An Interesting Case of Critical Spontaneous Ureteral Rupture.

Spontaneous rupture of the ureter in an uncommon presentation. We present a case of an 85-year-old female patient with a past medical history significant for hypertension and hyperlipidemia who presented to the emergency room (ER) due to abdominal pain and nausea. Computed tomography (CT) of abdomen and pelvis revealed proximal ureteral and ureteropelvic junction rupture with fluid within the left retroperitoneum and pelvis. No clear etiology was identified. The patient had a left percutaneous nephroureteral catheter tube (PNCT) placed in addition to being given broad-spectrum antibiotics for possible infection. She was noted to improve and was discharged with outpatient follow-up for tube removal. Our patient presented with a rupture of the ureter; however, the source remained elusive. CT scan assisted with the diagnosis but there is no evidence of hydronephrosis or mass. There are no clear treatment guidelines for spontaneous ureteral rupture as the presentation is rare. Treatment may involve percutaneous drainage and possibly antibiotics for concurrent infection. Surgical intervention may be required in cases where severe complications arise. Early diagnosis and management may prevent long-term morbidity and mortality.

Too young to break? A rare case of premenopausal osteoporosis.

We present a case of a 29-year-old female with fragility fracture of the ninth thoracic vertebrae with a z-score of -3.3 of the lumbosacral spine. She was worked up for secondary causes of osteoporosis, all of which was unrevealing except for a low vitamin D level which was repleted. She had genetic profile done, which revealed low-density lipoprotein receptor-related 5 mutation which was thought to the cause of premature osteoporosis. This report highlights a rare case of osteoporosis in a premenopausal female and challenges associated with premenopausal osteoporosis.

Pancoast-Tobias Syndrome: A Unique Presentation of Lung Cancer.

A 65-year-old man with 50 pack-year smoking history presented to the emergency department for evaluation of upper back and right shoulder pain secondary to a fall. Physical examination was notable for anisocoria with a constricted left pupil (miosis), mild ptosis of the left eyelid, and bilateral shoulder pain, right more than left, with both passive and active movements. Chest computed tomography identified a soft tissue mass at the left lung apex with extension into the pleural surface, associated with destructive osseous changes of the right scapula, adjacent ribs, and thoracic vertebral bodies. Imaging of the brain revealed multiple masses suspicious of metastatic brain lesions. Biopsy of the right supraclavicular lymph node revealed lung tissue adenocarcinoma and negative Kirsten rat sarcoma viral oncogene homolog (K-Ras), epidermal growth factor receptor (EGFR), B-raf proto-oncogene (BRAF), C-ros oncogene 1 (ROS1), and anaplastic lymphoma kinase (ALK) rearrangement. Recognizing Pancoast syndrome in patients with significant smoking history, anisocoria, and shoulder pain is crucial for identifying the underlying etiology and expediting the treatment.

Return of the old guard: a case of tetanus in an unvaccinated patient.

A 78-year-old woman with no known medical history presented with severe neck pain that began 4 days prior to admission located in the paraspinal cervical region radiating to the shoulders, legs and back. She had associated stiffness of her neck and progression of pain to her jaw and throat with progression to generalised body spasms with lower extremity stiffness and weakness that limited her ability to walk. She quickly developed dysphagia and odynophagia with subsequent generalised spasms and profound hypoxic respiratory failure requiring nasotracheal intubation. The presumptive diagnosis of tetanus was made and she was given tetanus toxoid immune globulin and Tdap vaccine. She was managed in the intensive care unit and after a week of admission, required a tracheostomy and gastrostomy tube placement. She required a prolonged hospitalisation stay of 21 days before being transferred to a long-term vent facility.