A fatal case of necrotizing fasciitis caused by Serratia marcescens

A patient with a history of type II diabetes mellitus (DM), end stage renal disease (ESRD), and congestive heart failure (CHF) developed necrotizing fasciitis caused by Serratia marcescens after scraping his leg on rocks in a river while fishing. Aggressive management with surgical debridement, antibiotics, and pressure support was unsuccessful.     

A rare case of postinfectious glomerulonephritis caused by pneumococcus in an adult patient

Postinfectious glomerulonephritis (PIGN) is commonly seen as a complication of infection with nephritogenic strains of group A streptococci, mostly with Streptococcus pyogenes. Pneumococcal pneumonia leading to glomerulonephritis has been reported in the pediatric literature, but only one adult case has been previously reported. We are presenting a case of postinfectious glomerulonephritis caused by pneumococcal pneumonia in an adult. In the present case, other possible etiologies of nephritic syndrome were ruled out with negative antineutrophilic cytoplasmic antibody (ANCA), anti-glomerular basement membrane antibody (Anti-GBM), antistreptolysin O (ASO), antinuclear antibody (ANA), HIV and viral hepatitis profile. The low CH50 indicated a complement-mediated injury. Renal biopsy was done showing immune complex-mediated crescentic glomerulonephritis consistent with postinfectious etiology. The patient received pulse dose steroids for 5 days followed by oral steroids. His urinary output improved along with normalization of his renal function, therefore dialysis was discontinued. We are presenting this case to alert clinicians to the possibility of postinfectious glomerulonephritis following pneumococcal pneumonia and to report the successful use of steroid therapy in such a situation.     

Myocardial abscess and fatal cardiac arrhythmia in a hemodialysis patient with an arterio-venous fistula infection

Myocardial abscess formation is a life-threatening complication that is frequently but not exclusively associated with infective endocarditis. To our knowledge there are only two case reports of myocardial abscess formation in hemodialysis patients. Only one of these reports describes a myocardial abscess of bacterial etiology secondary to an infected intravascular hemodialysis catheter. Furthermore, there are no reports of bacterial myocardial abscess occurring in a hemodialysis patient with an infected arteriovenous fistula. Myocardial abscess can manifest in a variety of clinical scenarios ranging from an asymptomatic state to a catastrophic myocardial wall rupture. In the case described, the myocardial abscess lead to a rapidly progressive course consisting of recurrent cardiac arrhythmias that were ultimately fatal. Our case involved the formation of a myocardial abscess in the presence of a methicillin-resistant Staphylococcus aureus bacteremia without any evidence of infective endocarditis. We report this case to call attention to the possibility of bacterial myocardial abscess occurring with infection of an arteriovenous fistula in a hemodialysis patient, which can manifest as recurrent severe cardiac arrhythmias refractory to medical therapy.     

A rare case of left diaphragmatic agenesis in an elderly patient

A 71-year-old man affected by left hemidiaphragmatic agenesis developed late severe constipation and occasional episodes of bowel obstruction. At left subcostal laparotomy, the stomach, transverse colon, splenic flexure, and spleen were located in the left hemithorax. Repair was performed with a 2-mm-thick expanded polytetrafluoroethylene (Gore-Tex) patch secured in place circumferentially as a new diaphragmatic dome. No early major complications and no recurrence at 34 months' follow-up were observed. To the best of our knowledge, this is the oldest treated patient with a true hemidiaphragmatic agenesis and is the eighth case reported in the literature. The use of the ePTFE soft tissue patch, thanks to its strength and pliability, affords good anatomical and functional repair.     

A case of an elderly patient treated for descending necrotizing mediastinitis

We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.     

Two concurrent appendiceal neoplasms in an elderly patient: A case report

IntroductionAcute appendicitis, one of the commonest surgical diagnoses, is rare and more complex presentation in the elderly. Physicians must consider atypical causes appendicitis in this population, which could affect the management of the patient.Presentation of caseAn elderly female presented with a two-day history of lower abdominal pain, associated with low-grade fevers and chills. Studies showed leukocytosis and computed tomography (CT) findings consistent with appendicitis. She underwent laparoscopic appendectomy. Intra-operatively, the Appendix had an unusual appearance, so a frozen-section was obtained, suggestive of a mucinous neoplasm with grossly clear margins. Despite the possibility that she may require a more extensive cancer operation pending the final Pathology results, the decision was made to complete the operation at this stage, and return at a later date if needed, after completing the patient's work-up with a colonoscopy to rule out any synchronous colonic lesions that could alter her surgical management. Final Pathology revealed both a low-grade appendiceal mucinous neoplasm, as well as a tip carcinoid tumor, both of which were adequately treated with appendectomy alone.DiscussionPhysicians treating elderly patients with appendicitis should suspect an atypical etiology, such as appendiceal cancer. Early identification and appropriate pre-operative counseling may alter the surgical management.ConclusionThe role and timing of right hemicolectomy in treating appendiceal cancers remain controversial, and should be evaluated on a case by case basis.     

Congenital right-sided diaphragmatic hernia in an elderly patient. A case report

Congenital diaphragmatic hernia is a rare condition in adulthood. It is even more exceptional when located on the right side. We describe a case of right-sided congenital diaphragmatic hernia in a 74-year old woman. The diagnosis was only made when the patient developed an acute intestinal obstruction after a laparotomy for a gynaecological benign tumour. The treatment of this condition is discussed. In our opinion, in elderly, the advantages of an elective operation in asymptomatic congenital diaphragmatic hernia have to outweigh the risks of the operation. However, if the patient shows symptoms of pulmonary dysfunction or motility disorders of the gut, or even when he has to undergo a laparotomy for a different reason, we advise to repair the hernia in order to prevent complications.     

Surgical treatment for acute ischemia caused by bilateral popliteal artery entrapment syndrome in an elderly patient: report of a case

We report the unusual case of a 73-year-old man who underwent surgery for bilateral popliteal artery entrapment syndrome (PAES). A medial approach was used to operate on the left leg, and the vein bypass was made from the superficial femoral artery to the crural artery through a subfascial route. A posterior approach was used to operate on the right leg and it was found that the mid-popliteal artery passed medial to and beneath the medial head of the gastrocnemius muscle and was severely compressed by an accessory slip of muscle. The vein bypass from the above-knee to below-knee popliteal artery was established through the original route after resection of the accessory slip of muscle. A postoperative arteriogram showed good bypass flow to the bilateral crural arteries. To our knowledge, this case represents the oldest patient with this disorder to be treated by surgery. Received: January 7, 2002 / Accepted: May 7, 2002 Reprint requests to: T. Sugimoto     

Pheochromocytoma in an elderly patient: report of a case

This is a case report of a pheochromocytoma which developed in a 67-year-old man. The patient presented himself with a productive cough and orthopnea, both of which were subsequently proved to be due to hypertensive heart failure. The diagnosis of a pheochromocytoma originating from the left adrenal gland was established endocrinologically and roentgenologically. Transperitoneal adrenalectomy was undertaken, and a tumor weighing 300 g was obtained. Histopathologically, the tumor was composed of two elements: cells with profuse cytoplasma having chromaffin-positive granules, and other cells consisting of spindle cells with mitosis. Surgical exploration could not identify another tumor or metastasis, and his blood pressure returned to normal, with normal catecholamine levels, after surgery. This is the first reported case of an elderly person with a pheochromocytoma complicated by congestive heart failure and renal insufficiency preoperatively; however, it was controlled well, and he underwent surgery successfully. This case constitutes the 64th report on a pheochromocytoma in persons over 60 years of age in the Japanese literature.     

Persistent overdose caused by a very small dose of intrathecal morphine in an elderly patient undergoing vaginal hysterectomy: a case report

Intrathecal opioid administration is a well established, inexpensive and effective, widely used procedure in the elderly and has well known side effects. We report a case of an elderly woman who received small doses of intrathecal opioids (sufentanil 2.5 microg and morphine 60 microg) for gynecological surgery and thereafter developed severe neurological side effects. She required prolonged treatment with very high doses of naloxone (16 mg).     

A case of cutaneous nocardiosis caused by Nocardia cyriacigeorgica in a diabetic patient

We present a case of cutaneous abscess with Nocardia cyriacigeorgica in a diabetic patient, and review the published work. This patient had infectious abscess on his left lower thigh and the right lower abdomen. The isolated organism was identified by DNA amplification and sequence analyses of the 16 S r RNA. After incision and drainage, the clinical application empirically used linezolid and SMZCo took eff ect.     

A case report of incomplete endocardial cushion defect with mitral stenosis in an elderly patient

The following paper describes a mitral valve replacement (SJM 27 mm), the patch closure (EPTFE) of an ostium primum atrial septal defect and tricuspid annuloplasty (De Vega’s method) in a 64-year-old female patient with an incomplete endocardial cushion defect and mital stenosis. Surgery revealed thickend, mitral valve leaflets and the presence of a cleft, findings similar to those observed in case of rheumatic degeneration. Investigation of patient hemodynamics confirmed a diagnosis of Lutembacher syndrome and a lower with left ventricle volume. After surgery, the volume of left ventricle increased and the patients clinical course was uneventful.     

Repetition of an unusual stress fracture in an anorexic man: a case report

Stress fractures of the fibula commonly occur distally in runners, whereas stress fractures of the proximal fibula are uncommon and typically occur in jumpers. Furthermore, it is rare for a stress fracture to be repeated in the same bone. We report a case of a repeated stress fracture of the proximal fibula in a male runner with abnormal gait that primarily involved excessive pronation. Unusual risk factors in this case were anorexia nervosa and use of an inhaled corticosteroid. The patient was treated conservatively, and healing of the fracture was completed at 12 weeks.     

A meningioma-mimicking tumor caused by Mycobacterium avium complex in an immunocompromised patient

Intracranial tuberculomas manifesting radiologically as typical dural-based "meningiomas" have been reported, most frequently in immunosuppressed patients. Their incidence is high in developing countries; they are only sporadically observed in Western Europe and North America, usually in patients with acquired immunodeficiency syndrome (AIDS). According to published reports, intracranial tuberculomas are always due to infection by Mycobacterium tuberculosis. We report a case of a 50-year-old woman with systemic lupus erythematosus (SLE) who presented with a dural based, meningioma-like mass in the right frontal region, resulting from a localized infection by Mycobacterium avium complex. Histologically, the mass resembled a meningioma in being composed of spindly cells arranged in a fascicular pattern. Immunohistochemical stains showed this tumor to consist of a large aggregate of AFB-laden histiocytes without caseating necrosis or multinucleated giant cells.