Many aetiological or associated factors have been described. Here we report a 39-year-old pregnant lady presented with left central serous chorioretinopathy preceded by an unusual emotional disturbance. She was not given any photocoagulative treatment to avoid possible photocoagulative complications. Post delivery, she presented with resolution of the CSC.     

A Case of Life-threatening Hemorrhagic Shock Due to Spontaneous Rupture of a Leg Varicose Vein

We report a case of massive, life-threatening from a varicose lesion of the right lower extremity. An 81-year-old lady was brought to the emergency room at our hospital because of massive bleeding from her right leg. She had had high ligation of the right saphenous vein at another hospital 2 years ago. After hemostat and transfusion, she recovered from hemorrhagic shock. Three-dimensional enhanced computed tomography angiography revealed a residual right great saphenous vein and recurrent varicose lesion. We performed high ligation of the great saphenous vein and closed all of the residual perforators. The patient was discharged hospital 10 days after the surgery and experienced no bleeding episodes within 8 months after the surgery. Certain high ligation and elimination of perforators of the great saphenous vein in surgery for varicose vein of leg is necessary to prevent lethal bleeding.     

Massive lower gastrointestinal bleeding secondary to colonic mucormycosis

Lower gastrointestinal bleeding is usually due to haemorrhoids, diverticular disease, or colorectal cancer. Infective causes of gastrointestinal bleeding are rare. A 70-year-old lady was admitted with septic shock secondary to community acquired pneumonia. She later developed massive lower gastrointestinal bleeding secondary to colonic mucormycosis. Her condition deteriorated rapidly and she died of septicemia. Mucormycosis of the colon is extremely rare and is still associated with a high mortality.     

Bilateral Choroidal Occlusion in Antiphospholipid Syndrome Associated with Systemic Lupus Erythematosus

This article reports a rare case of bilateral choroidal occlusion that occurred in a 24-year-old woman with antiphospholipid syndrome (APS) associated with systemic lupus erythematosus (SLE). This young lady concurred with aorta ventralis thrombosis and bilateral iliac artery occlusion when presented, and experienced a rapid deterioration of vision. She also has a history of recurrent miscarriage. Corticosteroid, immunosuppression and anticoagulation therapy were administered. Patients with APS associated with SLE are at risk for thrombotic phenomena, which may affect the ocular vessels of all sizes, including choroidal vessel. Our case alerts ophthalmologists and rheumatologists that bilateral choroidal occlusion may indeed be developed in patients with APS associated with SLE, and is a potential cause of visual morbidity.     

Pulmonary metastases of a papillary adeno-carcinoma of ovary in a pregnant lady

A 28 years young lady admitted to National Institute of Diseases of Chest and Hospital (NIDCH), Dhaka with the complaints of respiratory distress and cough for 2 months. She was in her last trimester of first pregnancy when she becomes dyspneic on exertion and at night. Gradually it increases in time and she become unable to walk when she consulted with specialists in Barisal. She was examined clinically and radiographically and found some opacity on both lung fields. She was on several antibiotics, but got no improvement. In the meantime, an emergency caesarean section was done to have a healthy baby and patient came to NIDCH for this unexplained breathlessness and cough. She was severely dyspneic, tachypnoic, cyanosed. There were bilateral coarse crepitations, bilateral opacities predominantly on both lower and middle zones of both lungs obscuring costo-phrenic angles on chest X-rays. CT scan of chest shows bilateral reticulo-nodular shadows with a homogenous opacity on right lower lung which enhances after contrast scanning. A CT guided FNAC was done from that opacity which revealed a papillary adeno-carcinoma with psammoma bodies on cytopathological study. Thereafter, to explore the primary site, thyroid gland, abdominal organs was assessed adequately and only positive finding was raised CA-125 (706 IU/ml) which was consistent with ovarian cancer. In this way, a primary ovarian carcinoma in a pregnant young lady with normal sized ovary that metastasizes to lung causing bilateral pleural effusion and lymphangitis carcinomatosa was explored. This was an unusual presentation of ovarian papillary adeno-carcinoma with cough and breathlessness at the last trimester of pregnancy in absence of any abdominal mass.     

Unilateral lower limb oedema in pregnancy

A 21 years old lady was admitted with severe pain and swelling of left lower limb in a pregnancy of 34 weeks of period of gestation. On examination there was pitting oedema of the whole left lower limb with extreme tenderness. Doppler USG of left femoral vein showed a thrombus in the process of recanalisation and no significant flow was demonstrated inside the lumen and USG for foetoplacental profile showed a single live foetus of gestational age 34 weeks. The case was diagnosed as deep venous thrombosis in pregnancy. She was treated with heparin injection 5000 unit subcutaneously twice daily throughout pregnancy along with antibiotics. In spite of proper management she developed extensive ulceration in left lower limb. She delivered normally a healty male child after induction with oxytocin dirp. The postpartum period was uneventful. Throughout this period heparin was continued and she was referred to surgery department for skin grafting.     

Spontaneous cutaneous endometriosis in Mons Pubis: review of literature

Cutaneous endometriosis is not a very often seen condition and is broadly classified as primary (spontaneous) and secondary. While perineal endometriosis arising in a previous scar has been reported, spontaneous cutaneous endometriosis in perineum is extremely rare and only three cases occurring in mons pubis have been reported in literature. We report a case of 34-year-old lady presented with a swelling in pubic region and associated dull aching pain of 1-year duration with no history of cyclical variation of symptoms. Investigations finally concluded a diagnosis of endometriosis and a Complete excision with clear margins. Clinicians should be aware that a spontaneous endometriosis in the perineum can occur and can have atypical presentation with no increase in size or pain during menstruation.     

Incidental early lung adenocarcinoma after surgery for catamenial pneumothorax

A 40-year-old female patient underwent surgery at our hospital for recurrent pneumothorax. A defect on the right diaphragm was diagnosed as ectopic endometriosis. However, air leakage continued 2 days after surgery. Chest computed tomography identified a 5-mm ground glass opacity in the right S3 field, suggestive of lung cancer. Ten days after the initial surgery, she underwent curative surgery for both pneumothorax and the lung tumor. The tumor was diagnosed as bronchioloalveolar carcinoma, but no other endometriosis was identified. The patient has remained well with no recurrence of lung cancer or pneumothorax since the second surgery.     

A case of persistent hyponatraemia due to reset osmostat

We report a case of a 65 year old Malay lady with long-standing diabetes mellitus, who presented to our institution with a one month history of worsening neck pain and progressive upper and lower limb weakness. She was stable despite severe hyponatraemia which was initially treated as syndrome of inappropriate anti-diuretic hormone (SIADH). This was consistent with her underlying illness which was concluded as cervical tuberculosis (TB) with spinal cord compression. She underwent decompression and bone grafting. Despite continuous treatment her serum sodium levels remained low. There were no other problems with her adrenals or thyroid. A water loading and hypertonic saline perfusion test was performed and supported the diagnosis of reset osmostat. Her serum sodium remained below the normal range and she was discharged well.     

Neurological manifestations following partial excision in spinal meningioma: case report

Presented here is a 16-year-old girl who was referred on 30th January 1996 with diagnosis of cord compression with spastic paraplegia with sensory level at T7/T8. CT scan myelogam confirmed soft tissue density mass displacing cord to the left with no dye being seen beyond T3. Thoracic spine decompressive laminectomy was performed on 1st January 1996 at Nairobi West Hospital extending from T3 to T6 level, which revealed a fibrous haemorrhagic tumour. Histology showed meningioma (mixed fibrous type and meningoepitheliomatous type) with many psammoma bodies. She had a stormy post-operative period, with infection and wound dehiscence. This was treated with appropriate antibiotics and wound care. She was eventually rehabilitated and was able to walk with the aid of a walking frame because of persistent spasticity of right leg. She was seen once as an outpatient by author on 6th July 1996, she was able to use the walking frame, but the right leg was still held in flexion deformity at the knee. She was thus referred to an orthopaedic surgeon for possible tenotomy. She was able to resume her studies at the University ambulating using a wheel chair and walking frame. She presented with worsening of symptoms in 2001 (five years after her first surgery). MRI scan thoracic spine revealed a left anterolateral intradural lesion extending from T3 to T5 vertebral body level compressing and displacing the spinal cord. She had a repeat surgery on 6th March 2001 at Kenyatta National Hospital; spastic paraparesis and urinary incontinenece persisted. She also developed bed sores and recurrent urinary tract infections. She was followed up by the author and other medical personnel in Mwea Mission Hospital where she eventually succumbed in 2005, nine years after her first surgery. This case is presented as a case of incompletely excised spinal meningioma to highlight some of the problems of managing spinal meningiomas when operating microscope and embolisation of tumours are not readily available. Also the family experienced financial constraint in bringing the patient for regular follow-up, and getting access to appropriate antibiotics, catheters and urine bags.     

Post-kala-azar dermal leishmaniasis (PKDL), HIV and pulmonary tuberculosis

Post-kala-azar dermal leishmaniasis is usually a sequel to visceral leishmaniasis. A 25-year-old woman presented with hypopigmented maculopapular lesions all over the body for the past 4 years without any previous history of visceral leishmaniasis. She was on treatment for leprosy and pulmonary tuberculosis for the past 2 months, but did not show any improvement. Investigations confirmed that she had post-kala-azar dermal leishmaniasis associated with pulmonary tuberculosis and HIV-1 infection. She was started on treatment for the triad of diseases, and showed improvement.     

Halothane induced hepatitis: case report

Halothane as a cause of hepatitis is rare and may be overlooked when evaluating a patient with sudden onset jaundice. A 34-year-old lady, a nurse, presented to the liver clinic with sudden onset non-pruritic jaundice. Viral and collagen serological tests were all normal, malaria and sickling tests were negative, but transaminases were elevated. She reported inadvertent exposure to halothane in surgical theatre where she works. She improved on conservative management, then had a re-exposure to halothane after three weeks and developed a similar clinical picture, which improved on conservative management. In an area endemic of malaria, hepatitis and haemolysing conditions like sickle cell anaemia, the diagnosis of halothane hepatitis requires high index of suspicion. The mechanism of halothane-induced hepatic damage in this patient is very likely idiosyncratic. This is because of the modest dose at first exposure and more severe clinical picture at re-exposure.     

Recurrent multiple myeloma presenting as a breast plasmacytoma

We describe a patient with multiple myeloma, who initially responded to chemotherapy and went into remission. She presented 10 months later with a right breast lump which was confirmed by core biopsy to be a plasmacytoma. Further treatment with radiotherapy, thalidomide and later second line chemotherapy appeared unsuccessful and she showed rapid disease progression with rising paraproteins and new extramedullary plasmacytoma lesions in the forehead, supraclavicular region, nasopharynx, liver, spleen, pancreas and paraaortic lymph nodes.     

Solitary plasmacytoma of bone--a rare disorder with an unusual evolution.

A 40 year old woman presented with a spinal epidural tumour, which on histology was shown to be a plasmacytoma. At that time she had no evidence of multiple myeloma. Ten months later, she developed a second isolated plasmacytoma in the spleen, for which she underwent splenectomy. Two years after her initial presentation she had another recurrence in the liver, followed by a full-blown picture of multiple myeloma. The myeloma was progressive and resistant to all forms of chemotherapy. She finally died of a massive gastrointestinal haemorrhage. The clinical features, natural evolution and management of solitary plasmacytomas are discussed.     

Diagnostic clues in an adult case of Leigh's disease

A previously-well 32-year-old woman presented with episodes of severe headache, neck pain, numbness of the tongue and facial sweating. In the course of her illness she became abulic, blind and quadriparetic and she suffered recurrent episodes of coma during which she became decerebrate and her brain-stem reflexes were absent. She had an adult form of Leigh's disease, which is an extremely-rare degenerative condition of unknown cause. The clinical, neuroradiological and neuropathological features are presented.     

Postpartum pneumomediastinum

A 21-year-old primigravida with previous history of pulmonary tuberculosis had a normal but assisted vaginal delivery after a prolonged second stage. Within 12 hours, she complained of dyspnoea and was found to have abnormal neck and anterior chest wall swelling. A diagnosis of subcutaneous emphysema was made and this was confirmed with the chest radiograph, which also revealed pneumomediastinum. She recovered well within four days with conservative treatment.     

Dyspnoea due to plasma transfusion-related acute lung injury

We describe an unusual case of unexpected dyspnoea following transfusion of fresh frozen plasma (FFP) in a previously-well 72-year-old woman. Our patient was scheduled for an ultrasonographically-guided liver biopsy for work-up for autoimmune hepatitis. She was given FFP to correct a prolonged prothrombin time. Shortly after the transfusion was initiated, she started coughing and became progressively dyspnoeic. Clinically, she was tachypnoeic with diffuse bilateral crepitations, and rapidly went into respiratory failure. She was intubated and placed on mechanical ventilation. Her condition improved and she was extubated by the second day, with no long-term pulmonary sequelae. A diagnosis of transfusion-related acute lung injury (TRALI) was made, based on the rapidity of onset and association with transfusion. This was confirmed by the findings of anti-human leukocyte antigen antibodies in both the patient and recipient blood. Our case highlights this important but under-recognised condition. The incidence, diagnosis and management of TRALI are also discussed.     

A case of generalised cutaneous granulocytic sarcoma in an elderly patient with myelodysplastic syndrome

Granulocytic sarcoma is a rare extramedullary malignant mass composed of primitive cells of the granulocytic lineage. It can arise from any part of the body and is frequently associated with haematological diseases, commonly acute myeloid leukaemia. Rarely, it has been found in conjunction with myelodysplastic syndrome. We report a case of cutaneous granulocytic sarcoma in a 73-year-old lady. The patient presented with a two-month history of multiple skin nodules which were confirmed by skin biopsy to be granulocytic sarcoma. Bone marrow examination was consistent with myelodysplastic syndrome. Localised radiotherapy to the skin lesions were given. She died from septicaemia six months after presentation. The management of this condition presents a diagnostic and therapeutic dilemma for both the pathologist and physician. In cases which are poorly differentiated as in this case, histological diagnosis is particularly difficult. Its definitive diagnosis would then require the additional use of a broad panel of immunohistochemical and cytochemical stains.     

A limited form of granulomatosis with polyangiitis in an ulcerative colitis patient receiving sulfasalazine

This is a case report of a 31-year-old lady who is known to have ulcerative colitis for 15 years and was on mesalazine. She presented with periorbital swelling, sinusitis, epistaxis, and was found to have positive anti-neutrophil cytoplasmic antibody and anti-proteinase-3 of a high titer. Biopsy from the maxillary sinus showed chronic non-specific inflammation and biopsy from the periorbital fat revealed inflammation and granulomatous changes. She had no other organ involvement. She was diagnosed with a limited form of granumatosis and polyangiitis and treated with methotrexate and prednisolone. The symptoms disappeared after treatment.