Type A fulminant Clostridium perfringens sepsis indicated RBC/Hb discrepancy; a case report.

BACKGROUND: Clostridium perfringens can cause various infections, including food poisoning, gas gangrene, cellulitis and fasciitis. C. perfringens septicemia is rare, but is a known cause of hemolysis by damaging red blood cell, and often proves rapidly fatal in emergency department (ED) situations. CASE PRESENTATION: A previously healthy 76-year-old man presented to the ED 8 h after onset of acute abdominal pain and diarrhea. Laboratory examination revealed a large discrepancy between the red blood cell count of 1.91 × 106/mm3 and the hemoglobin level of 10.3 g/dL, suggesting massive intravascular hemolysis. Computed tomography revealed liver abscesses with gas. During ED treatment, the state of the patient rapidly deteriorated and he entered cardiopulmonary arrest. Blood cultures finally identified C. perfringens. CONCLUSION: Intravascular hemolysis and red blood cell (RBC) / hemoglobin (Hb) discrepancy in the presence of infection should prompt ED physicians to consider C. perfringens septicemia and to act quickly to provide appropriate treatment.

Effect of Shakuyaku-kanzo-to in patients with muscle cramps: A systematic literature review.

BACKGROUND: Previous clinical studies have reported that Shakuyaku-kanzo-to (SKT) has a therapeutic effect on muscle cramps, but few studies have clarified how SKT acts to treat muscle cramps. The aim of this study was to perform an updated systematic review of clinical trials for SKT in patients with muscle cramps. METHODS: The literature was systematically reviewed to assess the effects of SKT in patients with muscle cramps. PubMed, Web of Science, Cochrane Library, Google Scholar, and Ichushi-Web were searched using the terms "Shakuyaku-kanzo-to" ("shakuyakukanzoto", etc), "clinical trials" and "muscle cramps". Two quality assessments were conducted independently by three authors. Data were extracted using a standardized extraction tool, and a qualitative synthesis of evidence was performed. RESULTS: Three randomized controlled articles were identified and enrolled in this study. A systematic review, but not a meta-analysis, was performed because of the high heterogeneity and limited number of studies. In patients with liver cirrhosis, the odds ratio (OR) for improvement with SKT compared to placebo was 1.27 (95% confidence interval [CI], 0.445-2.086) and compared to Goshajinkigan was 0.81 (95%CI, -1.734-0.114). The OR for improvement with SKT compared with eperisone hydrochloride in patients with lumbar spinal stenosis was 2.86 (95%CI, 0.980-4.744). CONCLUSIONS: Current evidence appears insufficient to allow a meta-analysis of the effects of SKT, but SKT might show efficacy in treating muscle cramps in patients with cirrhosis or lumbar spinal stenosis.

Killian-Jamieson diverticulum mimicking a thyroid nodule: A case report.

Killian-Jamieson diverticulum (KJD) is a rare disease of the cervical esophagus, often misidentified as thyroid nodules on ultrasonography. We performed carotid artery ultrasonography for an asymptomatic 68-year-old man. The ultrasound showed an oval nodule with heterogeneous echogenicity surrounded by a multilayered rim in the posterior left thyroid gland. As endoscopy and computed tomography confirmed pharyngoesophageal diverticulum in the anterolateral wall of the esophagus, we reached a final diagnosis of KJD. In cases where a thyroid nodule is detected by ultrasound, physicians should be aware of the possibility of KJD before performing invasive procedures.

The role of ultrasound imaging in adult patients with testicular torsion: a systematic review and meta-analysis.

PURPOSE: Our aim was to determine the accuracy of ultrasound (US) examination-based testicular torsion diagnosis in adult patients with acute scrotal pain. METHODS: A comprehensive electronic search was performed using internet retrieval systems up to 5 August 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The quality of eligible studies was assessed using Quality Assessment for Studies of Diagnostic Accuracy (QUADAS-2). The diagnostic value of ultrasound in patients with testicular torsion was evaluated using pooled estimates of sensitivity, specificity, likelihood ratio, and diagnostic odds ratio, as well as the summary receiver operating characteristics curve. RESULTS: Twenty-six studies with 2116 patients were included in the study. Overall diagnostic sensitivity was 0.86 [95% confidence interval (CI) 0.79-0.91] and specificity was 0.95 (95% CI: 0.92-0.97). Subgroup analysis of prospective studies showed pooled sensitivity of ultrasound for testicular torsion was 0.94 (95% CI 0.83-0.98), and pooled specificity was 0.98 (95% CI 0.94-1.00). Recent studies after 2010 showed diagnostic sensitivity of 0.95 (95% CI 0.84-0.99) and specificity of 0.98 (95% CI 0.93-0.99). CONCLUSIONS: This meta-analysis demonstrated that ultrasound represents an effective imaging modality for diagnosing testicular torsion in adult patients with acute scrotal pain.

Massive abscess with prolonged respiratory failure due to newly diagnosed myotonic dystrophy: A case report.

RATIONALE: Myotonic dystrophy is a progressive multisystem genetic heterogeneous disorder. General anesthesia with opioids increases the risk of prolonged postanesthetic respiratory recovery in myotonic dystrophy patients. PATIENT CONCERNS: A 20-year-old previously healthy woman was transferred to our emergency department for further workup of respiratory failure, and massive ascites with abscess caused by endometriosis. Hypercapnic respiratory failure persisted under intensive care unit (ICU) management, but finally improved after cessation of fentanyl as a sedative agent. DIAGNOSIS: Myotonic dystrophy type 1. INTERVENTIONS: Massive ascites with abscess was accordingly managed by drainage, antibiotics, and an antifungal agent. Myotonic dystrophy type 1 was confirmed after molecular genetic testing revealed a cytosine-thymine-guanine repeat length of 400 to 450 in the DMPK gene. OUTCOMES: The patient was discharged without complications on hospital day 69. LESSONS: Myotonic dystrophy should be considered when hypercapnic respiratory failure persists in sedated ICU patients. Opioids should not be used for perioperative management of patients with myotonic dystrophy.

An atypical case of atypical pneumonia.

Atypical pneumonia has been thought to account for 7%-20% of community-acquired pneumonia (CAP). The treatment for the pathogens that cause atypical pneumonia is different from that of other bacterial pneumonia. Therefore, identification of the causative pathogen in a primary care situation is crucial for adequate treatment of CAP. Mycoplasma infection is prevalent in the general population, but Mycoplasma pneumoniae with extrapulmonary symptoms is relatively rare. Herein, we report a case of CAP because of M. pneumoniae that presented with a wide variety of extrapulmonary diseases. Delayed administration of appropriate antibiotics may contribute to development of extrapulmonary manifestations.

Atypical spinal cord infarction: A case report.

INTRODUCTION: The abrupt onset of sensorimotor deficits is a neurologic emergency that requires immediate management. Acute spontaneous spinal cord infarction (SCI) is rare, but can cause the sudden onset of quadriplegia or quadriparesis. Magnetic resonance imaging (MRI) is an essential imaging modality to diagnose SCI. CASE PRESENTATION: A 75-year-old man with a history of diabetes mellitus type 2, hypertension, and dyslipidemia was transferred to our facility for further workup of the sudden onset of quadriplegia. Diffusion-weighted contrast MRI (DWI) on hospital day 8 revealed hyperintense signals predominantly at the grey matter, and a contrast T2 signal abnormality with a decreased apparent diffusion coefficient (ADC). Steroid pulse therapy was initiated because myelitis could not be completely ruled out, but this did not improve the neurological deficits. Spontaneous SCI was finally diagnosed as an exclusion diagnosis. Symptoms were gradually recovered with rehabilitation, and he was transferred to a rehabilitation facility on hospital day 40. CONCLUSION: MRI with DWI of the spine should be considered for an early diagnosis of SCI. A combination of DWI with ADC maps is recommended to distinguish SCI from other differential disorders.