Gastric volvulus through morgagni hernia: an easily overlooked emergency.

BACKGROUND: Intractable vomiting in an elderly patient is an emergency condition requiring prompt diagnosis and intervention. Acute gastric outlet obstruction due to gastric volvulus through Morgagni-type diaphragmatic hernia is an exceedingly rare cause of this nonspecific complaint. OBJECTIVE: Our aim was to highlight that Morgagni hernia, although rare in adults, should be suspected in the appropriate clinical setting, and that a clue toward diagnosis often comes from routine chest and abdominal x-ray studies. In addition, we emphasize the atypical radiological findings and importance of emergency surgical intervention in such a case. CASE REPORT: We describe the case of a 78-year-old woman who presented to the Emergency Department with a 4-day history of intractable vomiting, and with no definitive clue to the diagnosis on examination. Her routine chest and abdomen x-ray studies suggested abnormal air-fluid level at right hemithorax, which prompted a computed tomography (CT) scan of the abdomen and an upper gastrointestinal contrast study. Gastric volvulus through a foramen of Morgagni was diagnosed and transthoracic reduction of the contents was performed, along with repair of the defect. CONCLUSIONS: A symptomatic Morgagni hernia in adults, although rare, can present with a variety of symptoms ranging from nonspecific complaints of bloating and indigestion to the more severe complaint of intestinal obstruction. Gastric volvulus and obstructive features are less frequently reported as acute complications of these hernias, which need early identification and intervention.

Autoimmune Polyglandular Syndrome Type II Presenting as an Endocrine Emergency: A Case Report.

We describe the case of a 30-year-old male, a known patient of type 1 diabetes mellitus (DM) on insulin therapy, seeking medical attention for recent onset repeated attacks of hypoglycemia associated with generalized weakness and darkening of skin. Further evaluation and screening revealed autoimmune adrenal failure together with presence of Hashimoto's thyroiditis. The patient was diagnosed as a case of autoimmune polyglandular syndrome (APS) type II with complete triad of Addison's disease, type 1 DM and autoimmune thyroid disease. Anti-thyroid peroxidase, anti-glutamic acid decarboxylase and anti-endomysial antibodies were present in our patient. He was started on replacement therapy with physiological dose of prednisolone and thyroxine resulting in marked improvement in his symptoms. Recurrent hypoglycemia in a type 1 DM patient should raise a suspicion of underlying autoimmune adrenal insufficiency. Absence of obvious signs of thyroid dysfunction also poses a diagnostic challenge for the clinicians. This article aims at highlighting the importance of detailed evaluation together with long term followup of these patients and their relatives as overt clinical disease may only be the tip of the iceberg of other underlying organ-specific autoimmune diseases that may develop later in the course.

An occult filarial infection presenting as chyluria with proteinuria: a case report and review of literature.

Chyluria is the passage of chyle into urine, and develops as a result of communication between the lymphatic system and the urinary system. It is an unusual manifestation of lymphatic filariasis reported mainly from South Asian countries. We report the case of a 38-year-old man from an endemic area who presented with passage of milky urine. Physical examination did not reveal any lymphadenopathy or lymph oedema. Urine tests revealed nephrotic range proteinuria. A 99m technetium sulphur colloid lymphoscintigraphy confirmed connection between lymphatic vessels and the urinary tract. Predominant chyluria with no overt lymphatic filariasis remains an enigma.

An unusual cause of muscle weakness: a diagnostic challenge for clinicians.

The authors describe a 27-year-old male who presented with acute flaccid quadriparesis. The patient denied any history of similar episodes in the past. At presentation, the patient was tachycardiac with normal systolic blood pressure. He had marked flaccid weakness of both upper and lower limbs and furthermore, he was hypotonic and without tendon reflexes. Biochemical analyses revealed severe hypokalaemia (1.9 meq/l). The patient was given potassium supplementation. He showed complete recovery after the medical intervention. Successive investigations documented an undiagnosed case of Graves' disease. Hypokalaemia secondary to thyrotoxicosis was diagnosed as the cause of the paralysis. Thyrotoxic periodic paralysis is a rare neurologic manifestation of thyrotoxicosis. Absence of obvious signs of thyrotoxicosis poses a diagnostic challenge for the clinicians.

Lambert-Eaton myasthenic syndrome and solitary cerebellar metastasis in a patient with occult small-cell lung cancer: a rare experience.

The authors describe a case of 60-year-old male patient presented with a 6 month history of progressive weakness of all the four limbs, ataxia, droopy eyelids and bulbar features. Further laboratory and electrodiagnostic studies confirmed the diagnosis of Lambert-Eaton myasthenic syndrome (LEMS). MRI of the brain showed a cerebellar tumour which, following surgery was revealed to be a metastatic small-cell lung carcinoma. Paraneoplastic LEMS together with solitary cerebellar metastasis was diagnosed but no evidence of primary malignancy was detected. An extensive search for related malignancies failed to get any clue. The patient underwent a total surgical excision of tumour and the histopathology revealed a metastatic small cell carcinoma. This case highlights that rarely both paraneoplastic LEMS and cerebellar mass can precede the primary malignancy causing them.

Tropical pulmonary eosinophilia misdiagnosed as miliary tuberculosis: a case report and literature review.

Tropical pulmonary eosinophilia is prevalent in the tropical and subtropical regions of the world. It is an occult form of human filariasis and results from an exaggerated immune response to filarial parasites Wuchereria bancrofti and Brugia malayi. Tuberculosis is prevalent in our country and may mimic almost any pulmonary disease on chest skiagram. Here we describe a patient with acute chest symptoms and micro-nodular opacity over chest roentogenogram, diagnosed as miliary tuberculosis and treated accordingly. Actually he was suffering from tropical pulmonary eosinophilia and showed response to combined diethylcarbamazine and corticosteroid therapy. This case serves as a reminder that tropical pulmonary eosinophilia may be wrongly diagnosed as miliary tuberculosis if one rely solely on a chest X-ray with micronodular opacities. We also stress on early diagnosis and treatment of this condition to avoid unfavorable outcomes.

Prevalence of malnutrition and its correlation with various diseases in elderly patients in a tertiary care centre in eastern India.

Geriatric population is growing very fast but they do not receive due attention from the family members as well as in the society. So incidence of malnutrition is likely to be very high in them. This fact prompted us to evaluate nutritional status in this group of population. In this study persons more than 60 years were included. A total of 76 patients, both inpatients and outpatients, in a tertiary care centre were studied. Their ages ranged from 60-84 years. Their nutritional status were assessed clinically by body mass index (BMI), triceps skin fold thickness, waist-hip ratio (WHR), mid-arm muscle circumference (MAMC) and from investigational parameters like blood for total and differential counts, ESR, serum for albumin, sugar, urea, creatinine, cholesterol and routine urine examination. According to BMI, undernutrition was found approximately in a quarter of all the elderly under study while overnutrition which includes both overweight (BMI 25-29.9 kg/m2 of body surface area) and obesity (BMI > or = 30 kg/ m2 of body surface area) was found in only 14.5% of patients. Central obesity as per WHR was strikingly high in females (85%) compared to males.