Streptococcal gangrene presenting as hip pain: two case reports and review of the literature.

Two cases of streptococcal gangrene are reported. Both patients, with hip pain and no obvious source of infection, presented to the same orthopaedic team within a few days. After initial treatment with NSAIDs the outcome was fatal in the cases described. A review of the literature revealed that the administration of NSAIDs may accelerate the course of the disease. The authors conclude that this very rare cause of arthralgia and malaise should be excluded before the administration of NSAIDs for such complaints.     

Hepatic angiomyolipoma: Two case reports of caudate-based lesions and review of the literature

Two case reports of hepatic angiomyolipoma, both originating in the caudate lobe, are reported with a review of the literature. The liver is the second most common site of angiomyolipoma, an uncommon benign tumor of mixed mesenchymal origin. It is commonly diagnosed following abdominal pain or as an asymptomatic mass discovered on abdominal ultrasound or computed tomography scan. Of 74 cases reported, the lesions ranged from 0.3 to 36 cm in diameter and are noted between the first and eighth decade, with predominant female predilection. The right lobe is the most common site, with lesions arising in the caudate lobe comprising only five cases. The natural history of the hepatic lesion is unknown. Malignant invasion or metastatic disease has not been documented. Hepatic and renal angiomyolipoma can occur concurrently (13 of 60 cases), although the majority are not biopsy proven. Multicentric hepatic disease occurs. The correlation between tuberous sclerosis and hepatic angiomyolipoma is not confirmed histologically and occurs rarely. These lesions have a characteristic radiographic appearance due to high fat content. Histologically, angiomyolipoma are characterized by an admixture of adipose tissue, blood vessels, and smooth muscle cells. These lesions cannot reliably be differentiated from a malignant lesion based on clinical history, radiologic examination, and/or pathologic interpretation. If clinical suspicion for malignancy is low, then careful observation with serial radiologic follow-up is performed. The treatment for a symptomatic or suspicious lesion is resection, if feasible. Liver transplantation may be considered for large or centrally located lesions not amenable to resection. (Liver Transpl Surg 1997 Jan;3(1):46-53)     

Primary Pyomyositis of the muscles around the hip. case reports and literature review

The authors present three case reports of primary pyomyositis, a severe but rare disorder involving the muscles around the hip. In three boys, with an average age of 16 years, the disease developed suddenly in association with strenuous sporting activities. The boys had fever, pain and restricted motion at hip joints, haemoculture tests positive for Staphylococcus aureus and the presence of inflammatory markers. Magnetic resonance findings showed infiltrates and abscesses in the muscles around the hip. X-ray and computed tomography (CT) examination of the pelvis revealed bone irregularities near the pubic symphysis due to repeated avulsion injury to the medial group of the thigh muscles in two boys, and a fresh avulsion of the anterior inferior iliac spine in one boy. This patient developed reactive synovitis of the hip and iliopectineal bursitis. All three patients received intravenous antibiotic therapy, first with broad-spectrum and then with specific anti-staphylococcus antibiotics, for 2 to 3 months. Repeated puncture and drainage of the abscesses under CT guidance was performed in one patient; repeated surgery with abscess removal was necessary in two patients. The early diagnosis and combined conservative and surgical treatment prevented development of the third, septic stage of this disease which is commonly associated with serious complications.     

Peritalar dislocation: three case reports and literature review

Peritalar dislocation is an uncommon lesion, although its incidence has increased on account of the rise in motor vehicle accidents and improved radiological diagnostic techniques. In our review of the literature, we counted 312 cases described over the past 50 years. Medial dislocation represented the majority of cases (79%), lateral dislocation accounted for 22%, while poster and anterior dislocations seemed to occur rarely. We report the results of the treatment of 3 patients, one with an irreducible lateral dislocation, one with a irreducible medial dislocation, and one with a reducible medial dislocation. The obstruction to closed reduction for lateral dislocation was the interposed posterior tibial tendon. The obstruction to closed reduction for medial dislocation was an osteochondral impact-fracture of the upper medial part of the head of the talus spiking to the lateral corner of the navicular. Management consisted of immediate reduction and application of a short leg cast for 4 weeks. At long-term follow-up, all 3 patients had no complications and had returned to their pre-injury activities. Received: 18 June 2002, Accepted: 30 July 2002 Correspondence to: F. Rivera     

Appendicular mucocele: two case reports and literature review

The classification of mucinous tumors of the vermiform appendix is quite controversial, and includes a spectrum of neoplastic lesions ranging from benign proliferations, intraluminal, to invasive adenocarcinomas. Among the complications of appendicular mucinous neoplasms we should mention the “pseudomyxoma peritonei”, a condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelationous ascites. Mucinous neoplasms of the appendix are rare diseases of unknown etiology. The diagnosis is difficult because of poorly specific clinical, biochemical and imaging parameters, and their detection can be occasional. Most of the reported cases involving women of reproductive age (with a history of endometriosis, abdominal surgery or pelvic inflammatory disease). The definitive diagnosis requires histology and immunohistochemistry. Cytoredutive surgery combined with hyperthermic intraperitoneal chemoterapy (HIPEC) is now considered the best treatment for this disease.We present two cases treated with surgery and HIPEC.     

Intraspinal lymphangioma: 2 case reports and literature review

BACKGROUND: Lymphangioma of the soft tissue is not uncommon. However, as far as the authors know, intraspinal lymphangioma is clinically rare and very few cases have been reported previously. METHODS: Two patients who had backache and acratia of the lower limbs and difficulty in relieving themselves were examined by plain radiography and magnetic resonance imaging before surgery. Treatment consisted of the usual technique of surgical resection of the tumor microscopically. Histological examination of the resected material confirmed the diagnosis. Postoperative follow-up assessment was performed by magnetic resonance imaging. RESULTS: Intraspinal lymphangioma is very rare clinically and its cause remains controversial. Magnetic resonance imaging can obtain precise position fixing, but it is hard to make preoperative qualitative determination. The most effective treatment of intraspinal lymphangioma is to excise it totally. CONCLUSIONS: The clinical appearance of intraspinal lymphangioma has no character. Magnetic resonance imaging is important in diagnosing it. The most effective treatment of intraspinal lymphangioma is to excise it totally. Further observation is recommended because of the possibility of local recurrence.     

Detrusor-sphincter dyssynergia: four case reports and literature review

Detrusor-sphincter dyssynergia is responsible for major impairment and is factor for social and professional activity repercussions. METHODS: We have studied the clinical and urodynamic finding in four patients (two men and two women) with detrusor-sphincter dyssynergia. Mean age is 36 years (26-44 years). Dyssynergia was secondary to tuberculosis meningitis in one case, surgery for rectal adenocarcinoma in one case, tight vertebral canal in one case and in one case the cause is indeterminate. The detrusor-sphincter dyssynergia were treated by autocatheterism in two cases, antibiotherapy antituberculosis associated with an anticholinergic drugs in one case and by alpha-blockers agent in another. RESULTS: Quasi-complete salvage of the motor deficit and the dysfonctional voiding in a patient treated by antibiotherapy antituberculosis associated with an anticholinergic drugs. As well, maid evolution in patient treated by alpha-blockers agent and who practice self catheterization. CONCLUSION: Optimal treatment is unknown, and the existence of several cures indicated the limit of all therapeutic methods.     

Metformin-associated lactic acidosis: case reports and literature review

BACKGROUND: Lactic acidosis is a widely recognized, though rare, side effect of metformin. This paper describes five patients admitted to Chang Gung Memorial Hospital from 1 September 1998 to 31 May 2001 suffering severe lactic acidosis caused by metformin, and reviews the literature. PATIENTS: Five cases diagnosed as having meftormin-associated lactic acidosis (MALA) were discovered during the study period. Three had normal renal function before the onset of MALA and two had attempted suicide bytaking large amounts of metformin. One patient with end-stage renal disease developed MALA despite regularhemodialysis three times a week. One of the patients who had taken metformin to attempt suicide was not diabetic. RESULTS: All patients suffered severe metabolic acidosis with a high anion gap and blood lactate level. Four developed profound hypotension, and three of these also suffered acute respiratory failure. Three patients received conventional hemodialysis and two continuous renal replacement therapy. A young non-diabetic female who had taken a large dose of metformin to commit suicide died from multiple organ failure despite aggressive treatment. CONCLUSIONS: Lactic acidosis is a serious reaction to metformin, and hemodialysis (the treatment of choice) should be done urgently to prevent serious complications. MALA should be suspected in patients presenting with wide anion gap metabolic acidosis and high blood lactate, even when they are non-diabetic.     

Renal angiomyolipoma: 6 case reports and literature review

We report 6 cases of renal angiomyolipomas and review the pertinent literature concerning this disease. One case involved the rare association of tuberous sclerosis and pregnancy. Another patient without tuberous sclerosis had renal cell carcinoma and later suffered a contralateral angiomyolipoma. The pathological conditions of renal angiomyolipomas with and without tuberous sclerosis are discussed. Since angiomyolipomas present with multiple clinical similarities to renal cell carcinoma, the primary task for the clinician is to differentiate this hamartoma from carcinoma. The distinguishing characteristics and the clinical management of renal angiomyolipomas are discussed.     

Eccrine poroma: review of the literature and case reports

Eccrine poromas are raised papular or nodular lesions that usually appear as a solitary flesh-colored or erythematous mass. They vary in size from 2 to 12 mm. in diameter and usually occur on the hairless surfaces of the feet. The authors believe surgical excision is the preferred treatment.     

Cutaneous leiomyosarcoma: case reports and review of the literature

Two patients with leiomyosarcomas are described, both men with lesions located in the upper trunk. Both lesions were present for more than 10 years. The diagnosis was established after excisional biopsy. The diagnostic criteria are a tumor size greater than 2.5 cm in diameter; a mitotic rate of 1 or more per 5 high-power fields in cellular areas; and electron microscopic verification of smooth muscle cells. The literature is reviewed and the clinical presentation of the 2 patients is discussed. Wide excision is the treatment of choice after histological diagnosis.     

Acute neurogenic pulmonary edema: case reports and literature review

Neurogenic pulmonary edema (NPE) is an underdiagnosed clinical entity. Its pathophysiology is multifactorial but largely unknown. We report two cases of NPE and review the literature on NPE cases reported since 1990. A 21-year-old man had a seizure episode following cranioplasty. He became increasingly dyspneic, and clinical and laboratory signs of respiratory failure were evident. Chest radiography and computed tomography showed bilateral diffuse infiltrates. After supportive measures were taken, complete respiratory recovery occurred in 72 hours. A 52-year-old woman had several seizure episodes following subarachnoid hemorrhage due to a cavernoma. She became increasingly dyspneic upon arrival at the hospital. After tracheostomy and oxygen support were established, chest radiography showed bilateral diffuse infiltrates. Respiratory recovery was excellent, and the patient was eupneic with normal results of chest radiography 48 hours later. Fourteen reports (21 cases) were found. Thirteen patients were female, and the mean age of the patients was 31.6 years. The most frequent underlying factor was subarachnoid hemorrhage (42.9%). Symptom onset occurred <4 hours after the neurologic event in 71.4% of cases. One third of the patients presented with pink frothy sputum. Chest radiography showed bilateral diffuse infiltrates in 90.5% of cases. Supportive measures included oxygen support and vasoactive drugs. Recovery was usually very rapid: 52.4% of patients recovered in <72 hours. Almost 10% of patients died of NPE. Our two cases had clinical and laboratory features in common with most NPE cases. Physicians should remember NPE when neurologic patients suddenly become dyspneic. The mortality rate is high, but surviving patients usually recover very quickly.     

Step-cut medial malleolar osteotomy: literature review and case reports

Talar dome pathology involving the medial half of the talus is a common occurrence. Direct visualization of this region of the ankle joint can be challenging because of anatomical constraints. Many lesions can be seen arthroscopically and, with the aid of a distractor, can be successfully treated. However, because of adhesive capsulitis and/or the size and location of the lesion, an open arthrotomy or a transmedial malleolar osteotomy may be required. The purpose of this article is to review the literature on techniques developed for gaining access to this area of the ankle and to highlight the step-cut medial malleolar osteotomy (SCMMO) and modifications that can be made to it to facilitate joint access. Two case studies are used to exemplify the SCMMO and modifications used to increase talar dome access. Because of anatomic constraints, many foot and ankle surgeons recommend osteotomy of the medial malleolus to gain access to the posteromedial aspect of the ankle. The step-cut approach is technically simple to perform; it can be safely modified when treating central lesions, it has inherent osseous stability that minimizes risk of displacement during rehabilitation, and it has a broad cancellous surface area, which facilitates osseous union. The authors recommend this procedure when an osteotomy is needed to gain access to the posteromedial ankle joint.     

Pediatric basal cell carcinoma: case reports and literature review

Basal cell carcinoma (BCC) is a rare disease in the pediatric population that usually presents in children with predisposing genetic conditions. It is often diagnosed on final pathology of an excisional biopsy, and the treatment may be delayed in younger populations because of a physician's low index of suspicion. Increased knowledge of BCC by pediatric caregivers would expedite definitive therapy for childhood BCC as well as any necessary evaluation by subspecialists for predisposing syndromes. We report 3 cases of BCC in pediatric patients and review the literature concerning BCC in children.     

Elastofibroma dorsi: 8 case reports and a literature review

A series of 8 cases of elastofibroma is reported, and the clinical, pathological and imaging features and different therapeutic modalities are reviewed. On this basis, we suggest an algorithm for the diagnosis and treatment of elastofibroma. Briefly, marginal excision is the treatment of choice in symptomatic patients, while followup appears to be a good solution in asymptomatic ones.     

Morphea of the breast: case reports and review of literature

Morphea of the breast is an uncommon skin condition associated with autoimmune disorders and has also been described following radiotherapy. The inflammatory stage of morphea can commonly be mistaken for a breast abscess or inflammation. We report two cases of localized scleroderma affecting the breast with no history of autoimmune disease or radiation treatment. In both the cases, the lesions improved with the use of topical steroids.