Propranolol-exacerbated mesenteric ischemia in a patient with hyperthyroidism

OBJECTIVE: To report a case of acute mesenteric ischemia associated with the use of oral propranolol. CASE SUMMARY: A 59-year-old white man was admitted to the hospital with chronic diarrhea and weight loss. The patient was diagnosed as having hyperthyroidism. Therapy with propylthiouracil 100 mg 3 times daily and propranolol 20 mg twice daily was initiated on an outpatient basis. The following day, the patient was readmitted to our hospital with increased abdominal pain and bloody diarrhea. Angiography revealed superior mesenteric artery occlusion. Antegrade aorta-mesenteric bypass surgery was performed for revascularization, and the patient was discharged 10 days after the surgery. The patient was well both clinically and endoscopically at a follow-up visit 8 months later. DISCUSSION: Although mesenteric ischemia is a devastating illness of varied causes, drug-associated mesenteric ischemia is rarely seen. By decreasing cardiac output and selective vasodilatory receptor inhibition in the splanchnic circulation, propranolol can cause a decline in splanchnic blood flow. An objective causality assessment indicated that propranolol was the possible cause of the arterial occlusion. CONCLUSIONS: Propranolol may rarely be associated with mesenteric ischemia. In cases of newly developed acute abdomen undergoing propranolol therapy, physicians should be aware of this rare and serious adverse reaction to this drug.     

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.     

急诊疑似肠系膜动脉缺血患者血浆D-二聚体的检测及临床意义

目的探讨血浆D-二聚体检测在急性肠系膜动脉缺血(AMAI)中的应用价值。方法对124例疑诊为AMAI急腹症患者进行前瞻性研究。疼痛发作24h内抽血检测D-二聚体、纤维蛋白原、活化部分凝血活酶时间、凝血酶原时间、凝血酶时间。用阳性似然比评价D-二聚体水平在诊断急性肠系膜动脉缺血中的价值。结果9例确诊为AMAI中,D-二聚体中位数为1.6(0.4-5.6)mg/L,明显高于39例炎性疾病患者(P<0.01),高于22例肠痉挛患者(P<0.05)。D-二聚体水平>1.5mg/L结合心房颤动、女性等临床特征,计算阳性似然比为14.9。急性肠系膜动脉缺血患者中无一例D-二聚体水平<0.3mg/L。结论D-二聚体水平检测在急腹症诊断中对排除急性肠系膜动脉缺血性疾病有重要价值。     

Massive bilateral renal angiomyolipomatosis and multifocal micronodular pneumocytes hyperplasia associated with tuberous sclerosis: A case report

Tuberous sclerosis (TS) is an autosomal-dominant disorder characterized by a variety of hamartomatous lesions in various organs. Various organ involvements can be detected with radiology: neurologic involvement (cortical tubers, subependymal nodules and white matter abnormalities), renal involvement (angiomyolipoma) and pulmonary involvement (pulmonary lymphangioleiomyomatosis, multifocal micronodular pneumocyte hyperplasia). Here, we are reporting a case of tuberous sclerosis with multiple organ involvement and massive bilateral AMLs in a 49-year-old female patient.     

Synchronous tumors: Hodgkin disease presenting in mesenteric lymph nodes from a right hemicolectomy for colon carcinoma

The authors report the case of a 56-year-old male diagnosed with Hodgkin disease involving the mesenteric lymph nodes recovered from a right hemicolectomy for colonic adenocarcinoma. The liver and bone marrow were also involved by Hodgkin disease. Synchronous colonic carcinoma and lymphoma in the same patient is a rare occurrence, and Hodgkin disease involving the mesenteric lymph nodes is uncommon as well.     

Laparoscopic diagnosis of mesenteric venous thrombosis

Diagnosis of mesenteric venous thrombosis is almost always delayed, due to the aspecificity of the complaints and the clinical findings, as well as the laboratory investigations. Earlier diagnosis is essential to improve the present grim mortality rate. We report a case of mesenteric venous thrombosis in a 25-year-old female. Early diagnosis was made by gynecological laparoscopy. After resection and anastomosis, the outcome was uneventful.     

Tuberculous ileitis in a renal transplant recipient with familial Mediterranean fever: Gray-scale and power Doppler sonographic findings

The ileocecal area is the most common site of involvement of intestinal tuberculosis. We report the case of a 26-year-old renal transplant recipient with familial Mediterranean fever who developed tuberculous ileitis. Gray-scale sonography and CT showed circumferential thickening of the bowel wall and enlargement of the mesenteric lymph nodes. Power Doppler sonography revealed markedly increased vascularity in the wall of the affected ileal segment and in the mesenteric nodes. Some nodes had no flow at the center owing to caseation necrosis, a finding consistent with the diagnosis of tuberculous ileitis. Colonoscopy was performed, and histopathologic examination of biopsy specimens revealed acute inflammatory changes. Cultures of the specimens confirmed the presence of Mycobacterium tuberculosis. We conclude that findings on power Doppler sonography may support a diagnosis of tuberculous ileitis and avoid clinical mismanagement.     

Mycotic aneurysm of the superior mesenteric artery in a young woman

Aneurysm of the superior mesenteric artery (SMA) is rare. We, in this study, present the case of a 21-year-old woman with a history of heroin abuse who was admitted to our hospital for infective endocarditis complicated by floating vegetation at the posterior mitral valve. After receiving 2-week antibiotic treatment, the patient had acute abdominal pain. Computed tomography demonstrated an aneurysm at the SMA. The mycotic aneurysm was resected and the mitral valve was repaired successfully. This report reviews the pathophysiology of mycotic aneurysms of the SMA and role of computed tomography in the differential diagnosis of this condition from acute mesenteric ischaemia.     

Reversed intestinal malrotation with concurrent cecal carcinoma

A 57-year-old man was admitted with a type 2 (ulcerated with clear margin) cancer in the cecum. Contrast-enhanced CT showed that the superior mesenteric vein was anterior to the superior mesenteric artery, and the patient was suspected of having intestinal malrotation. A laparoscopic-assisted ileocecal resection was performed. At operation, the cecum and the transverse colon passed through the root of the mesentery behind the superior mesenteric artery with the duodenum. Therefore, this was thought to be a reversed-type intestinal malrotation. After the operation, 3D-CT colonography with duodenography images were reconstructed to retrospectively confirm the diagnosis of a reversed malrotation. These images clearly demonstrated the abnormal anatomy and overall orientation of the intestine. Patients with a reversed intestinal malrotation and concurrent cecal cancer are extremely rare. Herein, we present a patient who underwent a laparoscopic-assisted ileocecal resection for cecal cancer that presented concurrently with a reversed intestinal malrotation.     

Mesenteric inflammatory myofibroblastic tumor mimicking a necrotized malignant mass in an adult: case report with MR findings

Inflammatory myofibroblastic tumors are lesions that usually affect young adults and children. Numerous extrapulmonary sites of these tumors have been found, but the mesentery is a very unusual location for an inflammatory myofibroblastic tumor and it is extremely rare in an older patient. Inflammatory myofibroblastic tumor of the mesentery is often demonstrated as a large and infiltrative lesion with heterogeneous enhancement. Its diagnosis is recognized as difficult and it often mimics malignant tumor. We report a case of mesenteric inflammatory myofibroblastic tumor mimicking a necrotized malignant mass in a 55-year-old man who was examined with magnetic resonance imaging. To our knowledge, this is the first report of magnetic resonance imaging of mesenteric inflammatory myofibroblastic tumor with extensive central necrosis in an older patient.     

Disseminated Rhodococcus equi infection in a kidney transplant patient without initial pulmonary involvement

Rhodococcus equi is increasingly recognized as an opportunistic pathogen in solid organ transplant recipients. Primary pulmonary involvement is the most common finding. We report a case of a 42-year-old female kidney transplant recipient who developed multiple disseminated abscesses caused by R. equi while on adequate antimicrobial therapy. The patient presented with subcutaneous abscesses in the hip region and mamma and had 2 intracerebral abscesses. There were no clinical and radiologic signs of pulmonary involvement in contrast to most clinical cases described in the literature. R. equi was cultured from all abscesses. The patient died of progressive neurologic complications. Post mortem examination confirmed infection with R. equi and showed microscopic evidence of necrotizing pneumonia. This report shows that R. equi should be considered as a cause of infection in solid organ transplant recipients even without initial clinical and radiologic signs of pulmonary involvement. Despite adequate therapy, the outcome can be fatal.     

Giant left atrial myxoma in an elderly patient: natural history over a 7-year period

We present the case of a 71-year-old woman with a 7-year history of a giant left atrial myxoma. The myxoma was attached to the atrial septum and occupied almost the entire left atrial cavity. The patient was hospitalized 4 times because of dyspnea on exertion, palpitations, fatigue, general asthenia, and weight loss. During prior hospitalizations, the patient had refused cardiac surgery. She developed several complications, including atrial fibrillation, mitral and tricuspid regurgitation, mesenteric embolism, pulmonary edema, and thrombotic stroke. We herein describe the natural history of left atrial myxoma in an elderly patient over a 7-year period.     

Pacemaker malfunctions in Danon's disease

We describe a case of a 30-year-old man with Danon's disease, an X-linked genetic disorder due to deficiency of lysosomal-associated membrane protein 2 with secondary intracytoplasmatic glycogen and autophagic material storage. This disease is characterized by skeletal muscle involvement, mental retardation, ophthalmic abnormalities, and cardiac disease. In this patient, cardiac involvement was characterized by hypertrophic cardiomyopathy in young age, preexcitation, and parossistic atrioventricular block. The patient underwent to an implantable cardioverter defibrillator implantation for conduction disorders and for primary prevention of sudden death, a frequent event in Danon's disease. This case report describes cardiac involvement with conduction disorders and multiple pacemaker malfunctions in Danon's disease.     

A case report of phaeohyphomycosis caused by Cladophialophora bantiana treated in a burn unit

Black molds are a heterogeneous group of fungi that are distributed widely in the environment and that occasionally cause human infection. The spectrum of disease includes mycetomas, chromoblastomycosis, sinusitis, and superficial, cutaneous, subcutaneous, and systemic phaeohyphomycosis. Cladophialophora bantiana, an agent of phaeohyphomycosis, causes rare infections mainly of the central nervous system. Extracerebral involvement is uncommon, and only a few cases have been reported. We present the case of a 32-year-old immunosuppressed female who developed a cutaneous phaeohyphomycosis from C. bantiana. The patient was treated in a burn unit with wound care, surgical excision, grafting, and itraconazole. Patients with complex fungal infections represent yet another population with specialized needs that are adequately met in a verified burn center.     

Successful treatment of pyoderma gangrenosum with concomitant immunoglobulin A nephropathy: A case report and review of literature

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition of an unknown etiology and is often associated with immune diseases. However, PG rarely shows visceral involvement, especially in the kidney. A 20-year-old female presented with pedal edema and skin ulceration of both lower limbs. The skin lesion began as an erythematous plaque and then became a blister. She also complained of abdominal distension and a decreasing urine volume. Laboratory data showed high proteinuria, hypoalbuminemia and hyperlipidemia. Her skin and kidney were biopsied. The pathological results indicated PG and immunoglobulin A (IgA) nephropathy. The patient was finally cured with prednisolone in combination with cyclosporine A (CsA).     

Chronic mesenteric arterial insufficiency: results of revascularization in 33 cases.

The symptoms of mesenteric arterial insufficiency and the advantages of surgical revascularization have become widely recognized in recent years. Follow-up data are accumulating on patients who have had surgery for revascularization. In this study we report on 33 patients who had mesenteric revascularization for intestinal angina. Twenty-nine patients presented with postprandial pain; most had weight loss. Abdominal bruits were heard preoperatively in 26 patients. Aortogram demonstrated involvement of one mesenteric vessel in 13 (39%) patients and two or more vessels in 20 (61%). Revascularization was accomplished with the use of a Dacron graft or an autogenous vein bypass graft to 48 vessels. Endarterectomy and patch angioplasty were done once. One patient died in the early postoperative period. Of the other 32 patients, 30 (94%) had relief of symptoms. Eight patients died from 8 to 135 months after operation, but only one died from mesenteric vascular occlusion and bowel infarction. Five years after operation, 83% of the patients were alive; in ten years, 62%.     

Acute bowel ischemia following spinal surgery

Acute mesenteric ischemia is a morbid condition that may be difficult to diagnose due to nonspecific nature of its symptoms. To our knowledge, such a complication has not previously been reported after spinal surgery via the posterior approach. We describe the case of a 43-year-old woman who developed acute mesenteric ischemia several days after a surgical procedure for a lumbar spondylolisthesis via the posterior route. This chronic course is suggestive for venous intestinal ischemia. Prone position and hypotension during the procedure may have favored blood stasis and mesenteric vein occlusion in this patient with an inherited hypercoagulable state.     

Disseminated peritoneal plasmacytoma following cardiac transplantation

Posttransplant lymphoproliferative disorders (PTLD) are an important comorbidity in immunosuppressed transplant patients. We describe a unique case of PTLD, a disseminated peritoneal plasmacytoma in a 56-year-old cardiac transplant patient presenting with ascites. The associated computed tomographic findings include omental thickening, mesenteric stranding, and ascites.     

Preoperative sonographic diagnosis of midgut malrotation with volvulus in adults: the "whirlpool" sign.

Midgut malrotation and volvulus, found mostly in children, are rare and difficult to diagnose preoperatively in adults. We report 2 cases in which a 68-year-old man and a 75-year-old woman presented with intermittent cramping abdominal pain, abdominal distention, and vomiting. Abdominal sonography demonstrated wrapping of the superior mesenteric vein and bowel loops around the superior mesenteric artery (the "whirlpool sign") in both patients. Abdominal CT revealed similar findings. The diagnoses of midgut volvulus and mesenteric malrotation were made, and the patients underwent laparotomy. The man was confirmed to have duodenojejunal malrotation and volvulus, and the woman had cecal volvulus. The whirlpool sign is valuable for the preoperative diagnosis of mesenteric vessel malrotation and midgut volvulus.     

Major venous resection and reconstruction using a minimally invasive approach during laparoscopic pancreaticoduodenectomy: One step forward

In the current era of technological advancement, the feasibility of laparoscopic pancreaticoduodenectomy has been established. However, major venous resection and reconstruction along with laparoscopic pancreaticoduodenectomy is still considered a complex procedure. A 47‐year‐old woman presented with obstructive jaundice secondary to carcinoma in the pancreatic head. Triphasic abdominal CT revealed a 2.7 × 3.0‐cm heterogenous mass in the pancreatic head with peripancreatic lymphadenopathy without vascular involvement. The patient was scheduled for laparoscopic pancreaticoduodenectomy. During mobilization, the tumor was found adherent to the superior mesenteric vein. Therefore, vascular resection and reconstruction was accomplished laparoscopically along with pancreaticoduodenectomy. The duration of superior mesenteric vein occlusion was 45 min. The patient had an uneventful recovery and was discharged on postoperative day 10. Major venous resection and reconstruction during laparoscopic pancreaticoduodenectomy using a minimally invasive approach is feasible in selected patients. Adequate experience in complex laparoscopic pancreatic surgery is required before attempting this procedure.