Ewing's sarcoma arising from the right sided chest wall: a case report.

Ewing sarcoma (ES) is a malignant tumour prevalent in young adults with a reported 5-year survival ranging between 40 and 60% in most studies. Majority of the patients with ES are usually diagnosed late with significant chest wall mass, chest pain or respiratory distress. Case presentation: Here, the authors present a case of a 21-year-old female with a diagnosis of right sided chest wall ES treated with neoadjuvant chemotherapy followed by surgical resection of the mass. Clinical findings and investigations: The patient presented to the Surgical OPD with shortness of breath for 6 months associated with chest pain on the right side. Radiological investigations including chest X-ray and multi-detector row computed tomography chest was done. Additionally, diagnosis of ES was confirmed with histopathological examination of the mass obtained from fine needle aspiration cytology. Interventions and outcome: She was planned for safe maximal resection of tumour with chest wall reconstruction using double prolene mesh with bone cement and the defect was sutured with adjacent ribs. Good outcome was noted on postoperative period with resolution of symptoms. Relevance and impact: This procedure is now commonly used and is considered as an effective treatment for chest wall tumours, which was also noted in our case and the procedure is also well tolerated.

Accidental gunshot injury with left-sided lung injury and D11 burst fracture: a case report.

Penetrating chest injuries are mainly caused by gunshot trauma and stab injuries. These lead to damage to the vital structures, which requires a multidisciplinary approach for management. Case presentation: We present a case of an accidental gunshot injury (GSI) to the chest resulting in left-sided hemopneumothorax, left lung contusion, and D11 burst fracture with spinal cord injury. The patient underwent thoracotomy to remove the bullet along with instrumentation and fixation of the D11 burst fracture. Clinical discussion: Penetrating trauma to the chest requires prompt resuscitation and stabilization with eventual definitive care. Most GSIs to the chest require chest tube insertion, which helps to create negative pressure in the chest cavity, allowing adequate time for the expansion of the lungs. Conclusion: GSIs to the chest could give rise to life-threatening conditions. However, the patient must be stabilized for at least 48 h before performing any surgical repair to ensure that there are fewer complications following surgery.

Supraventricular tachycardia and deep vein thrombosis following Moderna vaccination: A case series.

There have been reports of deep vein thrombosis and supraventricular tachycardia following the Moderna vaccination. The timing of SVT and DVT just after vaccination in our case series could suggest possible temporal relationships to the vaccination. But further studies are needed to establish such evidence.

Vascular Injury to the Neck by a Bamboo Stick: A Case Report.

Penetrating neck injuries causing rupture of sternocleidomastoid muscle along with transection of major vessels of the neck have significant morbidity and mortality due to the risk of severe hemorrhage and cerebral infarction. However, there are no universal guidelines for the management of penetrating neck injuries. Here, we report a case of a 67-year-old female with a lacerated wound on the left side of the neck with a complete transection of the left sternocleidomastoid muscle along with transection of internal jugular vein and two superficial branches of internal carotid artery following penetrating injury to the neck by a bamboo stick. It was managed by emergency wound exploration with ligation of the injured vessels with repair of sternocleidomastoid muscle. Post-operatively the hemorrhage was controlled and the patient was discharged on the fourth postoperative day. Thus, in a case of penetrating injury to the neck, prompt surgical wound exploration is beneficial.

Rhegmatogenous Retinal Detachment with Spontaneous Dialysis of the Ora Serrata in Neurofibromatosis Type 1: A Case Report.

Neurofibromatosis type 1 is a genetic disorder that follows an autosomal dominant pattern of inheritance. Ocular involvement is not uncommon, but spontaneous dialysis of the retina in the absence of a history of trauma is a rare clinical entity. Rare cases of retinal involvement such as retinal detachment or dialysis of ora serrata could be linked with the abnormal cell-matrix formation in neurofibromatosis type 1. Here, we present a case of a 36-year-old man having Neurofibromatosis Type 1 with spontaneous dialysis of ora serrata without prior history of ocular trauma. A routine fundoscopic examination should be done in addition to the examination of the anterior chamber in patients with neurofibromatosis type 1 despite the absence of ocular complaints. Keywords: case reports; neurfibromatosis type 1; ora serrata; retinal; retinal detachment.

Circumferential intimal tear with thrombosis of right superficial femoral artery due to penetrating injury by bull horn: A case report.

In agrarian countries where bulls are used for farming and stock breeding, bull horn injuries are common. Bull horn injuries range from blunt trauma to penetrating injuries, which can cause massive hemorrhage. Vascular injuries to the limbs by goring bull horn injury usually involve transection of vessels but rarely cause intimal tear with thrombus formation. Here, we report an unusual case of a 33-year-old male with circumferential intimal tear with thrombosis in the subintimal region of the right superficial femoral artery without transection of the vessel following penetrating injury to the right thigh caused by a bull's horn. There was a pulse deficit above the popliteal artery, and Doppler ultrasonography revealed decreased flow indicative of underlying femoral vessel injury for which the wound was surgically explored. It was followed by right superficial femoral arteriotomy at the site of the thrombus with the evacuation of a 6 cm long clot, revealing a 6 cm long endothelial injury in the same vessel. Next, an interposition reversed saphenous graft was placed in the same location. Following this, Doppler ultrasonography was done that revealed restoration of blood flow to the site of thrombosis. Thus, in a case of bull horn injury, thrombosis should be ruled out with prompt surgical wound exploration despite the presence of an intact vessel.

Placement of cuffed tunnelled permanent hemodialysis catheter in patients with end stage renal disease: A cross sectional study.

Background: End-Stage Renal Disease (ESRD) is a significantly increasing condition warranting renal replacement therapy. Gaining vascular access for catheter placement for this procedure is of paramount importance. These can be done by temporary and permanent cuffed tunnelled catheters. The present study aims to analyze the outcome of permanent hemodialysis catheters and their efficacy in the case of patients suffering from end-stage renal disease. Materials and methods: A cross-sectional study was conducted on 32 patients who underwent permanent tunnelled catheter intervention along with details of follow-up from January 1st, 2021 till December 31st, 2021. Results: Among 32 patients, the mean age of the patient was 50.25 ± 18.10 years with 62.5% females. The site of insertion was right 27(84.37%) and left internal jugular vein in 4 (12.50%) and 1 patient (3.12%) in the left common femoral vein. Bleeding the peri-catheter site was observed in 4 (12.5%), infection was found among 2 patients (6.25%), thrombosis in the catheter in 7 (21.87%) patients. Indication for the procedure was due to failure of arteriovenous fistula in 21 (65.62%), lack of maturation of the AVF in 9 (28.12%) and patients awaiting transplantation in 2 (6.25%). The mean months of follow-up of the patients were 5.9 months (SD 4.4 months, range 1 month-12 months). Total 25 (78.1%) of the catheters were patent till the time of follow-up. Seven (21.9%) of the patients required manipulation once after which they also had functioning permanent catheters. The mean month on which manipulation was required was 4.1 months (SD 2.3months, range one month to seven months). Conclusion: Permanent cuffed tunnelled catheter has good patency and can be an alternative to an arteriovenous fistula.

Venous pseudoaneurysm of left brachiocephalic fistula treated by excision and aneurysmorrhaphy: A case report.

INTRODUCTION AND IMPORTANCE: Brachiocephalic fistula, an arteriovenous fistula approach for hemodialysis in Chronic Kidney Disease patients, can cause various complications. Pseudoaneurysm in the venous end of the arteriovenous fistula is one of those unusual presentations, and can lead to the failure of vascular access. CASE PRESENTATION: We present a case of a 38-year-old female with pseudoaneurysm in the venous end of the left brachiocephalic fistula presenting as painless swelling for one month. Surgical management was done with excision followed by aneurysmorrhaphy. CLINICAL DISCUSSION: The repair is associated with risks of arteriovenous fistula failure, thromboembolism, bleeding manifestation and graft rupture. Surgical correction should be done as early as possible with consideration of size, location, and available resources. CONCLUSION: Venous pseudoaneurysm in a brachiocephalic fistula is an unusual complication which requires prompt surgical correction.

Klippel-Trenaunay Syndrome: Case series from a university hospital of Nepal.

Introduction: Klippel Trenaunay Syndrome (KTS) is a rare congenital malformation with capillary and venous malformations and soft tissue/bony overgrowth with or without lymphatic malformation. Cutaneous vascular stain, varicosities and tissue hypertrophy represent its main clinical features. Besides, the patient can develop thromboembolic pathologies, recurrent bouts of infection, stasis eczema, limb length discrepancy and intolerable pain typical of intraosseous involvement. Methods: Here, we report a case series of seven patients aged 10-45 who presented to our centre with clinical features suggestive of KTS. Out of them, six patients had involvement of unilateral lower limb, while only one had involvement of bilateral lower limb. They all had typical cutaneous vascular stains and underlying venous malformation, while one patient had developed complications with multiple ulcer formation. Outcomes: An interdisciplinary team of vascular surgeons, dermatologists, interventional radiologists, orthopaedics, and physiotherapists managed the cases. We performed an individualized treatment as per the patient's presentation, which included a combination of supportive, medical, interventional radiologic, and surgical interventions. The follow-up outcomes of all the patients revealed significant resolution of symptoms. Conclusion: Patients with KTS can have diverse presentations. Therefore, clinicians should ensure an individualized treatment with the involvement of a multidisciplinary team for proper management and prevention of complications.

Combined vascular malformation of neck: A case report.

Vascular malformations are developmental anomalies occurring due to defective vasculogenesis. Depending on the number of vessels involved, they are subgrouped into simple or combined types. Combined vascular malformations are a rare clinical entity with two or more vascular malformations (capillary, venous, arteriovenous, lymphatic) present in one lesion. Due to the complexity of these lesions, clinicians should employ an interdisciplinary approach with multi-staged treatment for the proper management. Here, we report a case of a lady with a combined vascular malformation in the right side of the neck who presented to our department with a complaint of progressively increasing swelling for three months. A multidisciplinary team of vascular surgeons, interventional radiologists and physiotherapists were involved in its treatment. Initially, Doppler ultrasonography was performed, which revealed a vascular lesion with arterial and venous components and a flow void region suggestive of lymphatic malformation, further confirmed by magnetic resonance imaging (MRI). A multistage treatment modality was employed where intralesional steroid was initially administered in the lesion area to shrink the vessel's size. Next, venous malformation targeted sclerotherapy was performed preoperatively, followed by intraoperative ligation of the feeding vessel and excision of remaining malformation. Postoperatively the patient had no wound site complication and was discharged on the fourth postoperative day with advice to follow rehabilitative neck exercises. One month follow-up revealed complete resolution of the malformation. Thus, in the case of combined vascular malformation, multistage treatment modalities with a multidisciplinary team should be employed for proper treatment.

Traumatic gastric laceration with injury of splenic and celiac vessel following intentional self-harm by crashing of motor vehicle: A case report.

Intra-abdominal injury due to blunt trauma accounts for 5-10% of all traumatic cases. It usually occurs secondary to motor vehicle collision, pedestrian injury, and falls. Typically these result in injury to solid abdominal organs-liver and spleen, hollow visceral organs, and rarely the abdominal vasculature. Blunt abdominal trauma causing concurrent injury to the hepatic branch of the celiac artery and the associated vein along with gastric laceration is a rare presentation and has a high mortality rate, thereby warranting prompt evaluation. While the initial stabilization should follow Advanced Trauma Life Support guidelines, the adherence to nonoperative management or operative care depends upon the severity of the injury and the patient's clinical status. Here, we present an unusual case of gastric and splenic laceration with damage to the hepatic branch of celiac artery, splenic artery, and the associated vein following blunt abdominal trauma in a 12-year-old child following intentional self-harm by crashing a self-inflicted motor vehicle. Despite the negative preoperative radiological finding, the case was managed successfully with the laparotomic correction of the damaged stomach segment, splenectomy, and repair of the damaged artery, and ligation of the transected vein to control hemorrhage.

Klippel Trenaunay syndrome in a 3-year-old: A case report.

INTRODUCTION AND IMPORTANCE: Klippel-Trenaunay syndrome (KTS) is characterized by a triad of port-wine stain, varicose veins and soft tissue or bony hypertrophy of lower limb. Varicose veins in Klippel Trenaunay syndrome are mostly distributed in the lateral aspect of the lower limb. The exact etiology of KTS is not known, and the treatment usually starts with conservative management- limb elevation, compression stockings and physiotherapy. However, some cases are severe enough to warrant surgical management. CASE PRESENTATION: Here we present a case of a 3-year-old male child with clinical features suggestive of Klippel Trenaunay Syndrome managed successfully with sclerotherapy of persistent lateral marginal vein of servelle. At one month follow-up the vein was sclerosed and there was a significant reduction in varicosities of leg. CLINICAL DISCUSSION: Starting treatment of varicose veins in Klippel Trenaunay Syndrome in children is effective in preventing long-term complications in adults. Thus, treating venous malformation with sclerotherapy is warranted in early childhood to prevent venous hypertension and chronic venous insufficiency. CONCLUSION: Varicose veins in KT syndrome can be managed successfully by sclerotherapy of lateral marginal vein of servelle resulting in significant reduction in varicosities of leg.

Anticoagulation failure in pulmonary thromboembolism in COVID-19 pneumonia despite prolonged anticoagulation: A case series.

Introduction: Moderate to severely ill patients diagnosed with Coronavirus disease 2019 (COVID-19) pneumonia develop a series of complications and less frequently, we might witness cases of Pulmonary Thromboembolism (PE)-refractory to the standard treatment with Low Molecular Weight Heparin (LMWH). The aim of this case series is to report the presentation and management of pulmonary thromboembolism secondary to COVID-19 pneumonia. Method: We report a case series of seven cases aged 40-70 who were presented in Dhulikhel Hospital with COVID-19 symptoms in different stages. The case details were extracted from their medical reports of the hospital. The written informed ethical consents were obtained from all the cases and their voluntary participation was assured. Outcome: The cases in the case series admitted with COVID-19 pneumonia, after diagnostic investigation (Chest x-ray, HRCT, CTPA) were suggestive of COVID-19 Pneumonia with ARDS and pulmonary thromboembolism. The cases received rivaroxaban, a newer anticoagulant-15 mg twice daily for 21 days and after discharge, they were asked to continue once daily doses for 9 weeks. Significant improvement was witnessed, with the presence of additional intervention including rehabilitative chest exercises. Conclusion: Pulmonary thromboembolism secondary to COVID-19 pneumonia is a life-threatening condition. Rivaroxaban is seen to be very effective in the management of this condition when an anticoagulation failure occurs even after the therapeutic dose of low molecular weight heparin. Future studies may require more scientific investigations to prevent complications even in the early stages of COVID-19.