Tension pneumothorax in a patient with Covid-19 pneumonia initially misdiagnosed as volvulus.

Tension pneumothorax is a condition that can present with a myriad of symptoms, including chest pain, shortness of breath, rapid breathing, and tachycardia. If left untreated, these signs and symptoms can progress to shock causing haemodynamic collapse and even death. At times, it may be difficult to identify tension pneumothorax. We present the case of a 59-year-old male with a prolonged initial hospital course that eventually led to a diagnosis of tension pneumothorax with the use of CT scans rather than traditional X-rays. This case reinforces the idea that clinicians should have a wide differential diagnosis in mind when dealing with vague symptoms and should not hesitate to use different diagnostic modalities to help confirm a diagnosis.

Case report: Congenital mesoblastic nephroma.

INTRODUCTION AND IMPORTANCE: Congenital mesoblastic nephroma is a common benign renal tumor that mainly affects infants below the age of six months (Daskas et al., 2002). Identifying the pathology type is crucial for determining the appropriate plan of action and predicting the patient's prognosis. CASE PRESENTATION: A one-day-old Hispanic neonate was referred for surgical evaluation after detecting a LUQ mass. Ultrasound imaging revealed a heterogenous solid mass that infiltrated the hilum of the left kidney. The patient underwent a left radical nephrectomy, and the pathology results indicated that the mass was consistent with the classic type of congenital mesoblastic nephroma. The patient will be closely monitored by nephrology with frequent abdominal ultrasounds. CLINICAL DISCUSSION: The case describes a one-day-old female baby with an asymptomatic LUQ abdominal mass, which was diagnosed as mesoblastic nephroma. The baby was born full-term with no significant medical history, and after experiencing hypertensive episodes, she underwent a left radical nephrectomy to remove the tumor. Pathology confirmed mesoblastic nephroma, classic type, and the patient was diagnosed with stage I disease since the tumor was entirely resected with no renal vessel involvement. Follow-up ultrasounds were recommended to monitor for recurrence, and chemotherapy may be considered if recurrence occurs (Pachl et al., 2020). Calcium and renin levels should also be monitored (Bendre et al., 2014). CONCLUSION: Although congenital mesoblastic nephroma is typically benign, patients require ongoing monitoring for potential paraneoplastic syndromes. Furthermore, certain types of mesoblastic nephroma can progress to malignancy, necessitating close follow-up during the first few years of life.

Frontal subcutaneous lipoma associated with large interhemispheric lipoma and corpus callosum agenesis.

Intracranial lipomas are extremely rare fat-containing lesions that comprise 0.1%-0.5% of all primary brain tumors. They are congenital lesions that arise due to persistence and maldifferentiation of the meninx primitive (subarachnoid space precursor). We report a case of a 30-year-old woman who presented with seizures due to an intracranial lipoma and no neurological deficits. CT (computerized tomography) imaging findings demonstrated a large interhemispheric partially calcified lipoma that communicated with a large scalp lipoma and was associated with agenesis of the corpus callosum. Compared to the prior CT imaging, the lipoma increased in size from 3.4 cm to 4.1 cm transversely. A recent CT angiogram done due to suspicion of an aneurysm showed the lipoma now measuring 6 cm by 4.7 cm. Most cases of intracranial lipoma have been reported in the pediatric age group. Here, we report a rare case of interhemispheric intracranial lipoma in the adult age group. This case also demonstrates the importance of imaging modalities for detecting intracranial lipoma without performing invasive brain biopsy.

Arterioureteral Fistula in the Setting of Radical Cystoprostatectomy and Ileal Conduit Creation.

Arterioureteral fistulas (AUF) following ileal conduit reconstruction are rare and not well-studied. We present a life-threatening bleed from an AUF due to an ileal conduit urinary diversion. In addition, we identify the challenges in the diagnostic process as well as management strategies. We present a 63-year-old male with ileal conduit reconstruction for bladder cancer with an AUF developing years after the reconstruction, which was ultimately managed with angioplasty.

Erratum to: Acute abdomen in a 54-year-old COVID-19 patient: a case report.

[This corrects the article DOI: 10.1093/jscr/rjab198.].

Novel method of using angioembolization for treating testicular hemorrhage after blunt trauma.

Testicular or scrotal trauma is a rare form of trauma in the United States. Blunt trauma to the testicle can lead to testicular tunica albuginea rupture, testicle contusion, testicle hematoma, testicle torsion and epididymal injury. We report a case of a 48-year-old male patient who presented with right sided scrotal swelling and pain from a motorcycle collision. This turned out to be from a testicular rupture and resulting in a hematoma. The patient's active bleeding from the right testicular artery was controlled by arterial embolization. Most reported cases of testicular artery bleeds are due to iatrogenic hemorrhage or non-traumatic injuries. Here, we report a rare case of testicular artery bleed due to a blunt trauma from a motorcycle collision. In conclusion, the testicular artery bleed was controlled successfully via testicular arterial embolization, making it a potential option for non-operative management for stable hemorrhage of the testicular artery.

Rare case of papillary fibroelastoma resection with concomitant cox-maze IV procedure.

Primary cardiac tumors represent 0.1% of all cardiac tumors, making them a rare pathologic phenomenon. The second most common cardiac tumors are papillary fibroelastomas, which also represent the most common valvular tumors. This report examines a rare case of a patient that underwent resection of papillary fibroelastoma with simultaneous Cox-Maze IV procedure for treatment of atrial fibrillation. This 67-year-old male patient was initially scheduled for transcatheter ablation for treatment of rate-controlled atrial fibrillation. During a pre-procedural trans-thoracic echocardiogram, it was discovered that the patient had a moderately sized pedunculated mass on the aortic valve, suspicious of papillary fibroelastoma. Despite the patient having no history of embolic events or aortic insufficiency from the papillary fibroelastoma, the transcatheter ablation procedure was canceled. He was referred to cardiothoracic surgery for further evaluation, and it was determined that this patient was a candidate for papillary fibroelastoma resection along with Cox-Maze IV procedure for atrial fibrillation.

Unusual Presentation of Isolated Nonbacterial Thrombotic Tricuspid Valve Endocarditis in Systemic Lupus Erythematosus With Secondary Antiphospholipid Syndrome: A Case Report.

Nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, is one of the most prevalent cardiac presentations seen in patients with systemic lupus erythematosus (SLE). It is a condition that is characterized by noninfectious lesions affecting cardiac valves. The most common sight for this disease to affect is the left-sided mitral and aortic cardiac valves. It rarely involves the right-sided tricuspid valve. However, having a secondary condition that increases risk for hypercoagulability can potentiate the severity and frequency of cardiac valvular disease in SLE. In this report, the authors describe a rare case of a patient who presented with clinically symptomatic isolated-sterile tricuspid valve vegetations likely due to antiphospholipid syndrome (APLS) on top of SLE. Optimal medical and surgical managements of these vegetations are not well defined. Criteria call for surgical intervention in infective endocarditis when there are severe heart failure or valve dysfunction, prosthetic valve infection, recurrent systemic emboli, large mobile vegetations, and other detrimental complications. However, intervention for sterile vegetations should also be discussed if the patient can benefit from it clinically and if it can improve quality of life. The authors discuss this case in the context of the relevant medical and surgical literature.

A rare presentation of delayed traumatic lumbar hernia after motor vehicle collision.

Traumatic abdominal wall hernia is defined as protrusion of bowel or an abdominal organ through a disruption of musculature and fascia following a severe blunt trauma. We report a case of a patient who had a delayed presentation of a traumatic, superiorly located paralumbar hernia months after the initial admission.

Predicting Difficult Airway Intubation Based on Maxillofacial Trauma: A Retrospective Study.

Purpose The purpose of this study was to determine which types of facial injuries in traumatic patients' wounds cause difficult intubation for anesthesiology team. By anticipating potential complications with airway management, the surgeons can be better prepared for emergent cricothyrotomy if needed. This could include prior to the planned procedure in the operating room (OR) as well as in emergent conditions in trauma bay. Methods Trauma patients with facial injuries in a level II trauma center from January 2007 to September 2017 that required intubation were evaluated for types of facial injury. Anesthesiology intubation documents were reviewed to determine which types of facial injuries were associated with difficult intubation per anesthesiology documentation. Results A total of 232 subjects were selected and it was found that patients with LeFort II facial fracture, bilateral mandibular fracture, and facial fracture associated with basilar skull fracture were noted to have difficult intubation by the anesthesiology team. Conclusion On the basis of CT imaging findings, our study demonstrates that certain types of facial fractures could pose difficult intubation. Surgeons should be aware of these injuries and be ready to intervene with emergent cricothyrotomy if necessary.

A case of esophageal ulcer and hemorrhage due to aberrant subclavian in a COVID positive patient.

Coronavirus Disease 2019 (COVID-19), a global pandemic, is a respiratory infection that impairs the lungs among many other organs. We report a case of a COVID-19 positive patient requiring prolonged mechanical ventilation with nasogastric tube for enteral feeding, leading to esophageal ulcer and hemorrhage, from an aberrant right subclavian artery.

Comparative Analysis of Patients with Robotic Hiatal Hernia Repairs with and without Collis Gastroplasty.

INTRODUCTION: After extensive mediastinal dissection fails to achieve adequate intra-abdominal esophageal length, a Collis gastroplasty(CG) is recommended to decrease axial tension and reduce hiatal hernia recurrence. However, concerns exist about staple line leak, and long-term symptoms of heartburn and dysphagia due to the acid-producing neoesophagus which lacks peristaltic activity. This study aimed to assess long-term satisfaction and GERD-related quality of life after robotic fundoplication with CG (wedge fundectomy technique) and to compare outcomes to patients who underwent fundoplication without CG. Outcomes studied included patient satisfaction, resumption of proton pump inhibitors (PPI), length of surgery (LOS), hospital stay, and reintervention. METHODS: This was a single-center retrospective analysis of patients from January 2017 through December 2018 undergoing elective robotic hiatal hernia repair and fundoplication. 61 patients were contacted for follow-up, of which 20 responded. Of those 20 patients, 7 had a CG performed during surgery while 13 did not. There was no significant difference in size and type of hiatal hernias in the 2 groups. These patients agreed to give their feedback via a GERD health-related quality of life (GERD HRQL) questionnaire. Their medical records were reviewed for LOS, length of hospital stay (LOH), and reintervention needed. Statistical analysis was performed using SPSS v 25. Satisfaction and need for PPIs were compared between the treatment and control groups using the chi-square test of independence. RESULTS: Statistical analysis showed that satisfaction with outcome and PPI resumption was not significantly different between both groups (P > .05). There was a significant difference in the average ranks between the 2 groups for the question on postoperative dysphagia on the follow-up GERD HRQL questionnaire, with the group with CG reporting no dysphagia. There were no significant differences in the average ranks between the 2 groups for the remaining 15 questions (P > .05). The median LOS was longer in patients who had a CG compared to patients who did not (250 vs. 148 min) (P = .01). The LOH stay was not significantly different (P > .05) with a median length of stay of 2 days observed in both groups. There were no leaks in the Collis group and no reoperations, conversions, or blood transfusions needed in either group. CONCLUSION: Collis gastroplasty is a safe option to utilize for short esophagus noted despite extensive mediastinal mobilization and does not adversely affect the LOH stay, need for reoperation, or patient long-term satisfaction.

Surgeon's Impact on Opioid Epidemic Following Uncomplicated Laparoscopic Appendectomy and Cholecystectomy.

The opioid crisis in the United States remains a major issue that is directly linked to the prescribing practices of physicians. There is a lack of consistency in post-operative prescribing of narcotic medications. We have designed a retrospective study to evaluate factors that contribute to the prescription of opioids following common laparoscopic procedures. In this study, we analyzed peri-operative medications and pain requirements and how they relate to the frequency in which narcotics are prescribed at Saint Joseph's University Medical Center (SJUMC), a level two trauma center and teaching hospital. We also studied how the frequency of narcotic prescriptions is related to patient demographics and surgeon practices. We propose that standardizing pain medication protocols will be an effective way to decrease overall narcotic use as well as prescriptions for common laparoscopic procedures.

Incidental discovery of goblet cell carcinoid, a rare appendiceal malignancy case report.

Goblet cell carcinoid (GCC) tumor is a rare appendiceal carcinoma that has had several names throughout its history. Often found incidentally on pathology following an appendectomy, treatment includes a right hemicolectomy and possible adjuvant chemotherapy. Survival rate has been shown to be correlated with the histological features. Here, we report a 45-year-old African American male who presented with signs and symptoms consistent with acute appendicitis, but was ultimately diagnosed with GCC. After undergoing a right hemicolectomy, he continues to undergo long-term surveillance with his oncologist. Due to the rarity of this tumor, we describe the history of GCC and our recommendations for surgical and long-term management.

Peripancreatic schwannoma: A case report.

INTRODUCTION: Schwannomas are a benign tumor of peripheral nerve sheath origin. Although most commonly arising in the extremities, head, and neck there have been rare cases of schwannomas presenting within or adjacent to the pancreas reported in the literature. PRESENTATION OF CASE: We present an asymptomatic and otherwise healthy 57-year-old male with an incidental peripancreatic mass measuring 3.5 × 3.7 cm found on abdominal computed tomography (CT). The patient underwent complete enucleation of the mass at our hospital. Pathological analysis of the excised specimen showed spindle shaped cells. Immunohistochemical staining was positive for S100 protein expression, confirming the definitive diagnosis of peripancreatic schwannoma. The patient's postoperative course was uneventful. DISCUSSION: Schwannoma is a commonly benign, encapsulated, and slowly growing tumor arising from myelin producing cells of peripheral nerves. A schwannoma presenting within or adjacent to solid abdominal viscera, such as the pancreas, may be challenging to diagnose preoperatively as it may mimic other lesions. Radiological appearance of schwannoma may be nonspecific and definitive diagnosis is reliant upon pathological analysis. The use of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) may assist the clinician in preoperative diagnosis, however these interventions are not widely available. Accurate preoperative diagnosis of a peripancreatic schwannoma is of high importance as it may preclude unnecessary pancreatectomy or radical resection. CONCLUSION: Although rare, schwannoma should be part of the differential diagnosis of a cystic or solid appearing mass within or surrounding the pancreas. Total resection carries an excellent prognosis with little to no documented recurrence.

Acute abdomen in a 54-year-old COVID-19 patient: a case teport.

Although primarily a respiratory virus, coronavirus-19 acts on the gastrointestinal tract to cause symptoms such as anorexia, nausea, vomiting and diarrhea. One possible mechanism involves the ACE2 receptor, which serves as the primary receptor for virus entry into the gastrointestinal epithelium. We describe the case of a 54-year-old-male with recent coronavirus disease 2019 (COVID-19) infection, who later presented with nausea, vomiting, diarrhea and progressively worsening diffuse abdominal pain for 1 week. He was diagnosed to have a small bowel obstruction; however, continued to have progressively worsening pain and failed conservative management. No cause for the obstruction was found in the operating room. Gastrointestinal involvement occurs in at least two-thirds of patients with coronavirus infection. Viral entry into the small bowel, triggering an inflammatory response, and virus-induced microthrombosis of the microcirculation have been postulated as a possible mechanism for paralytic ileus/small bowel obstruction.

Rare Presentations of Rapidly Growing Liposarcomas.

Liposarcomas (LSs) are a rare form of malignant tumors. They are the most common primary neoplasms of the retroperitoneum. While these tumors rarely metastasise, they are characterised by local recurrence and infiltration. Moreover, most are asymptomatic and hence grow to massive sizes before becoming symptomatic. Here, we report two unique cases of giant retroperitoneal liposarcomas seen in our urban tertiary care centre. The first case is that of a 53-year Dominican male, who developed a massive recurrence of his retroperitoneal LS within a span of just two months after initial resection  ̶ an exceedingly rare occurrence. The second case is that of a 67-year Peruvian female, who was found to have a retroperitoneal LS, causing complete displacement of the viscera in her right hemiabdomen. Key Words: Liposarcomas, Recurrence, Retroperitoneum.

Debulking of Advanced Gastrointestinal Stromal Tumor With Peritoneal Carcinomatosis Refractory to Imatinib and Sunitinib: A Case Report.

Gastrointestinal stromal tumors (GISTs) are non-epithelial stromal tumors that arise in the gastrointestinal tract. Pharmacological treatments for GIST are tyrosine kinase inhibitors. For metastatic disease, debulking may be helpful in reducing the tumor burden, thus increasing the effectiveness of tyrosine kinase inhibitors. Debate on whether resection would benefit the patient is still present. Here is a case of a 52-year-old African American male presenting with metastatic malignant GIST with peritoneal carcinomatosis refractory to imatinib and sunitinib. Since this patient had stage IV metastasis it was ultimately decided to proceed with a therapeutic debulking procedure. For this patient, the procedure increased the effectiveness of the medication and reduced mass effect symptoms, improving quality of life.

COVID-19 Precipitating Status Epilepticus in a Pediatric Patient.

BACKGROUND As the severe acute respiratory syndrome coronavirus 2 (SARS CoV2) spreads around the world infecting people of all ages, clinicians and researchers are working to gather data on the presentation of coronavirus disease (COVID-19). Further study is necessary to better diagnose and treat COVID-19 patients. CASE REPORT We describe the case of an 8-year-old boy admitted with status epilepticus, who also tested positive for COVID-19, while afebrile, with no initial respiratory symptoms. Benzodiazepines were given per treatment guidelines, abating the seizure activity. He subsequently developed respiratory distress and desaturation requiring temporary emergent intubation. All clinical symptoms resolved within a few hours. Results of a computed tomography (CT) scan of the brain were within normal limits. Results of a 24-h electroencephalogram (EEG) were abnormal, indicative of diffuse cerebral dysfunction. As a result of intubation and findings of bilateral infiltrates on chest x-ray, a COVID-19 test was administered and the result was positive. CONCLUSIONS For proper diagnosis and treatment, patients and clinicians should be aware that COVID-19 may not present in the typical fashion of respiratory distress and fever. The present case suggests a rare neurological presentation of COVID-19.

Primary Myxoid Liposarcoma of the Lower Back in an Adult Female Patient: An Extremely Rare Presentation.

Myxoid liposarcoma is the second most common type of liposarcoma that typically presents in the lower extremities and has a predilection for men. Manifestation of this tumor in the lower back is rare. We report the first known case of an adult woman presenting with a soft tissue mass in her lower back. Following excision and further workup, the mass was positive for rearrangements of the DDIT3 (CHOP) gene at the 12q13 locus, consistent with the diagnosis of a myxoid liposarcoma. The tumor was noted to be intramuscular and extended into the margins, requiring re-excision at the previous resection site. Biopsy of the re-excised area was negative for evidence of residual myxoid liposarcoma. We report this case to highlight the importance of considering myxoid liposarcoma as a differential diagnosis in soft tissue masses presenting in the lower back.