THROMBOTIC MICROANGIOPATHY ASSOCIATED WITH OPANA ER INTRAVENOUS ABUSE A Case Report.

Thrombotic microangiopathy is characterized by endothelial changes and microvascular stenosis. Several entities such as pregnancy, infection, connective tissue diseases, and drugs are associated with secondary thrombotic microangiopathy. Recently, new reformulation of Opana ER had been associated with thrombotic microangiopathy when injected intravenously. Here, we report the case of a 37-year-old man who developed renal failure and hemolytic anemia secondary to Opana ER intravenous abuse. Renal biopsy pathology was consistent with thrombotic microangiopathy likely caused by Opana ER intravenous abuse.

A port-wine stain in association with underlying syndrome.

Klippel-Trenaunay syndrome (KTS) is a capillary-venous vascular malformation condition characterized by capillary malformation, soft tissue and bone hypertrophy, and varicosities. Here we present the case of a 29-year-old man who presented with port wine stain and recurrent ulcerations on his right leg. This leg was also larger than the left one. His condition was consistent with KTS. We discuss the pathogenesis, clinical presentation, complications, and treatment modalities of KTS.

An unusual cause of abdominal pain in a male patient: Endometriosis.

A rare case of abdominal pain secondary to endometriosis in a 52-year-old man with cirrhosis is presented. The patient had a repair of recurrent inguinal hernia 7 months prior to presentation. An exploratory laparotomy revealed a 4.5 cm × 2.5 cm cystic mass attached to the urinary bladder and the inguinal area. The mass pathology showed a cystic lumen of diameter of 1.5 cm filled with old blood and surrounded by thick muscular mass. Microscopically, the lesion consisted of thick smooth muscle fibers that concentrically surround a central lumen that is bordered by endometrium such as glands and stroma. Immunostains were positive for estrogen receptors and progesterone receptors in the glandular component and for CD10 in the stroma, which is consistent with endometriosis.

Short gastric artery apoplexy after gagging.

Abdominal apoplexy, the spontaneous hemorrhage into the peritoneal cavity, is usually caused by a rupture of visceral vessels such as short gastric arteries. Several factors such as pregnancy, hypertension and atherosclerosis have been described in association with abdominal apoplexy. Blunt trauma, inflammatory conditions, aneurysm rupture and rarely vomiting are some predisposing conditions. We report a very unusual case of a patient who had a spontaneous short gastric artery acute hemoperitoneum caused by forceful gagging during teeth brushing. The patient was treated with blood transfusion, fluids resuscitation, laparotomy, and suture ligation of the bleeder vessel. We also review the medical literature of abdominal apoplexy, a rare etiology of acute abdomen that should be recognized early in the Emergency Department.

Trans-omental hernia as a rare cause of small bowel obstruction.

Internal hernia is a very rare case of small bowel obstruction (incidence: 0.2-09%) with a significant mortality rate of about 45%. It has few different forms including congenital or acquired and persistent or intermittent. According to its anatomic location, internal hernia has multiple different types. Trans-omental type is the rarest one that only accounts for 1-4% of internal hernia cases. It can be discovered incidentally but can also cause small bowel strangulation and obstruction with very high mortality rate. Based on presentation, immediate diagnosis and urgent surgical intervention are crucial to save the patient's life. Only very seldom cases o f trans-omentalhernia were reported in the literature that always had acute presentation. We report a very rare case of trans-omental hernia that started with slow presentation over decades with vague abdominal symptoms but then developed acute small bowel obstruction that necessitated immediate surgery.

Migraine with benign episodic unilateral mydriasis.

Pupil asymmetry or anisocoria can have benign or malignant causes, and be categorized as acute or chronic. It can also be a normal finding in about 20% of cases. Benign episodic unilateral mydriasis is an isolated benign cause of intermittent pupil asymmetry. The exact pathophysiology is not always understood. According to one hypothesis, it is due to discordance between the sympathetic and parasympathetic systems. It is occasionally seen in patients with migraine. Some authors consider it a limited form of ophthalmoplegic migraine. We report a case of benign episodic unilateral mydriasis diagnosed in a 30-year-old lady with a history of migraine who had extensive negative neurological evaluation.

Median arcuate ligament syndrome: a nonvascular, vascular diagnosis.

Median arcuate ligament syndrome (MALS) is often diagnosed when idiopathic, episodic abdominal pain is associated with dynamic compression of the proximal celiac artery by fibers of the median arcuate ligament. The character of the abdominal pain is often postprandial and associated with gradual weight loss from poor food intake, suggestive of chronic mesenteric ischemia. However, the pathognomonic imaging feature of dynamic, ostial celiac artery compression with expiration does not consistently predict clinical improvement from revascularization. Proposed but unproven pathophysiological mechanisms include neurogenic pain from compression of the splanchnic nerve plexus and intermittent ischemia from compression of the celiac artery. Alterations in blood flow and ganglion compression are both associated with delayed gastric emptying, another physiological correlate of the clinical syndrome. Published reports describe a variable response to revascularization and nerve plexus resection suggest a need for translational research to better characterize this poorly understood clinical entity. We illustrate the current gaps in our knowledge of MALS with the case of a 51-year-old woman with a 4-year history of chronic abdominal pain who responded to a combination of ganglion resection and celiac artery reconstruction.

Kartagener syndrome.

Kartagener syndrome is a rare, ciliopathic, autosomal recessive genetic disorder that causes a defect in the action of the cilia lining the respiratory tract and fallopian tube. Patients usually present with chronic recurrent rhinosinusitis, otitis media, pneumonia, and bronchiectasis caused by pseudomonal infection. Situs inversus can be seen in about 50% of cases. Diagnosis can be made by tests to prove impaired cilia function, biopsy, and genetic studies. Treatment is supportive. In severe cases, the prognosis can be fatal if bilateral lung transplantation is delayed. We present a case of a 66-year-old woman with chronic recurrent upper respiratory infections, pseudomonal pneumonia, and chronic bronchiectasis who presented with acute respiratory failure. She was diagnosed with Kartagener syndrome based on her clinical presentation and genetic studies. She expired on ventilator with refractory respiratory and multiorgan failure.

Spontaneous lateral abdominal wall hematoma complicating chronic obstructive pulmonary disease exacerbation.

Lateral abdominal wall hematoma is a rare and potentially life-threatening condition. We report a case of a spontaneous lateral abdominal wall hematoma that developed in a patient with severe cough caused by chronic obstructive pulmonary disease (COPD) exacerbation. The hematoma resolved with conservative management.

A leiomyosarcoma of the small bowels causing obscure gastrointestinal bleeding diagnosed by capsule endoscopy.

An 80-year-old woman presented with recurrent occult gastrointestinal bleeding requiring blood transfusions. She underwent endoscopy and colonoscopy that failed to identify the cause of bleeding. An enteroscopy revealed duodenal arteriovenous malformation that was cauterized. However, anemia and occult gastrointestinal bleeding recurred. A repeat enteroscopy was negative. A wireless capsule endoscopy showed a lesion in the small bowel. Pathology revealed a leiomyosarcoma. This case confirms the importance of capsule endoscopy in the diagnosis of obscure bleeding and detection of small bowel tumors.

Influenza viruses and the evolution of avian influenza virus H5N1.

Although small in size and simple in structure, influenza viruses are sophisticated organisms with highly mutagenic genomes and wide antigenic diversity. They are species-specific organisms. Mutation and reassortment have resulted in newer viruses such as H5N1, with new resistance against anti-viral medications, and this might lead to the emergence of a fully transmissible strain, as occurred in the 1957 and 1968 pandemics. Influenza viruses are no longer just a cause of self-limited upper respiratory tract infections; the H5N1 avian influenza virus can cause severe human infection with a mortality rate exceeding 50%. The case death rate of H5N1 avian influenza infection is 20 times higher than that of the 1918 infection (50% versus 2.5%), which killed 675000 people in the USA and almost 40 million people worldwide. While the clock is still ticking towards what seems to be inevitable pandemic influenza, on April 17, 2007 the U.S. Food and Drug Administration (FDA) approved the first vaccine against the avian influenza virus H5N1 for humans at high risk. However, more research is needed to develop a more effective and affordable vaccine that can be given at lower doses.