Postoperative tetanus after laparoscopic obturator hernia repair for strangulated ileus: report of a case.

This report presents the case of an 84-year-old woman who developed tetanus 3 days after the resection of a gangrenous small intestine caused by obturator hernia incarceration. The diagnosis of tetanus was clinically made after the appearance of generalized spastic contractions with opisthotonus. Clostridium tetani organisms residing in the gastrointestinal tract were presumed to have been endogenously inoculated into the strangulated intestine, where it produced tetanospasmin, causing tetanus. The patient successfully recovered after aggressive intensive care. There have been 16 case reports of tetanus occurring after gastrointestinal surgical procedures. Primary care physicians should thus be aware of the fact that, although extremely rare, C. tetani residing in the gastrointestinal tract can provide a possible endogenous source of tetanus infection.

The key to improving prognosis for aneurysmal subarachnoid hemorrhage remains in the pre-hospitalization period.

BACKGROUND: Despite advances in neurosurgical management, aneurismal subarachnoid hemorrhage (aSAH) still has high mortality and morbidity. This study aimed to clarify how delaying hospital admission after aSAH contributes to worse prognosis even today and to find the possibility for an improvement of its prognosis by early admission. METHODS: Four hundred twenty-one consecutive patients are the basis for this study. Cause of delay was classified into 5 categories: patient delay (PD), doctor delay (DD), transportation delay (TD), no delay (ND) (within 2 hours of onset), and others. Condition of each patient was assessed at time of onset and admission using H&K. The relationships between cause of delay and worsening of Hunt and Kosnik grading (H&K) were examined. RESULTS: The median delay time was 1.7 days. Only 41% of patients visited our institution without delay. Admission delay, especially PD and DD, exhibited a significant correlation to worsening of H&K. In addition to nondirect admission, misdiagnosis or delayed diagnosis contributed significantly to worsening of H&K. Incidence of DD has declined in recent years, whereas that of PD has increased. Consequently, no change in total number of delays was found. CONCLUSIONS: There remains much room for an improvement of prognosis for aSAH by early admission. We need to fully realize this reality and to directly face this problem.

Granulocyte colony-stimulating factor-producing lung cancer and acute respiratory distress syndrome.

Granulocyte colony-stimulating factor (G-CSF)-producing lung cancers are known to cause extreme leukocytosis. However, acute respiratory distress syndrome (ARDS) caused by G-CSF-producing lung cancer is extremely rare. We present a case of G-CSF-producing lung cancer with marked leukocytosis, which rapidly led to severe ARDS after the patient developed pneumonia. The present case suggests that extreme leukocytosis may easily lead to ARDS, triggered by infection. Thus, G-CSF-producing lung cancer with marked leukocytosis should be carefully monitored before surgery and during treatment.

Extracranial vertebral artery aneurysm ruptured into the thoracic cavity with neurofibromatosis type 1: case report.

OBJECTIVE AND IMPORTANCE: We are sometimes involved in the care of patients with neurofibromatosis Type 1 because of the associated disorders of cervicocerebral vessels. However, extracranial vertebral artery aneurysm in neurofibromatosis Type 1 is very rare. We present the first reported case of a rupture of an extracranial vertebral artery aneurysm into the thoracic cavity in a patient with neurofibromatosis Type 1. CLINICAL PRESENTATION: A 52-year-old woman who presented with a decrease in left-sided grip and numbness of the left upper limb was admitted. During history taking, she developed shock. Radiological examination revealed that a left extracranial vertebral artery aneurysm had ruptured into the thoracic cavity. With consciousness decreasing gradually because of hemorrhagic shock, the patient became comatose. INTERVENTION: Balloon occlusion of the vertebral artery proximal to the aneurysm was performed and surgical ligation was attempted, but cardiac arrest occurred immediately after the beginning of surgery, and the patient died. The vertebral artery proximal to the aneurysm was removed for pathological examination. CONCLUSION: In this case, the changes noted were interpreted as changes showing fragility of the vascular wall secondary to neurofibromatosis Type 1. Patients with neurofibromatosis Type 1 exhibit disorders of cervicocerebral vessels, and in some cases progression may follow a violent course. Periodic follow-up of such patients and early diagnosis are important.

A case of unknown origin subarachnoid hemorrhage immediately following drainage for chronic subdural hematoma.

A 56-year-old man treated with anticoagulants complained of a gradually worsening headache. A left chronic subdural hematoma (CSH) was shown by head computed tomographic (CT) scans and the operation, one burr hole surgery under local anesthesia, itself was performed uneventfully. However, immediately after we began draining the hematoma at the patient's bedside, the patient complained of a sudden headache. CT scans showed a subarachnoid hemorrhage (SAH). Cerebral angiography was immediately performed, but the source of hemorrhage could not be found. The next day, a CT scan showed that most of the SAH had disappeared. To our knowledge, there are no previous reports of SAH of unknown origin following surgery for CSH. The likely mechanism for the occurrence of the SAH, in addition to a coagulopathy due to anticoagulant therapy, could include the possibility that the drainage of the hematoma produced a movement of the hemisphere along with hyperperfusion that resulted in the rupture of a weak subarachnoid vessel, such as a perforating artery.