Suppurative thyroiditis caused by ingested fish bone in the thyroid gland: a case report on its diagnostics and surgical therapy.

BACKGROUND: Accidental ingestion of fish bone is a common cause of otolaryngological emergency. Migration of the ingested bone into the thyroid gland, however, occurs very rarely. The associated clinical presentation, symptoms and duration of discomfort are also highly variable between patients and can be diagnostically challenging. CASE PRESENTATION: Here, we report the case of a 71-year-old female patient presenting with an ingested fish bone that migrated into the right thyroid lobe as a rare cause of suppurative thyroiditis with the clinical features of sepsis. We outline the diagnostic approach, peri- and intraoperative management as well as complications. It is proposed that besides endoscopy, imaging methods such as ultrasound or computed tomography may be necessary to verify the diagnosis and location of an ingested fish bone. Prompt surgical removal of the foreign body and resection of the infectious focus is recommended to minimize the risk of local inflammation, recurrent nerve lesions and septic complications arising from the spread of infection. CONCLUSION: Fish bone migration into the thyroid gland is an extremely rare event, the successful detection and surgical management of which can be achieved through a careful interdisciplinary approach.

Liver abscess in the caudate lobe caused by a fishbone and treated by laparoscopy: a case report.

BACKGROUND: Ingestion of fish bones leading to gastric perforation and inducing abscess formation in the caudate lobe of the liver is very rare. CASE PRESENTATION: A 67-year-old man presented to our hospital with a 2-day history of subxiphoid pain. There were no specific symptoms other than pain. Laboratory tests showed only an increase in the number and percentage of neutrophils. Contrast-enhanced Computerized tomography (CT) of the abdomen showed two linear dense opacities in the gastric cardia, one of which penetrated the stomach and was adjacent to the caudate lobe of the liver, with inflammatory changes in the caudate lobe. We finally diagnosed his condition as a caudate lobe abscess secondary to intestinal perforation caused by a fishbone based on the history and imaging findings. The patient underwent 3D laparoscopic partial caudate lobectomy, incision and drainage of the liver abscess, and fishbone removal. The procedure was successful and we removed the fishbone from the liver. The patient was discharged on the 9th postoperative day without other complications. CONCLUSIONS: Liver abscess caused by foreign bodies requires multidisciplinary treatment. Especially when located in the caudate lobe, we must detect and remove the cause of the abscess as early as possible. Foreign bodies that perforate the gastrointestinal tract can penetrate to the liver and cause abscess formation, as in this case. When exploring the etiology of liver abscesses, we should investigate the general condition, including the whole gastrointestinal tract.

Biliary stent migration as a rare cause of ileal perforation.

The incidence rate of biliary stent migration is 3-6 %; most cases are asymptomatic, with elimination of the piece in the feces.

Migration of fish bones into abdominal para-aortic tissue from the duodenum after leading to duodenal perforation: a case report.

BACKGROUND: Migration of fish bones into abdominal para-aortic tissue after penetrating the junction of 3rd and 4th part of duodenum is incredibly rare. CASE PRESENTATION: A 68-year-old man was admitted to our hospital with persistent colic in the lower abdomen after eating fish two weeks ago. Abdominal computed tomography (CT) scan showed High density streaks along the anterior and lower edges of the 3rd part of duodenum with peripheral exudation and localized peritonitis. Esophagogastroduodenoscopy didn't find foreign bodies and perforations in the digestive tract. Laparoscopic surgery and intraoperative endoscopy were made to detect foreign bodies and perforation site was found. After transition to open surgery, the fish bone was found in abdominal para-aortic tissue and removed without complications. Postoperative recovery is smooth, and the patient resumed normal diet and was discharged. CONCLUSIONS: It is difficult to choose a treatment plan for foreign bodies at the 3rd part of the duodenum, because it is difficult to judge the damage caused by the foreign body to the intestine and the positional relationship with the surrounding important organs. Conservative treatment or surgical treatment both have huge risks. The handling of this situation will extremely test the psychology, physical strength and professional experience of the surgeon.

Another Use for EUS: Removal of a Transesophageal-Migrated Mediastinal Foreign Body.

Removal of foreign bodies from the upper gastrointestinal tract, though a common occurrence, can be technically challenging and risky. We report the case of a young man that, after eating a pizza cooked in a wood-burning oven, reported a sense of foreign body. Though the first evaluation by fiberoptic laryngoscopy found no foreign body, after a few weeks, the patient was readmitted from the ER for worsening symptoms and fever. A CT scan showed a metallic mediastinal foreign body inside a large fluid collection. After multidisciplinary evaluation, an endoscopic removal was attempted by accessing the mediastinal collection through EUS-guided positioning of a Hot Axios™ stent. The cavity was drained by naso-esophageal suction. The foreign body was a fragment of the brush used to clean the oven. The patient is now doing well after 7 months.

Rectal Perforation by an Intrauterine Device Leading to Fatal Intra-Abdominal Sepsis and Necrotizing Fasciitis.

BACKGROUND: Colorectal injury from an intrauterine device (IUD) is rare but may lead to major complications. CASE: A 55-year-old woman presented to a tertiary care hospital with 4 days of generalized weakness, confusion, dysuria, and lower back pain. She provided a vague history of an unsuccessful attempt to remove an IUD 30 years prior. A computed tomography scan demonstrated an IUD in the rectal lumen, with gluteal and pelvic gas and fluid collections. Emergency surgery found necrotizing fasciitis. Despite multiple debridements, sigmoidoscopic IUD removal, and long-term intravenous antibiotics, the patient died from sepsis and multiorgan failure. CONCLUSION: IUDs require proper monitoring and timely removal to prevent potential complications associated with organ perforation.

Inferior Vena Cava Filter Migrated to Left Ventricle.

Inferior vena cava (IVC) filters have been widely used to prevent pulmonary emboli in patients with venous thromboembolism. Here we report a rare case of complete pericardial tamponade with severe mitral and tricuspid valve regurgitation due to a fractured IVC filter. A 38-year-old male came to our emergency department with a 19-day history of progressive chest tightness. Chest x-ray revealed a tethering catheter fractured at the level of the junction of the superior vena cava and the right atrium. We performed open surgery and discovered that a steel wire had punctured the atrioventricular septum, the mitral valve, and finally the posterior wall of the left ventricle. The patient recovered quite well and was discharged after 1 week.

Endoscopic management of a duodenal perforation secondary to a migrated biliary plastic stent.

The migration of plastic biliary prostheses occurs in up to 14 % of patients undergoing biliary stenting. Duodenal perforation is a rare but very serious complication. A delay in diagnosis complicates management and worsens prognosis.

Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature.

BACKGROUND: Endoscopic retrograde biliary drainage (ERBD) is the most frequently performed procedure for treating benign or malignant biliary obstruction. Although duodenal perforations secondary to the biliary plastic stent are quite rare, they can be life-threatening. The treatment strategies for such perforations are diverse and continue to be debated. CASE PRESENTATION: We report three cases of duodenal perforation due to the migration of biliary plastic stents that were successfully managed using an endoscope. The three patients were admitted on complaints of abdominal pain after they underwent ERBD. Abdominal computerized tomography (CT) revealed migration of the biliary plastic stents and perforation of the duodenum. Endoscopy was immediately performed, and perforation was confirmed. All migrated stents were successfully extracted endoscopically by using snares. In two of the three cases, the duodenal defects were successfully closed with haemostatic clips after stent retrieval, and subsequently, endoscopic nasobiliary drainage tubes were inserted. After the endoscopy and medical treatment, all three patients recovered completely. CONCLUSIONS: Duodenal perforations due to the migration of biliary stents are rare, and the treatment strategies remain controversial. Our cases and cases in the literature demonstrate that abdominal CT is the preferred method of examination for such perforations, and endoscopic management is appropriate as a first-line treatment approach.

Spinal Cord Stimulation with Surgical Lead Improves Pain and Gait in Parkinson's Disease after a Dislocation of Percutaneous Lead: A Case Report.

Spinal cord stimulation (SCS) is receiving increasing interests for treating pain and gait disorders in patients with Parkinson's disease (PD). In an SCS study, it is hard to apply a double-blind approach, especially at low frequencies, as the stimulation normally induces paresthesia which can be perceived by the patient. We herein demonstrate a case treated with SCS in which a blinding design was accomplished by an accidental dislocation of a stimulation lead. A 73-year-old man with PD was admitted to our hospital because of relapsed low back pain. This was due to the dislocation of a previously implanted SCS lead, which caused a decrease in its effectiveness in alleviating pain (from 81 to 43% measured by King's Parkinson's Disease Pain Scale) and improving gait (from 35 to 28% measured by the timed up and go test). A second SCS surgery using a paddle lead solved this problem, with improvements in pain and gait rebounded to 81 and 45%. In this case, the paresthesia induced by SCS (using either a paddle lead or percutaneous leads) was below the threshold of perception when the patient was sitting and standing, and a dislocation of one previously implanted percutaneous lead did not cause evident changes in his sensation of paresthesia. At last follow-up, the patient's quality of life had improved by 40% as measured by the 8-item Parkinson's Disease questionnaire (PDQ-8). This study could serve partly as a proof that low-frequency SCS is effective in improving pain as well as gait problems in PD patients, which was unlikely a result of a placebo effect.

Intracardiac foreign body: A rare cause of recurrent fungemia.

BACKGROUND: An intracardiac foreign body causing recurrent fungemia is a rare clinical situation. Clinicians should be that aware of rare sources of sepsis despite a thorough history and examination. RESULTS: The authors describe a 63 year-old man, with unremarkable past medical history, who presented with a fever for 2 weeks. Blood cultures persistently grew Candida albicans and Streptococcus constellatus. Echocardiogram assessment showed a suspected vegetation over the tricuspid valve. Surgical exploration with median sternotomy and cardiopulmonary bypass revealed a tooth-pick impacted within the right atrium surrounded by vegetation. The authors postulate accidental ingestion of the foreign body and translocation into the right atrium via the esophagus and thoracic cavity. CONCLUSION: Surgical removal of symptomatic intracardiac foreign bodies is highly recommended.

Cannula migration through an undiagnosed patent foramen ovale and embolic cerebrovascular accident in a patient with femoral venoarterial extracorporeal membrane oxygenation.

We present a case report of a patient with a pulmonary embolus placed on venoarterial extracorporeal membrane oxygenation who developed venous cannula migration through an undiagnosed patent foramen ovale causing an ischemic stroke due to a thrombus and requiring thrombectomy and device closure of the atrial defect.

Acute obstructive cholangitis due to fishbone in the common bile duct: a case report and review of the literature.

BACKGROUND: Choledocholithiasis is an endemic condition in the world. Although rare, foreign body migration with biliary complications needs to be considered in the differential diagnosis for patients presenting with typical symptoms even many years after cholecystectomy, EPCP, war-wound, foreign body ingestion or any other particular history before. It is of great clinical value as the present review may offer some help when dealing with choledocholithiasis caused by foreign bodies. CASE PRESENTATION: We reported a case of choledocholithiasis caused by fishbone from choledochoduodenal anastomosis regurgitation. Moreover, we showed up all the instances of choledocholithiasis caused by foreign bodies published until June 2018 and wrote the world's first literature review of foreign bodies in the bile duct of 144 cases. The findings from this case suggest that the migration of fishbone can cause various consequences, one of these, as we reported here, is as a core of gallstone and a cause of choledocholithiasis. CONCLUSION: The literature review declared the choledocholithiasis caused by foreign bodies prefer the wrinkly and mainly comes from three parts: postoperative complications, foreign body ingestion, and post-war complications such as bullet injury and shrapnel wound. The Jonckheere-Terpstra test indicated the ERCP was currently the treatment of choice. It is a very singular case of choledocholithiasis caused by fishbone, and the present review is the first one concerning choledocholithiasis caused by foreign bodies all over the world.

Limb Stent Occlusion from Intraoperative Nellix Stent Migration and Prolapse.

BACKGROUND: Incidence of Nellix stent migration is uncommon despite the absence of a proximal fixation mechanism. We present a case of intraoperative Nellix stent migration to highlight the potential complications. Our patient had renal artery occlusion and threatened limb stent perfusion as a result of intraoperative stent migration, with resultant prolapse of the Nellix endobag. We also present a successful salvage procedure to deploy an additional stent to restore limb stent flow. CASE: A 71-year-old Chinese gentleman with symptomatic concomitant infrarenal abdominal aortic aneurysm and bilateral common iliac aneurysms was discussed at a multidisciplinary meeting and deemed suitable for endovascular sealing of the aneurysms with the Nellix device. Prefilling imaging confirmed satisfactory stent positions bilaterally below the level of renal arteries. Routine filling of endobag was performed with stent-graft molding by standard angioplasty technique. Final check angiogram did not identify any endoleaks and demonstrated adequate sealing of the aneurysm. Unfortunately, patient developed acute kidney injury postoperatively. This was attributed to contrast-induced nephropathy. The creatinine level peaked at 150 µmol/L and stabilized. Ultrasound duplex on the seventh postoperative day however diagnosed absent left renal artery flow. An interval computed tomography aortogram at 3 month also detected threatened limb stent occlusion from the contralateral endobag prolapse. Subsequently, the patient underwent successful extension of the threatened limb stent to restore luminal flow. DISCUSSION: Retrospective examination of angiographic images confirmed that the left renal artery flow was preserved on the completion angiogram. The difference in level of limb stents observed postmolding compared to premolding widened from 1 mm to 6 mm due to a degree of stent bowing within the iliac arteries. We postulate the left renal artery occlusion was either caused by further proximal migration of the right limb stent due to the left stent bowing within the curve of the iliac artery or endobag prolapse post molding. Mismatched, unopposed filling of the endobags after the molding process could result in an unexpected behavior of prolapsing into the contralateral limb stent and obstruct luminal flow. This case highlights a significant sequalae of proximal migration after the molding process of Nellix. Augmenting the level of limb stent to the same level may be necessary and easily achieved with additional stent deployment. We recommend close inspection of completion angiogram to check for stent migration, and if required for additional angiograms to be taken perpendicular to each other or use of adjuncts such as intravascular ultrasound post endobag filling to document stent positions in relation to adjacent renal arteries, luminal flow, and detect any early intraoperative migration.

Bone wax migrates to the orbit in a patient with a frontal sinus abnormality: a case report.

BACKGROUND: Bone wax is the most widely used hemostatic bone sealant because of its availability, ease of use, immediate action, and minimal adverse effects. Several complications have been reported to be associated with the use of bone wax, such as infection, osteohypertrophy, pain, granuloma formation, allergic reaction, and thrombosis. Here, we present a rare complication, namely, bone wax migration, which developed after a craniotomy on a patient who had a frontal sinus abnormality. CASE PRESENTATION: A 51-year-old woman complained of pain and swelling in her left eye accompanied by difficulty opening the left eyelid after undergoing a craniotomy. An examination revealed left eye proptosis with ptosis, eyelid swelling, and increases in intraorbital pressure and intraocular pressure (IOP). According to a CT and an MRI of the orbit, we found that the intraoperative bone wax had migrated to the orbit, thereby causing compression. We also found that the basal frontal sinus of the patient was congenitally defective, which may have induced the migration of the bone wax. Given that the patient recently underwent a craniotomy and given the risks associated with orbital surgery, she refused to undergo a surgery to remove the bone wax. Thus, the patient was administered mannitol intravenously daily, accompanied by topical Timolol, to reduce the intraorbital pressure and IOP. This treatment led to a gradual decrease in IOP and intraorbital pressure, and these parameters remained stable after treatment ended. During the 6-month follow-up, the best corrected visual acuity improved, and ptosis and restricted eye movements also improved significantly. CONCLUSIONS: We report a case of bone wax migration that developed after a craniotomy on a patient who had a congenital defect in the basal frontal sinus. Extra caution should be taken when using bone wax, and a comprehensive understanding of the patient's intracranial anatomy is important for decreasing the incidence of bone wax migration. Additionally, when a patient presents with symptoms of ocular compression, bone wax migration should be considered in addition to typical radiological changes.

Traumatic cervical fusion hardware displacement presenting with dysphagia and dysphonia.

Surgery for degenerative cervical myelopathy has been increasing in incidence. Almost 20% of patients have complications related to their surgery, although hardware extrusion is rare and generally reported in the first post-operative month. We report the case of a woman with new dysphagia and hoarseness secondary to traumatic screw dislodgement into her pre-vertebral space 5 months after cervical discectomy.

Predictive factors for complications associated with penetrated fish bones outside the upper gastrointestinal tract.

PURPOSE: To investigate predictive risk factors for complications associated with migrating fish bones in the surrounding tissue of upper gastrointestinal tract. METHODS: A retrospective analysis over 12 years was conducted of 45 cases of buried fish bones in the surrounding tissue of upper gastrointestinal tract with complications. Meanwhile, a control group, including 39 cases of prolonged buried fish bones in the surrounding tissue of upper gastrointestinal tract without complications, was set. Patient clinical data were collected and analyzed to predict the risk factors for complications. RESULTS: The results of Chi-square test and univariate analysis both showed a significant difference in length of fish bone (> 2 cm), a history of concurrent medical illness (diabetes mellitus and renal hypofunction), symptoms (medium or heavy pain and dysphagia), and duration of significant symptoms (> 7 days) between the complication group and non-complication group. Multivariate analysis further identified length (> 2 cm), diabetes mellitus, medium or heavy pain, dysphagia, and duration of significant symptoms (> 7 days) as independent risk factors for complications. CONCLUSIONS: The consequences of fish bones migrating outside the upper gastrointestinal tract are various in different people. Awareness should be raised when encountering a patient ingesting a long fish bone, having a history of diabetes mellitus, presenting with significant discomforts, or these discomforts lasting for a long time. This study will help practitioners counsel their patients on the risks and `benefits of surgery versus observation of this condition.

Methicillin-Resistant Staphylococcus aureus Meningitis from Transanal Migration of a Ventriculoperitoneal Shunt.

BACKGROUND: Bowel perforation is a rare complication of ventriculoperitoneal (VP) shunt placement that can result in anal protrusion of a VP shunt. Retrograde migration of bacteria through the shunt can lead to central nervous system (CNS) infections, such as meningitis, most commonly caused by Escherichia coli or other enteric pathogens. Here we present a case of methicillin-resistant Staphylococcus aureus (MRSA) meningitis from transanal migration of a VP shunt. CASE REPORT: A 2-month old female with a history of VP shunt placement presented to the emergency department (ED) after her mother noticed a tube in the patient's diaper. On examination, a white tube was noted to be protruding from the patient's anus. Plain radiographic shunt series showed an intact VP shunt terminating outside of the patient's body. Cerebrospinal fluid (CSF) cultures grew MRSA. A diagnosis of MRSA meningitis secondary to spontaneous bowel perforation of a VP shunt was made. The patient went to the operating room for externalization of her shunt. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case of MRSA meningitis following transanal migration of a VP shunt to be reported in the literature. While anal protrusion of a VP shunt is rare, CNS infection from this complication results in a high mortality rate. In addition, not all cases of bowel perforation from a VP shunt will present with the shunt exiting the body. Therefore, in a patient with a history of a VP shunt who presents with symptoms of meningitis, it is important for emergency physicians to heavily consider intestinal perforation by VP shunt as a possible etiology.

Bone Causing Abdominal Groans.

Gastrointestinal complications secondary to fish bone ingestion are rare, however important to recognize in timely manner to prevent morbidity and mortality. Diagnosis is often challenging in setting of non-specific and variable symptoms and lack of history of fish bone ingestion. Diagnostic imaging particularly computed tomography is crucial for diagnosis. However, emphasis should be given on identifying underlying cause of abdominal complications because fish bone is often missed unless specifically looked for. Identification of fish bone is essential for extraction of the inciting nidus. Emergency physician should be aware of this entity to identify it and triage the patients in timely manner. We describe here cases of sub-capsular liver abscess and acute cholecystitis caused by fish bone ingestion. The fish bone as a cause of these complication was initially missed in emergency.