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Case Reports in Pediatrics 2020Congenital duodenal web causing proximal duodenal obstruction leading to gastroduodenal emphysema is a very rare presentation in infancy. Due to persistent...
Congenital duodenal web causing proximal duodenal obstruction leading to gastroduodenal emphysema is a very rare presentation in infancy. Due to persistent peristalsis against the duodenal membrane, there is progressive stretching of the duodenal web leading to windsock deformity. We describe a rare case of a child with gastroduodenal emphysema and portal venous air due to duodenal obstruction secondary to a duodenal web. An eighteen-month-old male child, who was under investigation for failure to thrive, presented with a history of persistent projectile vomiting and progressive abdominal distension for two days. The abdominal ultrasound scan revealed air within the portal vein and in the wall of the stomach. Plain X-ray abdomen confirmed the presence of gas in the gastric wall and in the proximal duodenal wall. Upper gastrointestinal contrast study revealed complete obstruction at the second part of the duodenum. The child underwent emergency laparotomy, which revealed a duodenal web as the cause of the duodenal obstruction. During the surgery, windsock deformity was noted. This case illustrates that although rare, proximal duodenal obstruction due to duodenal web may present in early childhood and that alarming imaging features such as gastric emphysema and portal venous air could be associated with benign conditions.
PubMed: 32015925
DOI: 10.1155/2020/9897208 -
Biomedical Journal Oct 2019Severe headaches, projectile vomiting, focal neurological deficits and early onset seizure are regarded as early warning symptoms of subarachnoid hemorrhage (SAH)....
BACKGROUND
Severe headaches, projectile vomiting, focal neurological deficits and early onset seizure are regarded as early warning symptoms of subarachnoid hemorrhage (SAH). Earlier diagnosis based on such warning symptoms theoretically would improve the clinical prognosis. However, it is still not clear whether the prognosis is correlated with early warning symptoms. Here, we reviewed warning symptoms and other predictive factors in the emergency room (ER) setting and examined their correlations with mortality.
METHODS
Ninety saccular aneurysmal SAH cases were reviewed in a single medical center between January 2011 and December 2013. We examined differences in mortality rate related to warning symptoms, SAH scales, onset-to-ER time, hydrocephalus, and aneurysm size, location, and complexity. Logistic regression analyses were performed to determine the correlations of warning symptoms and other predictive factors with mortality. Receiver operating characteristic (ROC) curve analysis was used to calculate the area the under curve (AUC) of SAH mortality prediction tools.
RESULTS
Warning headache, projectile vomiting, the Hunt and Hess scale, Fisher scale, World Federation of Neurological Surgeons (WFNS) grading scale, and modified WFNS (m-WFNS) scale, body mass index, aneurysm complexity and hydrocephalus were significantly different between the survivors and the decedents. The warning headache and WFNS grade were strongly correlated with mortality. The rate of prognostic prediction improved from 90.4% to 94.6% when warning headache was additionally evaluated.
CONCLUSIONS
With growing healthcare costs and recognition of the value of palliative care, early identification via warning headache and a detailed clinical history review is necessary for cases of aSAH.
Topics: Adult; Aged; Area Under Curve; Female; Headache; Humans; Male; Middle Aged; Prognosis; ROC Curve; Retrospective Studies; Risk Assessment; Subarachnoid Hemorrhage; Survival Rate
PubMed: 31783996
DOI: 10.1016/j.bj.2019.04.006 -
European Journal of Pediatric Surgery... Jan 2019A male infant aged 45 days presented with projectile nonbilious vomiting for 2 weeks. Ultrasound showed picture of idiopathic hypertrophic pyloric stenosis. Laparoscopic...
A male infant aged 45 days presented with projectile nonbilious vomiting for 2 weeks. Ultrasound showed picture of idiopathic hypertrophic pyloric stenosis. Laparoscopic pyloromyotomy was done, but postoperative vomiting that was mainly nonbilious continued without improvement. After 4 days of persistent vomiting, laparoscopic exploration was done and complete pyloromyotomy was confirmed and malrotation with complete Ladd's band was found, then case converted to open laparotomy and Ladd's procedure was done. Postoperatively, vomiting stopped completely and baby began gradual feeding till reaching full feed. Despite that the presentation of concurrent Idiopathic Hypertrophic Pyloric Stenosis with malrotation is extremely rare; a formal laparoscopic abdominal exploration should be done as the first step before proceeding to pyloromyotomy.
PubMed: 31763128
DOI: 10.1055/s-0039-1698400 -
Journal of Ayub Medical College,... 2019Gastrointestinal duplication cyst is a rare congenital anomaly with a reported incidence of 1 in 4500 live births. Any part of gastrointestinal tract from mouth to anus...
Gastrointestinal duplication cyst is a rare congenital anomaly with a reported incidence of 1 in 4500 live births. Any part of gastrointestinal tract from mouth to anus can be affected with this anomaly. Among gastrointestinal tract duplications, gastric duplication cyst is extremely rare (2- 9%). We are presenting a case of the stomach duplication in a four (04) day old male child who presented in our Emergency Department with complaints of non-bilious, non-projectile vomiting and visible bulge in upper abdomen since birth. Workup showed enteric duplication cyst which was excised. Complete surgical resection is the treatment of choice in gastric duplication cyst.
Topics: Congenital Abnormalities; Gastric Outlet Obstruction; Humans; Infant, Newborn; Male; Stomach
PubMed: 31535531
DOI: No ID Found -
Journal of Postgraduate Medicine 2019Intracranial hemorrhage (ICH) is rarely seen in patients with thalassemia. A seven-year-old male, known case of beta-thalassemia major, on irregular packed cell...
Intracranial hemorrhage (ICH) is rarely seen in patients with thalassemia. A seven-year-old male, known case of beta-thalassemia major, on irregular packed cell transfusions (elsewhere) and non-compliant with chelation therapy, presented with congestive cardiac failure (Hb-3 gm/dl). He received three packed red cell transfusions over 7 days (cumulative volume 40 cc/kg). On the 9th day, he developed projectile vomiting and two episodes of generalized tonic-clonic convulsions with altered sensorium. He had exaggerated deep tendon reflexes and extensor plantars. CT-scan of brain revealed bilateral acute frontal hematoma with diffuse subarachnoid hemorrhage (frontal and parietal). Coagulation profile was normal. CT-angiography of brain showed diffuse focal areas of reduced caliber of anterior cerebral, middle cerebral, and basilar and internal carotid arteries (likely to be a spasmodic reaction to subarachnoid hemorrhage). He required mechanical ventilation for 4 days and conservative management for the hemorrhage. However, on the 18th day, he developed one episode of generalized tonic-clonic convulsion and his sensorium deteriorated further (without any new ICH) and required repeat mechanical ventilation for 12 days. On the 28th day, he was noticed to have quadriplegia (while on a ventilator). Nerve conduction study (42nd day) revealed severe motor axonal neuropathy (suggesting critical illness polyneuropathy). He improved with physiotherapy and could sit upright and speak sentences at discharge (59th day). The child recovered completely after 3 months. It is wise not to transfuse more than 20 cc/kg of packed red cell volume during each admission and not more than once in a week (exception being congestive cardiac failure) for thalassemia patients.
Topics: Child; Humans; Intracranial Hemorrhages; Male; Polyneuropathies; beta-Thalassemia
PubMed: 31317877
DOI: 10.4103/jpgm.JPGM_127_19 -
Journal of Medical Case Reports Mar 2019The coexistence of neuromeningeal cryptococcosis and Kaposi's sarcoma is not surprising in a patient with human immunodeficiency virus infection and a low CD4 count,...
BACKGROUND
The coexistence of neuromeningeal cryptococcosis and Kaposi's sarcoma is not surprising in a patient with human immunodeficiency virus infection and a low CD4 count, although it is rarely described. However, we describe such an association in a patient with human immunodeficiency virus infection and a relatively high CD4 count.
CASE PRESENTATION
A 41-year old Cameroonian woman presented to our hospital with subacute occipital headaches associated with photophobia, blurred vision, phonophobia, projectile vomiting, and tonic seizures. In her past history, there was an human immunodeficiency virus infection known for 12 years, for which she had been taking (with good compliance) tenofovir-lamivudine-efavirenz-based antiretroviral therapy for the same period of time. One month before the consultation, gastric Kaposi's sarcoma had been diagnosed, justifying the treatment with doxorubicin she had received. A clinical examination was unremarkable. A computed tomography scan of her brain was normal, and cerebrospinal fluid analysis revealed Cryptococcus neoformans. Her CD4 count was 353/mm. Orally administered antifungal treatment with fluconazole (1200 mg/day) and flucytosine (1500 mg × 4/day) was started immediately, but she died on the sixth day of this treatment.
CONCLUSION
This clinical case shows that the coexistence of neuromeningeal cryptococcosis and gastric Kaposi's sarcoma is possible in all patients with human immunodeficiency virus infection, regardless of CD4 count.
Topics: Adult; CD4 Lymphocyte Count; Female; HIV Infections; Humans; Meningitis, Cryptococcal; Sarcoma, Kaposi; Stomach Neoplasms
PubMed: 30867046
DOI: 10.1186/s13256-019-1982-2 -
The Journal of Hospital Infection Jul 2019Vomiting is one way in which the body rids itself of harmful gastric contents rapidly. Whilst this process is generally beneficial for the emetic individual, it can pose...
BACKGROUND
Vomiting is one way in which the body rids itself of harmful gastric contents rapidly. Whilst this process is generally beneficial for the emetic individual, it can pose significant infection control issues if they are infected with a highly communicable pathogen such as norovirus. It is not known how far norovirus could spread through vomiting while remaining viable, particularly in far-reaching droplets and splashes that might be missed during cleaning.
AIM
To identify the potential level of dissemination of viable norovirus after simulated vomiting.
METHODS
This study used a system called 'Vomiting Larry' to simulate vomiting with infection medium containing the norovirus surrogate feline calicivirus (FCV) as a worst-case scenario for distribution and survival of viruses after simulated vomiting. Air and floor samples were taken after simulated vomiting, and analysed for viable virus via plaque assay. Analysis of covariance investigated differences in FCV concentration by sample volume and location.
FINDINGS
Whilst viable virus was not isolated from any air samples taken after simulated vomiting, FCV concentrations of ≥10 plaque-forming units/mL were recovered from almost all samples taken from the floor (88/90). These included small droplets of fluid that travelled 3 m away from the vomiting system. There was evidence that FCV concentration depended on both sample volume and location.
CONCLUSION
This study suggests that norovirus can survive being ejected even within small far-reaching droplets at concentrations capable of eliciting infection. Such droplets could easily go unnoticed and be overlooked during cleaning, adding to the challenge of controlling norovirus outbreaks.
Topics: Caliciviridae Infections; Calicivirus, Feline; Disease Transmission, Infectious; Environmental Microbiology; Microbial Viability; Models, Theoretical; Vesivirus; Viral Plaque Assay; Vomiting
PubMed: 30797885
DOI: 10.1016/j.jhin.2019.02.010 -
The Cochrane Database of Systematic... Jan 2019Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications can lead to permanent impairment of vision. People with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase.
OBJECTIVES
To assess the effectiveness of various medical interventions in the management of traumatic hyphema.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase.com; PubMed (1948 to June 2018); the ISRCTN registry; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the search was 28 June 2018.
SELECTION CRITERIA
Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical intervention or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions regarding age, gender, severity of the closed-globe trauma, or level of visual acuity at the time of enrollment.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted the data for the primary outcomes, visual acuity and time to resolution of primary hemorrhage, and secondary outcomes including: secondary hemorrhage and time to rebleed; risk of corneal blood staining, glaucoma or elevated intraocular pressure, optic atrophy, or peripheral anterior synechiae; adverse events; and duration of hospitalization. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean differences (MD).
MAIN RESULTS
We included 20 randomized and seven quasi-randomized studies with a total of 2643 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest.We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Eight trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60) as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two studies with 121 participants. We assessed the certainty of these findings as low and very low, respectively. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.31, 95% CI 0.17 to 0.55) in five trials with 578 participants, as did aminomethylbenzoic acid as reported in one study (RR 0.10, 95% CI 0.02 to 0.41). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention.The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no evidence of an effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed.
AUTHORS' CONCLUSIONS
We found no evidence of an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema took longer clear in people treated with systemic aminocaproic acid.There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema other than possibly to reduce the rate of secondary hemorrhage. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as binocular patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.
Topics: Adrenal Cortex Hormones; Aminocaproic Acid; Antifibrinolytic Agents; Aspirin; Bandages; Bed Rest; Child; Estrogens, Conjugated (USP); Eye Injuries; Humans; Hyphema; Mydriatics; Patient Positioning; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Tranexamic Acid; Visual Acuity; Wounds, Nonpenetrating
PubMed: 30640411
DOI: 10.1002/14651858.CD005431.pub4 -
BMJ Case Reports Sep 2018A 17-year-old young woman presented to Patan Hospital, Kathmandu, Nepal, with high-grade fever and headache for 4 days and non-projectile vomiting for 1 day. She...
A 17-year-old young woman presented to Patan Hospital, Kathmandu, Nepal, with high-grade fever and headache for 4 days and non-projectile vomiting for 1 day. She also had blurred vision with dizziness on and off. There was no abnormal physical finding. Enteric fever was suspected, and she was empirically started on azithromycin (20 mg/kg) for 7 days. She became afebrile after 2 days and was followed up in 7 days with diplopia since 5 days. At this time, the blood culture was positive for serovar typhi. On examination, there was isolated left lateral rectus palsy which accounted for her diplopia. Methylprednisolone (1 mg/kg) was prescribed which was tapered over 1 month and gradually her diplopia subsided. We hypothesise that vasculitic change in the blood vessel supplying the left abducens nerve could be causing the diplopia.
Topics: Abducens Nerve Diseases; Adolescent; Anti-Bacterial Agents; Anti-Inflammatory Agents; Azithromycin; Diplopia; Female; Humans; Methylprednisolone; Neuroprotective Agents; Typhoid Fever
PubMed: 30181402
DOI: 10.1136/bcr-2018-225746 -
Clinical Practice and Cases in... Nov 2017A 15-day-old male who was born at term presented with non-bilious projectile vomiting. He was nontoxic and his abdomen was benign without masses. Point-of-care...
A 15-day-old male who was born at term presented with non-bilious projectile vomiting. He was nontoxic and his abdomen was benign without masses. Point-of-care ultrasound (POCUS) showed hypertrophic pyloric stenosis (HPS). Typical findings include target sign; pyloric muscle thickness greater than three millimeters (mm); channel length greater than 15-18 mm; and lack of gastric emptying. The patient was admitted; consultative ultrasound (US) was negative, but repeated 48 hours later for persistent vomiting. This second US was interpreted as HPS, which was confirmed surgically. Pyloromyotomy was successful. Few reports describe POCUS by general emergency physicians to diagnose HPS. Here, we emphasize the value in repeat US for patients with persistent symptoms.
PubMed: 29849342
DOI: 10.5811/cpcem.2017.9.35016