Extensive ulnar nerve necrosis: a complication of tuberculoid leprosy.

Pure neural leprosy without cutaneous manifestations is a relatively rare manifestation of leprosy. It can present as a mono- or poly-neuritis with sensory and/or motor impairment. Neural leprosy may or may not be associated with thickening of the involved nerve. We report the case of a 14 year old boy with extensive ulnar nerve necrosis who was diagnosed to have tuberculoid leprosy. What makes this case unique is that we have here a case of pure neural leprosy with a single nerve turned 'necrotic'.

The doctrine of "Reasonable Doctor" in medical negligence: Need to be more reasonable.

The model of a 'reasonable doctor' has been quite successfully used to deliver justice in disputes involving medical negligence. However, many a times a doctor is held guilty of negligence when viewed through the narrow lens of an ideal 'reasonable doctor' and without looking into the circumstances under which he was working which could have actually led to the alleged act of negligence. This short write-up highlights the importance of applying this doctrine more reasonably in the best interest of all stake holders and the drawbacks of the doctrine of 'reasonable doctor' in adjudicating medical negligence cases with few international case laws.

Complete sternal cleft with tetralogy of Fallot.

Complete sternal cleft is a very rare congenital midline defect of the sternum. It is not uncommonly associated with intracardiac defects. We report a case of a 2-year-old child with complete sternal cleft and tetralogy of Fallot who presented with cyanotic spells. The child underwent total correction, followed by chest wall reconstruction on the next day.

Needle tract sinus following aspiration biopsy of papillary thyroid carcinoma: a case report.

BACKGROUND: Fine needle aspiration biopsy (FNAB) of the thyroid is a simple and safe investigation. Dissemination of malignant cells during FNA for papillary thyroid carcinoma is extremely uncommon. CASE: We report a 49-year-old woman who presented with a multicystic goiter and palpable cervical lymph nodes. Three sessions of FNAB (a total of 12 needle passes) from a complex cyst overlying the thyroid isthmus using a 22-gauge needle failed to reveal malignant cells. Following the FNAs she developed a persistent discharging sinus at the needle insertion site. Exploration of the neck and histopathologic examination confirmed a well-differentiated papillary thyroid carcinoma infiltrating the skin and strap muscles at a single focus. Debulking surgery with adjuvant radiotherapy had a satisfactory outcome in our patient. CONCLUSION: Skin sinus formation might have been prevented in our case by using a needle with a caliber < 22 gauge and avoiding multiple sessions of aspiration of the same thyroid nodule.

Lymphadenovarix in the axilla--an unusual presentation of filariasis.

Clinical manifestations of lymphatic filariasis depend on the area of lymphatic involvement and the duration of infection. A 21 year old man, resident in a filariasis endemic region, presented with multiple matted lymph nodes with cystic areas forming a large mass in his left axilla. An ultrasound scan of the axilla using a 7.5 MHz transducer revealed grossly dilated lymphatics but no filarial dance sign. Fine needle (21 G) aspiration cytology (FNAC) from the dilated lymphatics and solid areas in the lymph node mass revealed multiple microfilariae in a background of reactive lymphoid cells. Peripheral blood smears revealed microfilaremia with significant eosinophilia. Diagnosis of left axillary Bancroftian lymphadenovarix was made. On the administration of oral diethylcarbamazine, the diameter of the lymphatic vessels in the lymphadenovarix reduced considerably in size and microfilaremia disappeared. We report this case because axillary lymphadenovarix is a rare presentation of filariasis. This case is also unique since microfilariae were demonstrated in the fluid aspirated from the dilated lymphatics of the lymphadenovarix in the absence of live adult worms.

Laparoscopic control of spontaneous external hemorrhage from umbilical varix.

Spontaneous external hemorrhage from an umbilical varix is rare. We describe a 40-year-old man with cirrhosis and portal hypertension, who presented with recurrent external bleeding from an umbilical varix. The first episode was controlled by transfixation of the vein under local anesthesia. Contrast-enhanced CT scan demonstrated a hugely distended recanalized umbilical vein arising from the left branch of the portal vein and ending in the umbilical cicatrix. Recurrent bleeding necessitated laparoscopy and in-situ clipping of the bleeding vein in the falciform ligament. At six months' follow up the patient has no further bleeding.

Fetus in fetu or differentiated teratomas?

Two cases of congenital teratoma were operated upon. In view of the high degree of organoid differentiation of the teratomas with rudimentary limbs, intestine, brain-like and pulmonary tissues, it was difficult to distinguish it from fetus-in-fetu. In the light of the data obtained and extensive review of related literature, we consider that fetus-in-fetu and teratoma may not be unrelated entities. Our cases support the view held that fetuses in fetu are highly differentiated teratomas.

Early elevation of intra-abdominal pressure after laparotomy for secondary peritonitis: a predictor of relaparotomy?

BACKGROUND: Patients with secondary peritonitis often require relaparotomy; however, there is no consensus about the criteria for selecting patients who would benefit from early relaparotomy. Our goal was to evaluate whether elevated intra-abdominal pressure (IAP) during the early postoperative period could predict the need for relaparotomy. METHODS: A total of 102 consecutive adult patients with acute intra-abdominal conditions were admitted for laparotomy. Seventy-eight patients, who were diagnosed with secondary peritonitis at index surgery, underwent serial measurements of IAP. The primary outcomes measured in the study were incidence of postoperative peritonitis and mortality. RESULTS: Thirty-two of 78 patients with secondary peritonitis (41%) developed elevated IAP postoperatively. Sixteen (20.5%) of 78 patients developed postoperative peritonitis. Twelve of these 16 patients (75%) with postoperative peritonitis had significantly elevated IAP (P = 0.002) during the immediate postoperative period. Regression analysis revealed elevated IAP (P = 0.055) to be third most predictive of postoperative peritonitis in patients who underwent laparotomy for secondary peritonitis, after septic shock at admission (P = 0.012) and POSSUM score (P = 0.018). CONCLUSION: Our study shows that development of elevated IAP during the early postoperative period can increase the risk of postoperative peritonitis. IAP measured during the immediate postoperative period can be used as a predictor of early relaparotomy.