Colonic Diaphragm Disease: An Important NSAID Complication to Know.

Given the widespread use of nonsteroidal anti-inflammatory drugs, physicians should recognize the symptoms of colonic diaphragm disease, a rare but serious complication that can affect the large and small intestines.

Soft tissue injury of the lower extremity complicated by type II necrotising fasciitis highlighting the need for astute clinical practices and proper treatment.

Necrotising fasciitis (NF) is a soft tissue bacterial-derived infection characterised clinically by fulminant tissue destruction of the poorly blood-supplied muscle fascia and overlying subcutaneous fat. Although these infections first appear as minor superficial manifestations, they are capricious in nature and often lead to sepsis, organ failure and high mortality. We report a case of type II necrotising fasciitis in a 39-year-old Caucasian female patient who presented to the emergency department with cellulitis of her right foot and lower leg that rapidly developed into tissue necrosis. The patient course is of unique interest due to progressive history over a 104 days time frame with complications following surgical treatments and outpatient follow-up. We highlight the importance of early detection and pertinent clinical awareness from a wide range of medical specialties that were involved in this case, and how this process is critical, in order to properly diagnose and treat NF-derived tissue infections.

Large-cell neuroendocrine carcinoma (LCNEC) without pulmonary symptoms diagnosed in a cutaneous metastasis.

PATIENT: Female, 60 FINAL DIAGNOSIS: Large-cell neuroendocrine carcinoma Symptoms: Back pain Medication: - Clinical Procedure: Vertebroplasty Specialty: Oncology. OBJECTIVE: Unusual clinical course. BACKGROUND: An atypical presentation of large-cell neuroendocrine carcinoma was diagnosed from a metastatic nodule on the chest wall. CASE REPORT: The patient was a 60-year-old female who presented with intractable back pain with an MRI showing an L3 compression fracture and multiple lesions in L3, L5, and the pelvis. The patient had a 40-pack-year smoking history. On admission, a small, non-tender nodule was noted under her left breast on the chest wall. CT and PET scan confirmed diffuse metastases in the lumbar spine, brain, lung, liver, and pancreas, without knowing the primary site. The patient underwent L3 vertebroplasty and removal of the nodule on the chest wall. The pathology report of the nodule showed large cell neuroendocrine carcinoma (LCNEC). Immunohistochemical stains were positive for cytokeratin AE 1/3, TTF-1, CD56, Synaptophysin, and chromogranin. The stains were negative for CK7, Napsin, cytokeratin 20, GATA-3, mammaglobin, and CEA. A pathology diagnosis of metastatic LCNEC was made, with the lung as the most likely original site. CONCLUSIONS: Treatment consisted of pain control through an intra-thecal pump and whole brain radiation followed by systemic chemotherapy. This case elucidates the unusual cutaneous metastatic site for LCNECs, which was biopsied to confirm the diagnosis. This is the first case of LCNEC diagnosed by a cutaneous metastasis. In conclusion, it is possible to diagnose LCNEC of the lung at a distant metastatic site with careful histological and immunohistochemical examination, which can spare patients from more harmful biopsies.

Group G streptococcal sepsis, septic arthritis and myositis in a patient with severe oral ulcerations.

Lancefield group G streptococci (GGS) are a relatively less common cause of streptococcal infections but the incidence of which has been reported to increase in the recent years. Similar to group A streptococci, GGS produce localised and invasive infections. Streptococcal myositis is a very rare but highly fatal infection of muscles generally caused by group A streptococci. We report a case of sepsis, migrating septic arthritis and diffuse myositis caused by ß-haemolytic GGS. It is an unusual case of diffuse ß-haemolytic GGS myositis involving multiple muscle groups in a patient who demonstrated no skin lesions or sign of streptococcal toxic shock syndrome. The patient responded well to intravenous antibiotics without surgical intervention and experienced full recovery.

Fever of unknown origin in a patient with confirmed west nile virus meningoencephalitis.

West Nile Virus (WNV), an RNA arbovirus and member of the Japanese encephalitis virus antigenic complex, causes a wide range of clinical symptoms, from asymptomatic to encephalitis and meningitis. Nearly all human infections of WNV are due to mosquito bites with birds being the primary amplifying hosts. Advanced age is the most important risk factor for neurological disease leading most often to poor prognosis in those afflicted. We report a case of WNV meningoencephalitis in a 93-year-old Caucasian male who presented with fever of unknown origin (FUO) and nuchal rigidity that rapidly decompensated within 24 h to a persistent altered mental state during inpatient stay. The patient's ELISA antibody titers confirmed pathogenesis of disease by WNV; he given supportive measures and advanced to an excellent recovery. In regard to the approach of FUO, it is important to remain impartial yet insightful to all elements when determining pathogenesis in atypical presentation.

Delayed diagnosis of familial adenomatous polyposis in an adolescent patient with a coexisting eating disorder.

Colorectal carcinoma in the population aged less than 20 years of age is rare but associated with poor prognosis, which is attributable to advanced disease at presentation and higher incidence of the unfavourable mucinous histology. Colorectal carcinoma commonly presents with non-specific gastrointestinal symptoms in conjunction with iron deficiency anaemia. Many of these symptoms can mimic eating disorders, which are common in adolescent women. We present the case of a 20-year-old woman with previously undiagnosed familial adenomatous polyposis and colorectal carcinoma who experienced a significant delay in diagnosis, given a coexisting eating disorder mimicking her symptoms. After confirmation of the diagnosis by colonoscopy and genetic testing, the patient underwent a successful proctocolectomy and experienced full recovery. This case is a reminder that underlying organic pathology should always be excluded prior to a diagnosis of an eating disorder.

Hypoxic hepatitis and acute liver failure in a patient with newly onset atrial fibrillation and diltiazem infusion.

Hypoxic hepatitis (HH) most commonly results from haemodynamic instability and disruption of hepatic flow. The vast majority of cases are caused by cardiac failure, respiratory failure and septic shock. We report a case of HH, acute liver failure, acute kidney failure and progressive thrombocytopenia that developed following a hypotensive episode in a patient treated with intravenous diltiazem for a newly developed atrial fibrillation (A-fib). The pre-existing liver diseases, including chronic alcohol use and liver congestion secondary to right heart dysfunction, might have predisposed the patient to the development of HH. The patient was given supportive treatment and experienced full recovery of both liver and kidney function. To our knowledge, this is the first reported case of HH that occurred following ventricular rate control for acute A-fib. For patients with underlying liver diseases, closer blood pressure monitoring is warranted during diltiazem infusion.