http://www.jmedicalcasereports.com The latest research articles published by Journal of Medical Case Reports 2012-05-14T00:00:00Z IntroductionPseudomembranous colitis is known to be caused by Clostridium difficile; and, in 3-8% of patients, it lapses into an aggressive clinical course that is described as fulminant. We present herein a case of extremely rapid and fatal fulminant pseudomembranous colitis that developed after ileostomy closure, a minor surgical procedure. To the best of our knowledge, this is the first case report of fatal fulminant pseudomembranous colitis after closure of diversion ileostomy in an adult.Case presentationA 69-year-old man who had previously undergone low anterior resection and creation of diverting ileostomy for stage III rectal carcinoma was admitted for ileostomy closure. Preoperatively, he received oral kanamycin and metronidazole along with parenteral cefmetazole. The surgery and postoperative course were uneventful until the third postoperative day, when fever and watery diarrhea became apparent. The next day he presented epigastric and left lower abdominal pain. Computed tomography revealed a slightly distended colon. Later that night, his blood pressure fell and intravenous infusion was started.In the early morning of the fifth postoperative day, his blood pressure could be maintained only with a vasopressor. Follow-up computed tomography demonstrated severe colonic dilation. Colonoscopy confirmed the presence of pseudomembranous colitis, and so oral vancomycin was administered immediately. However, within 3 hours after the administration, his condition rapidly deteriorated into shock. Although emergent total colectomy with creation of an end ileostomy was performed, the patient died 26 hours after the surgery. The histopathological examination was consistent with pseudomembranous colitis. Conclusion: It is important to recognize that, although rare, there is a type of extremely aggressive pseudomembranous colitis in which the usual waiting period for medical treatment might be lethal. We consider that colonoscopy and computed tomography are helpful to decide the necessity of emergent surgical treatment without delay. http://www.jmedicalcasereports.com/content/6/1/130 Iku Abe Yutaka Kawamura Junichi Sasaki Fumio Konishi Journal of Medical Case Reports 2012, null:130 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-130 /content/figures/1752-1947-6-130-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 130 2012-05-14T00:00:00Z PDF IntroductionRivaroxaban, a new oral anticoagulant, is currently licensed for use in patients undergoing orthopaedic surgery. It is more efficacious than other anticoagulants such as Low Molecular Weight Heparin (LMWH) and does not require daily monitoring. It has also been shown to be efficacious in patients with venous thromboembolism (VTE) and acute coronary syndrome (ACS). Although haemorrhage is a known side effect of this new anticoagulant we could find no case reports in the literature of patients suffering severe haemorrhage whilst taking Rivaroxaban. Thus, we describe the first case of potentially fatal haemorrhage in a patient taking Rivaroxaban.Case presentationWe report the case of a 58 year old caucasian male with acute onset severe per rectum (PR) bleeding who had undergone total hip arthroplasty (THA) 4 weeks prior to the onset of symptoms and was taking Rivaroxaban in the post-operative period. Rivaroxaban was discontinued immediately but having required nine units in a peripheral hospital due to a rapidly decreasing Haemoglobin level, the patient was then transferred to a tertiary referral centre where he required eight units of packed red blood cells (PRBCs) over a 48 hour period to manage his ongoing haemorrhage and maintain haemodynamic stability. No source of bleeding was found on computed tomography (CT) angiography and the patient's condition improved over the following 48 hours with cessation of haemorrhage. The patient was discharged home well several days later. A follow up colonoscopy one week after discharge was normal. Conclusion: Although advantageous with regard to its oral availability and ongoing use without the need for daily monitoring, Rivaroxaban does not come without rare but severe side effects. When severe PR bleeding occurs in a patient taking Rivaroxaban,discontinuation of the offending agent and aggressive haematological replacement are the mainstays of treatment, especially when no source of bleeding can be found. As the first case described regarding severe haemorrhage and Rivaroxaban, those prescribing the medicine should remind the patient of the risk of such a serious side effect and the need for urgent medical attention if it occurs. http://www.jmedicalcasereports.com/content/6/1/129 Michael Boland Maria Murphy Marese Murphy Enda McDermott Journal of Medical Case Reports 2012, null:129 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-129 /content/figures/1752-1947-6-129-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 129 2012-05-14T00:00:00Z PDF IntroductionVincristine is an antineoplastic drug with a well-known efficacy in the treatment of acute lymphoblastic leukemia and many solid tumors. No more than twenty pediatric patients with vincristine-induced vocal cord palsy have been reported and this is the first case where glutamic acid was administered with the aim of preventing a relapse of laryngeal dysfunction.Case presentationThe larynx paralysis presented with hoarseness and stridor in a Caucasian 18-month-old girl and spontaneously resolved in about a month. In order to administer a subsequent full dose of vincristine the child received oral glutamic acid whose efficacy against vincristine neurological side effects has been reported. Conclusion: Since in our patient the amino acid proved to be ineffective in the prevention of the laryngeal paralysis relapse, we suggest that a dose reduction of vincristine should be preferred by oncologists as an initial approach after a case of drug induced vocal cord palsy. http://www.jmedicalcasereports.com/content/6/1/128 Piero Farruggia Serena Tropia Sonia Cannella Giuseppa Bruno Gaspare Oddo Paolo D'Angelo Journal of Medical Case Reports 2012, null:128 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-128 /content/figures/1752-1947-6-128-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 128 2012-05-14T00:00:00Z PDF IntroductionMyelolipomas are rare, benign tumours comprising mature adipose tissue and hematopoietic elements. The vast majority occurs within the adrenal glands but extra-adrenal myelolipomas have also been reported in the presacral region, retroperitoneum, mesentery, stomach, spleen , liver, mediastinum and lungs.Here we present a case of primary myelolipoma occuring in an unusual site- nasal cavity.We believe that this unique location of extraadrenal myelolipoma has not been previously described in the literature.Case presentationWe report a case of primary myelolipoma occuring in the nasal cavity of a 48-year-old Asian woman.With a review of the literature , we describe the aetiology, pathology, differential diagnosis of extradrenal myelolipomas. Conclusion: We present this case because of its unique location.Although myelolipomas are rare, we conclude that it should be considered in the differential diagnosis of lesions in this site. http://www.jmedicalcasereports.com/content/6/1/127 Smiley George Marie Manipadam Regi Thomas Journal of Medical Case Reports 2012, null:127 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-127 /content/figures/1752-1947-6-127-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 127 2012-05-14T00:00:00Z PDF IntroductionBenign multicystic peritoneal mesothelioma (BMPM) is an extremely rare tumor that occurs mainly in women in their reproductive age. Its preoperative diagnosis and adequate treatment are quite difficult to attain.Case presentationThe case was 23 years-old Japanese woman and had a history of right oophorectomy and left ovarian cystectomy for an ovarian tumor at 20 years of age. The left ovarian tumor had been histologically diagnosed as mucinous borderline tumor. Two years and 9 months after the initial operation, multiple cysts were found in the patient. Laparotomy was performed, and the uterus, left ovary, omentum, and pelvic lymph nodes were removed due to suspicion of recurrence of the borderline tumor. Histological examination, however, revealed that the cysts were not a recurrence of the borderline tumor but rather BMPM. There were no residual lesions, and the patient was followed up with ultrasonography. She remains free from recurrence 9 months after treatment. Conclusion: We report a case of BMPM mimicking recurrence of ovarian borderline tumor. BMPM should be suspected when a multicystic lesion is present in the pelvis as in the case presented here, especially in patients with previous abdominal surgery. http://www.jmedicalcasereports.com/content/6/1/126 Shuji Takemoto Ryosuke Kawano Kazumi Honda Aki Nakazono Kazuhide Shimamatsu Journal of Medical Case Reports 2012, null:126 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-126 /content/figures/1752-1947-6-126-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 126 2012-05-14T00:00:00Z PDF IntroductionStimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult populations with Attention Deficit Hyperactivity Disorder (ADHD). However, data regarding the optimal dosage in adults is still limited.Case presentationWe report the case of a 38-year-old Caucasian patient who was diagnosed with ADHD when he was nine years old. He then received up to 10mg Ritalinand 20mg Ritalin SR daily. When he was 13, his medication was changed to desipramine (Norpramin), and both Ritalin and Ritalin SR were discontinued; and at age 18, when he developed obsessive-compulsive symptoms, his medication was changed to clomipramine (Anafranil) 75mg/d. Still suffering from inattention and hyperactivity, the patient began college when he was 19, but did not receive stimulant medication until three years later, when Ritalin 60mg/d was re-established. During the 14 months that followed, he began to use Ritalin excessively, both orally and rectally, in dosages from 4800-6000mg/d. Four years ago, he was referred to our outpatient service, where his ADHD was re-evaluated. At that point, the patient's daily Ritalin dosage was reduced to 200mg/d orally, but he still experienced pronounced symptoms of ADHD, so this dosage was raised again. The patient's plasma levels consistently remained between 60-187 nmol/l--within the recommended range--and signs of his obsessive-compulsive symptoms diminished with fluoxetine 40mg/d. Finally, on a dosage of 378mg Concerta, his symptoms of ADHD have improved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding this report. Conclusion: Symptoms of ADHD in this adult patient, who also manifested a co-occurring obsessive compulsive disorder, dramatically improved only after application of a higher-than-normal dose of methylphenidate. We therefore suggest that clinicians consider these findings in relation to their adherence to current therapeutic guidelines. http://www.jmedicalcasereports.com/content/6/1/125 Michael Liebrenz Danielle Hof Anna Buadze Rudolf Stohler Dominique Eich Journal of Medical Case Reports 2012, null:125 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-125 /content/figures/1752-1947-6-125-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 125 2012-05-14T00:00:00Z PDF IntroductionCollision tumor is the meeting and eventual intermingling of two malignant neoplasms arising from independent topographical sites. Collision metastases of carcinomas in lymph nodes are a rare event. A current literature search revealed three cases of such a collision metastasis of prostatic and urothelial carcinoma, and only one of those cases had used immunohistochemical stains to distinguish the two tumors.Case presentationWe encountered a case of this rare entity in an 83-year-old African-American man who presented with increasing pelvic pain after a transurethral resection [TUR] of a high-grade bladder tumor and a negative metastatic computed tomography [CT]-chest, abdomen and pelvic scan work-up. A radical cystoprostatectomy was subsequently performed revealing a multicentric, high-grade, ill-defined infiltrating urothelial carcinoma infiltrating the right pericystic soft tissue. Histopathological examination of the prostate revealed a multicentric adenocarcinoma [Gleason 4 + 4] involving two pelvic lymph nodes. Interestingly, while the right pelvic lymph node was positive for metastatic prostatic adenocarcinoma alone, immunohistochemical studies of the left pelvic lymph node revealed a dual metastatic urothelial [cytokeratin[CK]-7 and pan-CK positive, prostate specific antigen [PSA] and CK20 negative] and prostatic [PSA and pan-CK positive, CK7 and CK20 negative] carcinoma. Conclusions: The collision of metastatic urothelial carcinoma and prostatic adenocarcinoma is unusual, and their biological behavior remains uncertain. A high index of suspicion along with thorough clinical examination, and immunohistochemical stains are an integral part of differentiating collision of urothelial carcinoma from prostate carcinoma, particularly when the two tumors are in close proximity with overlapping histological features. http://www.jmedicalcasereports.com/content/6/1/124 Tapan Bhavsar Jun Liu Yajue Huang Journal of Medical Case Reports 2012, null:124 2012-05-14T00:00:00Z doi:10.1186/1752-1947-6-124 /content/figures/1752-1947-6-124-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 124 2012-05-14T00:00:00Z PDF IntroductionMedulloepithelioma is a rare congenital tumor of the primitive medullary neuroepithelium. A significant proportion of patients with medulloepithelioma arising from the optic nerve die from intracranial spread or cerebral metastasis. This tumor presents within the first 2-6 years of life and is usually misdiagnosed clinically as other optic nerve tumors because it has no known distinct clinical features and because of its low frequency. We herein describe a new and atypical case of medulloepithelioma in a patient of the oldest reported age at presentation with an insidious clinical presentation and the longest documented disease-free survival period.Case presentationA 12-year-old Caucasian male patient with headache and unilateral amaurosis was referred for a presumed optic nerve glioma. Computed tomography showed optic nerve enlargement, and fundoscopy showed a whitish mass at the optic disc. The patient had been followed at his local hospital for 4 years for an "optic disc cyst" with no change or progression. He experienced mild, progressive visual impairment during that period. The patient was admitted for resection, and histopathological analysis revealed a medulloepithelioma of the optic nerve. Supplemental orbital radiotherapy was performed. The patient remained disease-free for 25 years. Conclusion: Medulloepithelioma of the optic nerve can clinically mimic more common pediatric tumors, such as optic glioma, meningioma, or retinoblastoma. Thus, medulloepithelioma should be included in the differential diagnoses of pediatric optic nerve lesions. Fundoscopy in these patients may provide relevant information for diagnosis. Anterior optic nerve medulloepitheliomas may behave differently to and have a better prognosis than more posteriorly located medulloepitheliomas. The present case illustrates that long-term survival can be achieved in patients with this malignant tumor. Natalia Pastora-Salvador Jose Abelairas-Gomez Jesus Peralta-Calvo Eugenia Garcia-Fernandez Carmen Morales-Bastos Monica Asencio-Duran Fernando Carceller-Benito Journal of Medical Case Reports 2012, null:123 2012-05-09T00:00:00Z ${item.identifier} /content/figures/1752-1947-6-123-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 123 2012-05-09T00:00:00Z PDF IntroductionTo our knowledge, this is the first time Triptorelin has been reported to cause BIH.Case presentationA 43 years old Caucasian woman who suffered from chronic menorrhagia was commenced on Triptorelin, a gonadotrophin releasing hormone (GnRH) analogue. Three days later, she developed gradually worsening headaches accompanied by bilateral visual disturbances. Examination revealed bilateral papilledema and enlarged blind spots on visual fields. A diagnosis of benign intracranial hypertension (BIH) was made confirmed on MRI scan. Conclusion: We recommend that the high risk patients (female overweight patients of reproductive age group) who are using any GnRH analogue (e.g. Triptorelin) should be periodically monitored for the possible development of BIH.Keywordsbenign intracranial hypertension, pseudotumor cerebri, GnRH analogue, Triptorelin http://www.jmedicalcasereports.com/content/6/1/122 Uday Kumar Bhatt Imran Haq Venkata Avadhanam Kim Bibby Journal of Medical Case Reports 2012, null:122 2012-05-03T00:00:00Z doi:10.1186/1752-1947-6-122 /content/figures/1752-1947-6-122-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 122 2012-05-03T00:00:00Z PDF IntroductionPerforation caused by CE impaction is extremely rare and, at present, only 5 cases of perforation from CE impaction are reported in the literature.Case presentationWe report here 2 cases of patients with undiagnosed small bowel stenosis presenting acute perforation after CE. Strictures in the small bowel were likely the inciting mechanism leading to acute SB obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.Case 1 was a 55-years-old Italian woman who underwent CE because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative abdominal US, upper endoscopy, colonoscopy, and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of CE. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed structuring ileal adenocarcinoma leading to perforation.Case 2 was a 60-year-old Italian male with recurrent episodes of abdominal pain and diarrhea who underwent CE after conventional modalities, including comprehensive blood and stool studies, CT, abdominal ultrasound, upper endoscopy, colonoscopy, barium enema, and small bowel follow-through, were not diagnostic. The patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn's stricture leading to perforation. Conclusions: The present report shows that although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration http://www.jmedicalcasereports.com/content/6/1/121 Giovanni De Palma Stefania Masone Marcello Persico Saverio Siciliano Francesca Salvatori Francesco Maione Dario Esposito Giovanni Persico Journal of Medical Case Reports 2012, null:121 2012-05-03T00:00:00Z doi:10.1186/1752-1947-6-121 /content/figures/1752-1947-6-121-toc.gif Journal of Medical Case Reports 1752-1947 ${item.volume} 121 2012-05-03T00:00:00Z PDF