Vascular air embolism (VAE) is a known complication of contrast-enhanced CT (CECT) scan occurring in venous or arterial circulation with a wide spectrum of presentations. We report a case of a 44-year-old woman with endometrial adenocarcinoma stage IVB complicated with liver abscess and pulmonary embolism who developed VAE following a routine CECT scan after the sixth cycle of chemotherapy. This was an incidental finding and the patient remained asymptomatic throughout. As such, she was treated conservatively and gradually recovered. This case report serves as a reminder that VAE should be considered in patients presenting with unexplained symptoms following this procedure.
We discuss the diagnostic challenge in an adult patient presented with purely ocular symptoms diagnosed with tuberculous meningitis (TBM). A 38-year-old woman presented with bilateral painless blurring of vision. There were bilateral sixth cranial nerve palsy and bilateral optic disc swelling. Optic nerve function tests were normal. Patient was lucid with no signs of meningism. Brain imaging were normal. She had a positive Mantoux test, high erythrocyte sedimentation rate but no clinical evidence of active pulmonary tuberculosis infection. Her Quantiferon-TB Gold in-tube test was negative. Cerebrospinal fluid analysis revealed a high opening pressure but no biochemical parameters to suggest TBM, hence she was treated as idiopathic intracranial hypertension. A diagnosis of TBM was finally made following a positive PCR for Mycobacterium tuberculosis Her vision improved with reduction in optic disc swelling following antituberculous treatment.
De Garengeot hernia is a rare finding of the vermiform appendix inside a femoral hernia sac. We report this occurrence in a 73-year-old woman who presented in the acute setting. There are no standardised surgical approaches and many different techniques have been described in case reports in the literature. We conducted a literature review of and found a total of 113 cases with addition of our case 114 unique cases were included for analysis. Inguinal incision was most cited (n=89). Concomitant laparotomy was needed in 13 patients, however, the association between type of incision and additional laparotomy was not significant (p>0.05). Laparoscopic surgery alone was performed in eight patients. Nine patients had hybrid surgery. The most common hernia repair was through suture technique with non-absorbable material (n=31). Mesh repair was used in 28 cases. More laparoscopic surgeries were done when the disease was diagnosed preoperatively (7/39, p<0.05).
A 57-year-old male chronic smoker with underlying diabetes mellitus presented with dysphonia associated with cough, dysphagia and reduced effort tolerance of 3 months' duration. Videoendoscope finding revealed bilateral polypoidal and erythematous true and false vocal fold with small glottic airway. The patient was initially treated as having tuberculous laryngitis and started on antituberculous drug. However, no improvement was observed. CT of the neck showed erosion of thyroid cartilage, which points to laryngeal carcinoma as a differential diagnosis. However, the erosion was more diffuse and appeared systemic in origin. The diagnosis of laryngeal perichondritis was made when the histopathological examination revealed features of inflammation, and the tracheal aspirate isolated Pseudomonas aeruginosa The patient made a good recovery following treatment with oral ciprofloxacin.
We report a rare, potentially sight-threatening ocular complication due to central venous stenosis related to a previous site of haemodialysis catheter. A dialysis-dependent woman in her 60s presented with left eye redness for 1 month followed by a remarkably prominent vessel on the left upper eyelid for 2 weeks. Examinations found left eyelid oedema with prominent venous dilatation on the upper eyelid as well as left eye mild proptosis, conjunctiva injection with corkscrew vessels, raised intraocular pressure, and dilated and tortuous retina vessels. Central thoracic venogram showed total occlusion on the left brachiocephalic vein with retrograde reflux to the jugular vein. An endovascular percutaneous transluminal balloon angioplasty was performed for the left brachiocephalic vein stenosis, which resolved the orbital, facial and neck venous congestion. The patient remained asymptomatic after 1 year.
A 58-year-old man presented with diplopia and partial ptosis for 10 years. It was non-progressive in nature, despite inadequate medical attention the patient received from non-specialists/general practitioners. He did not have fatigability or diurnal variation in weakness and was clinically stable without exacerbations of disease for a decade. He did not have features of Graves's disease, oculopharyngeal dystrophy, cranial nerve paralysis, polymyositis and stroke. The possibility of an atypical presentation of myasthenia gravis (MG) was considered and the patient was evaluated. Ice pack test was negative, Cogan's lid twitch (CLT) test was positive and high titres of acetylcholine receptor antibodies (AChR Ab) suggestive of MG were found. He was treated accordingly with a very good response.
Hyperkalaemic periodic paralysis is a rare skeletal muscle disorder which is characterised by episodic muscle paralysis associated with hyperkalaemia. Although it is an autosomal-dominant disease, cases of de novo mutations have been reported. We report the case of a 30-year-old woman, gravida 5 para 3+1, who was planned for an elective repeated caesarean section at 38 weeks and 3 days of pregnancy. She developed recurrent episodes of hyperkalaemic periodic paralysis after receiving corticosteroids. Intravenous calcium gluconate was administered to normalise potassium levels (from 6.3 mmol/L to 4.1 mmol/L). Extra anaesthetic precautions were taken during the caesarean delivery. Postoperatively, she was well and discharged from the ward. She encountered similar symptoms in her third pregnancy, and there was no family history of muscle weakness which suggested a de novo mutation. Pregnancy seemed to result in vulnerability to hyperkalaemic attacks as she was never symptomatic outside pregnancy.
Managing the difficult airway presents a great challenge to anaesthesiologists and emergency physicians. Although there are many methods and scoring systems available to predict and anticipate difficult airway, the dictum in emergency airway is to always expect the unexpected. We have encountered a novel simple method of improving laryngoscopic view in difficult airway. We report four cases of difficult airway encountered in our district hospital from November 2017 to December 2018, in which intubation was performed using a simple manoeuvre called supine left head rotation (LeHeR). In all these cases, LeHeR manoeuvre has proven to be successful after more than a single attempt at intubation using various methods. The manoeuvre improves drastically the laryngoscopic view of Cormack-Lehane from 3B and 4 to 1 and 2.
Jehovah's Witnesses (JW) is a branch of Christianity which was founded in 1872. However, their beliefs differ from other Christians in many ways. Majority of JW believe that it is against the teaching of God should they receive blood transfusion, while minority think receiving own blood or others is acceptable. These vast beliefs should always be respected by all medical practitioners to avoid medicolegal implications. The differing beliefs about blood transfusion is certainly a huge challenge to the surgeons and anesthesiologists, especially dealing with major surgeries. Thus, effective surgical and anaesthetic techniques are focused to minimise blood loss to avoid unnecessary blood transfusion. We report a JW patient who successfully underwent an emergency endoscopic transsphenoidal surgery secondary to pituitary apoplexy; highlighting our intraoperative acute hypervolaemic haemodilution technique to reduce blood loss.
Patients with medically refractory epilepsy (MRE) are indicated for vagus nerve stimulation (VNS) placement. Anaesthesia for VNS placement is extremely challenging and requires several considerations. We present a man in his 20s with MRE who successfully underwent VNS placement. We review the mechanism of action of VNS, anaesthetic challenges and measures to prevent seizures.
Wolff-Parkinson-White (WPW) syndrome is an extremely rare congenital cardiac conduction disorder. It is due to an aberrant pathway between the atrium and ventricle. This manuscript entails a man with an underlying WPW who was posted for an elective orchidectomy. We discussed the important perioperative precautions to prevent the precipitation of acute cardiac events.
Anaesthesia for patients with huge mediastinal mass is very challenging due to the cardiorespiratory embarrassment that may occur. We present a patient with this condition, which was complicated by total airway obstruction, intraoperatively. We discuss the importance of patient positioning and the role of spontaneous ventilation.
Intraoperative impending compartment syndrome (ICS) is an extremely rare but lethal occurrence that can involve the upper and/or lower limb(s). It commonly occurs in patients who undergo anaesthesia in various special positions such as lithotomy, lateral decubitus or prone. We present a patient who developed an ICS of his left forearm during a cervical spine surgery in prone position. This devastating condition was fortunately identified when the pulse oximetry, intra-arterial wave form and motor-evoked potentials signal disappeared abruptly from our monitors. We discuss our perioperative challenges and management for the patient which had eventually saved the patient's limb.
Acute stridor is often an airway emergency. We present a valuable experience handling an elderly woman who was initially treated as COVID-19 positive during the pandemic in November 2020. She needed an urgent tracheostomy due to nasopharyngeal (NP) diffuse large B-cell lymphoma causing acute airway obstruction. Fortunately, 1 hour later, her NP swab real-time PCR test result returned as SARS-CoV-2 negative. This interesting article depicts the importance of adequate preparations when handling potentially infectious patients with anticipated difficult airway and the perioperative issues associated with it.
Vagus nerve stimulation (VNS) is a neurostimulatory modality in treating patients with medically resistant epilepsy (MRE). It was introduced in 1997 and has been proven to reduce patients' dependency on antiepileptic drugs and seizure frequency. However, the usage of VNS in children with MRE has been limited, especially those with Lennox Gastaut Syndrome (LGS). Our teenage boy with this syndrome developed MRE and successfully underwent VNS placement. We discuss the perianaesthetic challenges, a brief description of VNS and the reported successes in patients with LGS.
Hip fracture-dislocation is extremely rare in sports and is most frequently seen after road traffic accidents. This injury is associated with considerable long-term disability and rapidly progressive joint degeneration. This case report illustrates two cases of hip fracture dislocation that occurred while playing recreational indoor football (futsal). Futsal is a fast-emerging recreational sport in Malaysia and we are now beginning to see high-impact injuries rarely encountered in recreational sports. Therefore, futsal cannot be taken lightly and it is important to take adequate precautions to prevent serious injuries when participating in such sports.
We describe an uncommon cause of paraneoplastic optic neuropathy in adenocarcinoma of the lung. A 45-year-old healthy woman presented with seizure and encephalitis, followed by an acute visual loss in both eyes for 1 week. Her visual acuity was no perception of light in the right eye and hand movement in the left eye. There was a generalised restriction of extraocular muscle movements in both eyes. Funduscopy showed a bilateral pale optic disc. A paraneoplastic antigen autoimmune profile showed a positive anti-CV2/CRMP-5 antibody. CT of the thorax revealed the presence of right apical lung mass, confirmed to be adenocarcinoma through a biopsy. She was scheduled for lung lobectomy and chemotherapy. Unfortunately, her health deteriorated and she passed away eventually.
Fetus-in-fetu (FIF) is a rare entity in which malformed parasitic twin grows inside the body of its twin. It is most commonly presented with mass in the abdomen. We present a case of a 15-year-old boy who presented with abdominal mass since infancy. Radiological investigations are suggestive of FIF. Intraoperatively, malformed fetus in a sac was found and excised. Postoperatively the patient recovers well and was put on follow-up.
Penetrating foreign body in the head and neck can be catastrophic from injury to the constellation of vascular and neural structures in the neck. Early recognition and prompt surgical intervention is imperative to save lives. Herein, we present an unusual case of iatrogenic foreign body-a coiled guidewire embedded in the deep neck space. The complications, radiological investigation and multidisciplinary surgical management are further discussed.
We report a case of renal cell carcinoma diagnosed after a patient was treated successfully with intravenous cyclophosphamide for her active proliferative lupus nephritis (classes III and V). After the intravenous cyclophosphamide regimen, the patient was asymptomatic with persistent microscopic haematuria, and no proteinuria. The renal cell carcinoma was located on the left kidney; incidentally, this was where the initial renal biopsy was done to diagnose lupus nephritis.