Confronting the Unseen: A Journey Through Primary Intra-orbital Squamous Cell Carcinoma.

Cases of squamous cell carcinoma (SCC) that are primary in origin occur even more infrequently due to the lack of squamous epithelium that is typically present in the orbital region. When SCC occurs in the orbit, it is more commonly due to invasion or metastasis from a local site. We report an uncommon case of intra-orbital SCC in a 74-year-old male, which is likely of primary origin. Brain, face, orbital, and neck magnetic resonance imaging proceeded to gather more information on the extent of the patient's orbital malignancy, which showed significant orbital burden and intracranial extension. The biopsy was performed with final pathology results showing moderately differentiated SCC. The patient was discharged with a follow-up with oncology for chemotherapy and a follow-up with oculoplastics for surgical intervention in nine months, after completing a course of chemotherapy with irradiation. We provide this case to shed insight into the difficulties associated with the extremely uncommon occurrence of primary SCC of the orbit.

Cytomegalovirus (CMV) Polyradiculopathy: An Important "AIDS-Defining" Illness Complication.

We present a case of cytomegalovirus (CMV) polyradiculopathy which occurred concomitantly with CMV encephalitis and CMV retinitis in a patient with HIV/AIDS. Our patient is a 43-year-old male who was admitted with progressive changes in mentation. Cerebrospinal fluid (CSF) analysis showed elevated white blood cell (WBC), low glucose, and elevated protein. The polymerase chain reaction (PCR) panel of CSF was positive for CMV, and other microbiology results were negative. Extensive bilateral CMV retinitis was also noted. The patient was started on ganciclovir and foscarnet, and two weeks after, highly active antiretroviral therapy (HAART) was initiated using Truvada and dolutegravir. The hospital course was complicated by urinary retention and bilateral lower extremity weakness with hypotonia, severe hyperalgesia, and allodynia. An electromyography (EMG) study demonstrated bilateral lumbosacral root dysfunction at L2-S1 with active neurologic changes indicating significant axon loss. Neurology was consulted, and the patient was diagnosed with CMV-induced polyradiculopathy. After three months of treatment, no improvement was noted on lower limbs as he continued with intravenous (IV) ganciclovir. The therapeutic response to induction therapy was discordant as improvement of encephalitis was noted, but not on polyradiculopathy after 180 days of treatment. This highlights the lack of data and treatment guidelines for established CMV polyradiculopathy and not only the necessity for prolonged treatment of CMV polyradiculopathy but also the difficulty in recovery of function once it has developed.

Empyema Necessitatis: A Rare Complication of Empyema.

Empyema necessitatis (EN) is an exceedingly rare complication of empyema. EN refers to the expansion and progression of an empyema beyond the thoracic cavity toward the skin wall. Herein, we present the case of a man with EN and detail his clinical course. A 42-year-old male with a prior history of substance use presented to the emergency department with three weeks of fever, cough, and progressively worsening pain overlying the left anterior chest wall. An empiric antibiotic regimen of cefepime, metronidazole, and vancomycin was initiated. Chest X-ray, ultrasound, and chest CT demonstrated a large region of loculation suspicious for a loculated empyema. On day 4 of admission, he underwent a video-assisted thoracoscopy followed by a left minithoracotomy, which confirmed the diagnosis of EN. The patient was discharged on hospital day 16 with marked clinical improvement and monitored for a year via an outpatient clinic. Symptoms did not recur, and there was complete resolution of EN. More predominant in the pre-antibiotic era with the progression of uncontrolled infections, EN is less commonly seen today. As such, EN requires a high degree of clinical suspicion for timely detection and management. Our case illustrates the importance of early intervention with antibiotics and surgical drainage.

Successful Management of Prolonged Acute Ischemic Priapism With Penoscrotal Decompression: A Case Report and Review of the Literature.

Intracavernosal injection of Trimix (a combination of phentolamine, papaverine, and alprostadil) is used for the treatment of erectile dysfunction. A rare but serious side effect of Trimix is priapism, a persistent erection lasting for more than four hours. Penoscrotal decompression is a newer technique being used to treat refractory and persistent ischemic priapism. Here, we report a unique case of priapism treated with penoscrotal decompression in a patient following an unmeasured injection of Trimix. A 36-year-old male presented to the emergency room complaining of a persistent painful erection over the previous five days following a Trimix injection and illicit methamphetamine use. At bedside, aspiration and irrigation were attempted without any improvement. Phenylephrine injection was contraindicated due to sinus tachycardia. The patient then underwent bilateral penoscrotal decompression on day six post-Trimix injection. The procedure was successful with a resolution of the erection, though some moderate corporal fibrosis was noted. At a 10-day follow-up, the patient reported moderate pain in his penis but had regained complete potency. Misuse of Trimix can cause persistent ischemic priapism. Penoscrotal decompression is a novel technique used to treat persistent ischemic priapism and has been shown to have positive efficacy in the resolution of priapism as well as in salvaging erectile function. To our knowledge, treatment of persistent priapism with penoscrotal decompression after using Trimix has not yet been reported in the literature. Given the rarity of this, our report highlights a unique case that has potential benefit for future practitioners who are faced with this clinical scenario.

"La Perla Del Mar": A Case Report on Subcutaneous Penile Implants.

The purpose of this report is to alert and inform the medical community about the presence and practice of subcutaneous penile implants (SPIs), which are used with the intent of increasing sexual pleasure. This case aspires to deflect plausible misconceptions in the specific populations who use the SPIs. This case study was performed in January 2023 at a tertiary care center in Miami, Florida. A 61-year-old Cuban male admitted for a routine hernia repair with an incidental finding of a benign SPI was interviewed and examined; an extended collection of historical information regarding the patient's penile implant was ascertained. The patient stated that there was a tradition among the men and adolescent individuals living along coastal cities/towns of Cuba such as Havana and Matanzas who would elect to have pieces of stones or gems or any solid objects shaped and molded into round objects that are used for the intent of increasing sexual pleasure. The patient referred to the implant as "La Perla Del Mar," which translates directly into "Pearl of the Sea." Upon visualization of the nodule on examination, a differential diagnosis may include infection (such as syphilis), granulomas, sarcoidosis, dermatofibroma, epithelial inclusion cyst, or malignancy. However, an appropriate workup informed us about the penile implant. Clinicians should employ caution in investigating a penile nodule by taking a detailed social and sexual history and physical exam from the patient if possible. This case and the literature review cited to bolster the notion of a lack of chronic symptoms due to the inserted objects. Several provocations for the implantation of an artificial penile nodule, in this case, maybe extrapolated, such as the desire for a prospective partner's pleasure/displeasure, group identification, or masculine embodiment. The main takeaways from this case report are the considerations that should be taken in the older Caribbean population for patients with the "Perla Del Mar" implantation and bolstering the notion of complete sexual education for clinicians regarding specific populations to enhance patient care.

Spider Angioma Number and Location as Potential Prognostic Indicators in Chronic Liver Disease: A Case Report.

Spider angiomas (SAs) are a well-known physical exam feature found in patients with chronic liver disease. While SAs are thought to correspond with a higher risk of mortality in chronic liver disease (CLD) patients, only few studies have been done to assess the number and location of SAs as prognostic indicators. We present a case of a 64-year-old patient with decompensated CLD who was found to have three SAs on physical exam. The patient presented to the inpatient service at a community hospital in Miami, Florida. He had experienced previous esophageal varices banding, had a Model for End-Stage Liver Disease (MELD) score of 31, and needed large-volume paracentesis due to significant ascites. It was determined that he had a very poor prognosis and was in need of a liver transplant. We suggest that more research is necessary to determine if there is a prognostic importance to the number and location of SAs in patients with CLD, as earlier interventions could potentially lead to improvements in outcomes through this physical exam finding.

Bulbar Artery Injury With Bladder Hematoma and Severe Anemia Due to Traumatic Foley Catheter Removal.

This case is described with the aim of informing about the high-level suspicion of bladder or urethral injuries in patients with traumatic Foley removal and their prolonged bleeding that should alert clinicians for a prompt urological intervention. A patient was initially admitted to the ICU with delirium and organ dysfunction due to an overdose of drugs. On the second day of his admission, he unintentionally removed his Foley catheter, which led to a course of gross hematuria. He was managed conservatively. After three weeks of hospitalization and stabilization, his profuse, constant bleeding was finally addressed. CT and ultrasound imaging was performed and revealed that his bladder was at an abnormal size and filled with blood. A cystoscopy and a fulguration of the bulbar artery were completed. Quick relief and recovery were noted after the procedure was finalized.

Rhabdomyolysis Associated With "Pruno" Prison-Made Alcohol Intake in Corrections Facility: A Case Report.

In this study, a case of severe rhabdomyolysis in a 28-year-old incarcerated patient is presented. The patient initially presented with emesis, abdominal pain, and myalgias to the clinic at the corrections facility and was treated with antiemetics and analgesics. The onset of symptoms occurred approximately 24 h after ingestion of an illicit substance produced by inmates. Despite intervention, the patient was eventually transferred to the hospital on the third day after symptom onset for further evaluation and treatment. The manuscript presents the events that preceded the diagnosis of rhabdomyolysis, as well as symptoms of hyperactive delirium that developed during the patient's hospital course, leading to the high suspicion of illicit substance intoxication as a contributing inciting factor of rhabdomyolysis. This study aimed to bring awareness to the medical community about substance use in the correction system and its consequences.

Global Longitudinal Strain as an Efficient Prognostic Tool in Hypertrophic Cardiomyopathy With Preserved Left Ventricular Ejection Fraction.

Intending to demonstrate the utility of the global longitudinal strain (GLS) in patients with hypertrophic cardiomyopathy (HCM) and preserved ejection fraction, we describe a case of a 54-year-old female who presented to our emergency department with an acute onset of palpitations and chest pain. The patient was noted to have a new onset of atrial fibrillation. An echocardiogram showed an unimpaired ejection fraction suggesting normal left ventricular systolic function with findings of concentric left ventricular and apical hypertrophy. However, the speckled ultrasound revealed a GLS of -6.2%, suggesting marked impairment of ventricular wall movement. A CHA2DS2-VASc score was calculated and yielded a score of 2, indicating a moderate risk for thromboembolism. After a full evaluation of the case, the patient was started on anticoagulation due to her GLS result that suggested stasis within the left ventricle that may lead to a thrombus. Additional advice was to follow up closely for possible automatic implantable cardioverter defibrillator placement. We conclude that GLS is a cheap and easy tool to utilize as an additional prognostic marker for cardiovascular complications, particularly among those who have progression of HCM or start with symptoms such as atrial fibrillation and may have impaired left ventricular systolic function despite a preserved ejection fraction. Thus, we encourage the medical community to utilize and further study this novel technology.

Effectiveness of Virchow's Node Fine-Needle Biopsy for the Discovery of Occult Metastatic Prostate Cancer.

In this case report, we describe the effectiveness of fine-needle aspiration of Virchow's node for the diagnosis of metastatic prostate cancer in a 62-year-old male without any medical history, negative urinary tract symptoms, and a normal digital rectal examination. The patient presented with respiratory distress, diffuse lymphadenopathy, and high levels of prostate-specific antigen. Multiple studies were done with inconclusive results until positive findings of the NKX3.1 gene were found in the immunostain smear of the Virchow's node, which led to the identification of metastatic prostate cancer.

A Case Report of Accelerated Pulmonary Silicosis: Hazardous Exposure in Underrepresented Community Members.

A 39-year-old undocumented male immigrant with occupational exposure to quartz, without significant medical history, presented with worsening cough, dyspnea, and weight loss for the past six months, with onset of symptoms starting two years ago. The patient was exposed to silicon dioxide for the past 10 years due to his occupation. Chest x-ray at the time of diagnosis reflected multifocal heterogeneous opacities; CT of the chest demonstrated eggshell calcifications and conglomerate opacities particularly involving the bilateral upper lobes. Transbronchial biopsy reflected non-necrotizing granulomatous inflammation. In the context of silica dust exposure, these findings suggest the diagnosis of accelerated silicosis. This case report seeks to bring attention to the potential increased risk of occupational diseases in the community members who have high exposure to environmental hazards.

Asymptomatic Cryptogenic Brain Abscess: A Case Report.

We report a case of a cryptogenic brain abscess in a 48-year-old immunocompetent male who was admitted for acute alcohol intoxication and a fall. A computed tomography scan (CT) of the brain showed a 10.5mm solitary mass in the parieto-occipital lobe. After his initial symptoms were resolved, there were no acute neurological or systemic symptoms. Due to the incidental CT finding, an extensive work up was conducted, including a brain biopsy, which resulted in a surprising diagnosis of brain abscess with no identified source of infection. He was treated with cefepime, metronidazole, and vancomycin. Literature review was done through PubMed searching for cases of cryptogenic brain abscesses with no neurologic symptoms. The review resulted in cryptogenic cases but no cases of asymptomatic cryptogenic brain abscesses.

Metastatic Clivus Chordoma: A Case of a Rare Tumor in a 29-Year-Old African American Male.

In this study, we report a case of a late-stage clival chordoma in a 29-year-old African American male and the unfortunate linear progression course since his initial diagnosis. Upon his initial encounter in 2020, radiation therapy did not offer any promising curative outcome. He was initially treated with a combination treatment of partial resection, radiation, and proposed oral imatinib, none of which modified the natural history and progression of his illness. Instead, these methods were performed as palliative measures to reduce the current size of the tumors and decrease growth rates to minimize his pain. Social issues acted as a contributory risk factor in his prognosis and due to the patient's socioeconomic barriers, he was not able to continue seeking available radiotherapy, leading to disease exacerbation. Poor adherence was noted with his follow-up. The risks of being affected by this disease are likely multifactorial and more reports of such cases need to be added to bridge this gap in the current literature. In addition, there is a gap in the current study of reports of such tumors found in diverse racial groups and in patients who are in their first few decades of life. Novel treatment strategies were reviewed, and it is expected they could generate assertive treatment guidelines.

Medicina basada en evidencias / Medicine based on evidences

Para responder si la MBE puede llenar el vacío de cienticidad en la práctica clínica en nuestro medio se aborda en forma epistémica el término evidencia, definiéndola como el dato sistematizado en relación a una hipótesis en el contexto de una teoría o cuerpo de conocimiento vigente. Se critica en nuestro medio la práctica de una medicina de rutina y autoritaria, por ende sin equidad. Se ejemplica los supuestos dentro de un escenario de práctica cotidiana y se adicionan fuentes para revisar las técnicas de la MBE o medicina basada en pruebas, basada a su vez en la epidemiología clínica, pretendiendo acercar la investigación clínica a la práctica diaria.

La edad como factor de riesgo en colecistectomía / The age as risk factor in cholecystectomy

Para identificar si la edad constituye un factor de riesgo quirúrgico, se analizó propectivamente información de 123 pacientes colecistectomizados en los hospitales Belén, Regional Docente y Víctor Lazarte Echegaray de Trujillo, Perú, durante el período marzo-diciembre de 1996. Los pacientes fueron agrupados en menores o igual a 65 años (grupo I) y mayores de 65 años (grupo II), siendo el promedio de edad 48 ñ 11.5 y 74 más menos 6.1, respectivamente. A cada paciente se aplicó la escala de Goldman modificada para valorar su riesgo quirúrgico y se realizó un seguimiento de su evolución intra y post operatoria hasta el momento del alta. Veintiséis pacientes (21.1 por ciento) presentaron complicaciones, 12 (16.2 por ciento) correspondieron al grupo I y 14(28.6 por ciento) al grupo II. La mayor frecuencia de complicaciones se encontró en el período post operatorio inmediato (18.7 por ciento). La edad constituyó un factor importante de complicación en el período postoperatorio inmediato atribuyéndosele un riesgo relativo de 2.64. La presencia de patología biliar aumentó el riesgo de complicación; si a ello asociamos la edad encontramos 77 por ciento de complicaciones en el grupo de mayor edad frente a un 41 por ciento en los menores de 65. Las complicaciones más frecuentes fueron infecciones de herida operatoria (7.3 por ciento), infecciones respiratorias (6.5 por ciento) e infecciones urinarias (3.3 por ciento). La mortalidad global encontrada fue de 2.43 por ciento, siendo 1.35 por ciento para los menores de 65 años y 4.08 por ciento para los mayores de esta edad. Se concluye que a mayor edad del paciente colecistectomizado se incrementa la morbimortalidad y este riesgo es mayor cuando hay patología del conducto biliar.

Neumonía nosocomial por Pseudomonas aeruginosa: fuentes de trnsmisión en unidades de terapia intensiva / Nosocomial pneumonia by pseudomonas aeuroginosa: sources of transmission in intensive therapy unit

El presente trabajo se llevó a cabo para determinar si las manos del personal que labora en las unidades de cuidado intensivo (UCI) y las unidades respiratorias son fuentes de transmisión de Pseudomonas aeruginosa. Para efecto de esta investigación descriptiva, en dos UCI de dos hospitales generales de la ciudad de Trujillo (Perú): Hospital Belén-MINSA, y Víctor Lazarte Echegaray-IPSS, y en 65 pacientes admitidos entre enero y junio de 1998 sin diagnóstico de neumonía nosocomial (NN), se recolectó muestrad de aspirado endotraqueal para identificación microbiológica. Las muestras fueron tomadas en dos fases, una hasta dentro de las 48 horas de su ingreso, y la otra cuando se diagnóstico clínicamente NN. Se tomó además muestras de las manos de 39 personas que laboran en UCI, así como 52 muestras de los tubos de las unidades respiratorias. Se identificó una incidencia de NN en 36.92 por ciento, la incidencia de NN por P. aeruginosa considerando la definición tradicional del CDC fue de 33.85 por ciento, y con la definición de portador (infección endógena secundaria y exógena) fue de 21.54 por ciento. El 91.67 por ciento de las NN en pacientes con asistencia ventilatoria fueron ocasionadas por P. aeruginosa. Respecto a las muestras de manos se encontró 11.54 por ciento de contaminación con P. aeruginosa y del total de tubos el 23 por ciento fue positivo a esta bacteria. Se estableció una relación de 88.89 por ciento entre infectados y portadores, la razón entre manos contaminadas e infectados fue de 27 por ciento, y entre infectados y tubos contaminados la razón fue del 100 por ciento. Estos datos fueron considerados como un indicador de patogenicidad intrínseca (portadores) o extrínseca (manos y equipos). Se asume teóricamente que las manos del personal y unidades respiratorias son fuentes de transmisión de P. aeruginosa. Se sugiere realizar trabajos de intervención controlando los factores de riesgo identificados.

Cateter venoso central e infección asociada / Catheter associated-sepsis, a prospective study

Para determinar la eficacia del cultivo de la punta del catéter venoso central (CVC), se realizó un estudio prospectivo en el Departamento de Patología Clínica, Servicio de Microbiología del Hospital E. Rebagliati-IPSS de Lima entre enero y marzo de 1993. Treinta y cinco puntas de catéteres, de otros tantos pacientes con diagnóstico de sepsis asociada a CVC, fueron cultivadas mediante la técnica cualitativa en tubos con caldo de tioglicato. La sensibilidad y especificidad encontradas fueron del 60 por ciento. El germen más frecuentemente aislado fue el Estafilococos no patógeno, 32 por ciento del total. Por su baja eficacia, el cultivo de la punta de catéter en caldo debería ser reemplazado por nuevas técnicas.