Postpartum subarachnoid hemorrhage - questions on gestational hypertension diagnosis and treatment threshold: A case report.

Hypertensive disorders of pregnancy (HDP) are a leading cause of morbidity and mortality for pregnant patients, but how aggressively to address non-severe hypertension in pregnancy remains controversial. The American College of Obstetrics and Gynecology (ACOG) currently recommends a blood pressure treatment threshold of 140/90 mmHg during pregnancy. However, 2017 American College of Cardiology/American Heart Association (ACC-AHA) guidelines define stage 1 hypertension by blood pressures of >130/80 mmHg within the general population. There is now an understudied population of pregnant patients considered to have stage 1 hypertension by ACC-AHA guidelines but who do not meet the treatment threshold by ACOG's standards. This article presents a patient who met ACC-AHA-defined stage 1 hypertension throughout her pregnancy and went on to develop severe hypertension and a postpartum subarachnoid hemorrhage (SAH) secondary to venous hemorrhage. She presented to the emergency department 17 days postpartum complaining of an extreme headache and with a blood pressure of 230/125 mmHg. Magnetic resonance imaging showed SAH in the parietal region adjacent to the superior sagittal sinus. Magnesium and labetalol were administered followed by a clevidipine drip. The patient was continued on antihypertensives and made a full recovery. This article's objective is to draw attention to the urgent need for increased clarity of practice guidelines, consensus between societies, and further study of peripartum health outcomes for pregnant patients defined as having stage 1 hypertension by 2017 ACC-AHA criteria.

A Case of Roseomonas gilardii Peritonitis Associated with a Flooded Peritoneal Dialysis Treatment Space.

Bacterial peritonitis is a key complication of Peritoneal Dialysis (PD) and a preventable cause of withdrawal from PD treatment. Infection generally arises from contamination with skin commensals during handling of the dialysis delivery system or from translocation of gastrointestinal organisms and more rarely from an environmental organism. Herein, we report the case of a 73-year-old admitted for PD-related peritonitis due to Roseomonas gilardii with an associated environmental exposure from a domestic plumbing issue. We describe the presentation, case, and antibiotic regimen progression from empiric therapy of ceftazidime and vancomycin IP to ciprofloxacin. We acknowledge the importance of performing laboratory sensitivities given the high antibiotic resistance of the Roseomonas genus. We offer that nephrologists should consider Roseomonas as a potential causative organism of peritonitis, especially when initial or further history reveals exposure to potentially contaminated water.

Intralobar pulmonary sequestration: incidental finding in an asymptomatic patient.

We describe a case of a 58-year-old male who presented to the emergency room with symptoms related to an appendicitis. A computed tomography scan with contrast confirmed the diagnosis of acute appendicitis but also revealed a mass medially in the base of the inferior lobe of the right lung. The mass measured 6.7 cm AP × 3.7 cm transverse. It had multiple lobulations and the anterior aspect was of very low density, possibly representing accumulated mucoid material. The mass had an arterial connection from the descending thoracic aorta and a venous drainage into the right pulmonary vein, classical features of intralobar pulmonary sequestration. The physical exam was unremarkable, and the patient had no history of pulmonary symptoms. This case helps increase awareness of intralobar pulmonary sequestration, a rare condition that may be asymptomatic.

Massive Hepatomegaly Secondary to Amyloidosis with Normal Liver Chemistries.

Amyloid light chain (AL) amyloidosis is a disease of misfolded, fibrous proteins, either kappa or lambda subtype, that can be deposited into one or more organs, caused by a proliferation of plasma cells. The liver is uncommonly the main organ system affected and rarely the only organ affected by amyloid deposition. With hepatic involvement, the most common presenting findings are hepatomegaly and elevation of serum alkaline phosphatase. We report a case of a 50-year-old male who presented to our gastroenterology clinic with marked hepatomegaly secondary to hepatic amyloidosis, in concert with bone marrow involvement and nephrotic syndrome. Biopsies in conjunction with Congo red staining demonstrated 95% replacement of hepatic structure and 80% replacement of bone marrow with amyloid deposition. Despite these findings, liver chemistries, renal function, and blood count were normal. Our case presents not only the rare finding of primary hepatic amyloidosis but also an atypical presentation of this disorder. Although rare, AL amyloidosis should be in a differential diagnosis of any patient who presents with unexplained hepatomegaly, nephrotic-range proteinuria, heart failure with preserved ejection fraction, fatigue, weight loss or a history of monoclonal gammopathy of undetermined significance.

Acute brachialis muscle tear in a pediatric patient.

Acute tears or ruptures of the brachialis muscle are rare events, with only 10 cases reported to date and all of which have been in adults. We report a case of an acute, complete tear of brachialis in an 8-year-old female that occurred while the patient was practicing a gymnastic move. Although rare, this case underscores the need to include brachialis tears in the differential diagnosis for musculoskeletal injuries at the elbow in all age groups.

Uterine Lipoleiomyoma in the Context of Adenocarcinoma.

We describe a case of a 63-year-old woman referred to an oncologist for treatment of endometrial adenocarcinoma. A computed tomography scan revealed the incidental finding of a 11.5 × 10.5 × 9.0 cm myomatous mass in the uterine corpus adjacent to, yet uninvolved with, the adenocarcinoma. Histopathological analysis confirmed the mass to be a lipoleiomyoma, a rare single variant of lipoma. These fatty tumors present similar to leiomyomas and as such are generally not harmful; however, the potential exists for diagnostic confusion with other uterine tumors. This case serves to further illuminate the findings associated with these rare tumors.

A case of thoracoabdominal splenosis.

We describe a case of a 38-year-old male with a remote history of motor vehicle trauma who presented to the emergency department with 1-week history of progressively worsening abdominal pain localized to the epigastric region. Patient history included splenectomy. Computerized tomography demonstrated multiple masses in the left pleural space as well as masses continuous with the diaphragm and abdominal wall in the left upper quadrant. In addition, a lobulated mass was identified in the right upper quadrant along the anterior right hepatic lobe. A diaphragmatic defect was noted containing splenic tissue. A diagnosis of splenosis was made. Disseminated splenosis presenting in both the thorax and abdomen is rare and poorly documented. This case serves to further illuminate this condition.

Marked coagulopathy without liver disease or anticoagulation therapy.

Symptomatic coagulopathies in celiac disease (CD) are rare. Here, we report a profound case of coagulopathy in a celiac. A 66-year old female without liver disease or anti-coagulation therapy presented with multiple ecchymoses, guaiac positive melanic stool, and a recent 4.5kg weight loss. Laboratory values included hemoglobin, 3.8g/dL; MCV, 66 fL; serum iron, 17µg/dL; platelet count, 580K/µL; white count, 14.2K/µL, and vitamin D,<5.0ng/mL. Additional values included partial thromboplastin time (PTT), >200s; prothrombin time (PT), >150s; INR, 20.5, putting her at extreme risk of bleeding. Vitamin K deficiency was assumed. The patient was given two units of fresh frozen plasma, packed red cells, and vitamin K intravenously. Endoscopy and biopsies demonstrated duodenal mucosal atrophy with cobblestoning, erosive gastritis, flattened duodenal villi and numerous intraepithelial lymphocytes. Transglutaminase serology demonstrated IgA TTG>100 U/mL (normal<3U/mL), confirming a diagnosis of CD. The patient's coagulopathy resolved within two days following admission. This case underscores the importance of CD testing in all patients with coagulopathies of unknown origin. Although coagulopathy is an uncommon presentation of CD, in extreme cases such as this, it has the potential to be life-threatening.

Giant hepatic cyst as a cause of gastric outlet obstruction.

We describe the case of a 58-year-old female who presented to her primary care provider with lifelong anorexia, 6-week history of liquid only diet and new onset epigastric abdominal pain radiating to the back accompanied by nausea and abdominal distension. An initial computed tomography scan with contrast demonstrated a massive simple hepatic cyst with mass effect compression of the duodenal sweep. Repetitive treatment with aspiration sclerotherapy using hypertonic saline provided initial resolution of symptoms and led to substantial reduction of cyst diameter. Repeat imaging demonstrated complete drainage of the cyst and decompression of the duodenum. Ultimately, the patient's symptoms returned 6 weeks later at which time she opted for surgical deroofing of the cyst. Surgery provided for complete resolution. This case appears to be the first to document the compression of second portion of the duodenum by a massive simple hepatic cyst causing anorexia and mimicking gastric outlet obstruction.

Intercostal artery pseudoaneurysm following thoracentesis: multi-modal imaging and treatment.

BACKGROUND: A pseudoaneurysm occurs as the result of a contained rupture of an arterial wall, yielding a perfused sac that communicates with the arterial lumen. Pseudoaneurysm of an intercostal artery is an extremely rare event but it carries with it a significant risk of rupture and subsequent hemothorax. It must be considered as a potential complication of thoracentesis. CASE PRESENTATION: Here, we report a rare case of an intercostal artery pseudoaneurysm following thoracentesis in an 82-year old male. The patient presented with respiratory distress 1 day after a therapeutic thoracentesis had been performed. Computed tomography (CT) with contrast revealed a left intercostal pseudoaneurysm with hemothorax and adjacent compressive atelectasis. Doppler ultrasound revealed bidirectional blood flow in the pseudoaneurysm sac. An intercostal arteriogram and thoracic aortogram aided in confirmation of the pseudoaneurysm and successful treatment with coil embolization. CONCLUSIONS: An intercostal pseudoaneurysm complication following thoracentesis is very rare but important to rule out as a possible cause of hemothorax after the procedure. Capturing this finding with the aid of multiple imaging modalities allowed for diagnostic certainty and rapid treatment with coil embolization, leading to a successful patient recovery.

Internal hernia with incarceration of the cecum through a loop created by an elongated fallopian tube.

We describe a case of a 61-year-old female who presented to the emergency department with a 2-week history of severe right and left lower abdominal quadrant abdominal pain that radiated to the back and was accompanied by nausea and vomiting. An initial computed tomography scan with contrast demonstrated unusual loops of small bowel in the left paracentral pelvis. Follow-up computed tomography scans revealed worsening dilation of the cecum. Exploratory laparotomy was indicated and revealed a mobile right mesenteric stalk, which had migrated to the left lower abdominal quadrant and become incarcerated within a loop formed by a 25 cm long left fallopian tube. The distal end of the fallopian tube was firmly adherent to the parietal peritoneum of the left lower quadrant. A right hemicolectomy and a left salpingo-oophorectomy were performed. This case appears to be the first to document the internal herniation of a mobile cecum and right mesenteric stalk through a highly unusual loop created by an elongated left fallopian tube.

Clinical Course of a Patient With Kidney Failure Due to Isolated Bilateral Renal Extramedullary Plasmacytomas.

Plasmacytomas are rare immunoproliferative monoclonal plasma cell diseases of lymphoid lineage that may present in an isolated or systemic manner. Systemic involvement is much more common than occurrences isolated to a particular organ, and for this reason, it is imperative to rule out systemic involvement for osseous and nonosseous isolated neoplasms. These neoplasms present unique challenges due to their location, extent of involvement, vague presentation, and dearth of treatment protocol. We report the case of a 69-year-old man who developed chronic kidney disease stage 4 between 2009 and 2012. Precipitous kidney failure, anorexia, fatigue, and flank pain necessitated clinical follow-up that ultimately led to thorough imaging and bilateral kidney biopsy. Protein electrophoresis, immunohistochemistry, and immunofluorescence were all consistent with bilateral renal extramedullary plasmacytomas. Treatment recommendations are often limited to prior case successes; however, chemotherapy, radiation, and surgery are the mainstay of treatment. Although surgery or combined therapy provides the best results for patients, such options are unfeasible with bilateral kidney involvement. Therefore, a chemotherapy regimen, similar to that for multiple myeloma, was determined to be most reasonable. Treatment consisted of 4 cycles of a bortezomib, cyclophosphamide, and dexamethasone regimen. Three months following chemotherapy, kidney function returned to baseline levels.

Large intramuscular lipoma of the tongue.

We describe a case of a 57-year-old man referred to an oral maxillofacial surgeon for a nontender, large intramuscular tongue mass. A computed tomography scan with contrast showed a homogenous right tongue intramuscular fatty mass measuring 3.8 cm × 2.8 cm in the axial dimension and 2.2 cm in the craniocaudal dimension. Histologic examination revealed multiple lobulated sections of mature adipocytes and occasional entrapped skeletal muscle fibers. The final pathologic diagnosis was intramuscular lipoma. Although lipomas account for approximately 50% of all soft tissue neoplasms, intramuscular (infiltrating) lipoma of the tongue is exceedingly rare.

Population-level effect of molecular testing and targeted therapy in patients with advanced pulmonary adenocarcinoma: a prospective cohort study.

Large cancer centres in the USA demonstrated that molecular diagnosis and targeted therapy improved overall survival of patients with advanced pulmonary adenocarcinoma. We validated this finding in a rural area of Switzerland, served by private practices, community hospitals and a tertiary referral centre. We conducted a prospective cohort study with the Cancer Registry of Central Switzerland, covering 4 cantons and 517,000 inhabitants. All residents newly diagnosed with stage IV pulmonary adenocarcinoma from 2010 to 2014 were enrolled. We obtained information on patients, tumour, molecular testing, therapy and survival. Three hundred forty-eight patients were included in the study. Molecular testing was performed in 279 (80%); 132 (38%) had oncogenic driver mutations: Kirsten rat sarcoma (KRAS, 16%), epidermal growth factor receptor (EGFR, 11%), anaplastic lymphoma kinase (ALK, 5%), human epidermal growth factor receptor 2 (HER2, 2%), B rapidly accelerated fibrosarcoma (BRAF, 1%), rearranged during transfection (RET, 0.5%), MET proto-oncogene (0.5%) and multiple mutations (2%). Fifty-six patients with an oncogenic driver mutation, mostly epidermal growth factor receptor (34) and anaplastic lymphoma kinase (12), received genotype-matched targeted therapy, at least 25 (45%) of whom in a clinical trial or named patient programme. Median overall survival was 18 months for patients with driver mutations and targeted therapy, 8 months for patients with driver mutations and conventional therapy and 10 months for patients with no driver mutation and conventional therapy. For patients with driver mutations and targeted therapy, overall survival was significantly better than that for patients with driver mutations and conventional therapy (HR 0.64, p = 0.04). Rigorous testing combined with optimal access to targeted therapy in clinical trials improved the prognosis of patients with advanced pulmonary adenocarcinoma in Central Switzerland. This effect was mainly driven by therapies targeting epidermal growth factor receptor and anaplastic lymphoma kinase.

[A very slow growing ankle swelling in a healthy male]. / Ein seltsamer subkutaner Knöcheltumor.

We describe the case report of a 66-year-old man with a very slow growing ankle tumour caused by a subcutaneous fungal abscess. Phaeoacremonium inflatipes, a member of the Dematiaceae family, was identified by needle puncture and culture of the non-odorous creamy yellow brown fluid. The fungal pseudocyst was surgically removed in toto and no further fungicidal drug therapy was required. Human infections by dematiaceous fungi causes subcutaneous phaeohyphomycosis, a rare, deep fungal infection of the skin and subcutaneous tissues usually acquired through traumatic skin lesions. In addition, systemic infections are reported, predominantly in immunosuppressed individuals.

Repetitive coronal polishing yields minimal enamel loss.

PURPOSE: The American Dental Hygienists' Association recommends selective polishing because of risk of enamel removal and lack of documented therapeutic value. The initial study documenting enamel loss from polishing used methods not acceptable for clinical use, while results from other studies are inconsistent. This study examines the effect of simulated life-time polishing on enamel thickness. Enamel loss from polishing is compared to the enamel thickness just coronal to the cementoenamel junction (CEJ) to relate results to clinical application. METHODS: Eight premolars and 18 molars were polished 150 times with coarse prophy paste, then pre- and post-polishing micrometer measurements were compared. Eight unpolished premolars and 18 unpolished molars were used as control groups. Average enamel thickness from 10 premolars and 10 molars just coronal to the CEJ was chosen to represent minimal enamel thickness, and was calculated using digital radiography. T-tests were used to compare group means. RESULTS: The mean measurement difference was significantly higher for the premolar treatment group than the control group, but no difference was noted between molar treatment and control groups. Neither treatment group demonstrated significant abrasion when compared to average minimal enamel thickness. Root abrasion was noted on 5 molars. CONCLUSION: The results of our study indicate that polishing may remove enamel, but the quantity removed is unlikely to be clinically relevant. Root surface abrasion seen on molars is disturbing, considering stain often occurs on exposed mandibular anterior root surfaces and may cause repeated and prolonged polishing. Further investigation into alternative stain removal methods is recommended.