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.
Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. A 21-year old gentleman presented with inguinal pain following a motorcycle accident and physical examination revealed absence of both testes within a well-formed scrotal sac with bilateral inguinal swellings. Ultrasonography confirmed viability and location of the testes at the superficial inguinal pouch. He underwent emergent surgical reduction with orchidopexy and was discharged the next day. No evidence of testicular dysfunction or atrophy was noted at follow-up. We reviewed reports of TTDs reported in English over the last two centuries and discuss its occurrence, evolution and management.
A 32-year-old woman presented with a 3 cm×3 cm left breast lump associated with bloody nipple discharge during her early pregnancy. Examination and ultrasonography showed benign features, whereas core needle biopsies revealed a benign papilloma. Six months after her delivery, a 6 cm×6 cm benign papilloma was completely excised via circumareolar incision. The majority of intraductal papillomas are small; however, they can also present as a large mass rarely. We should be wary of a malignant papillary lesion when there is the presence of atypia on core needle biopsy or imaging-histology discordance. A concordant benign papilloma with benign imaging findings is otherwise reassuring. Clinicians need to be aware of this uncommon presentation of large intraductal papilloma as a complete curative excision can be achieved through a cosmetically placed incision.
Malignant melanoma is cancer of the skin which commonly metastasises to the stomach. There have been no reported cases of emphysematous gastritis secondary to metastasis of malignant melanomas, to date. However, a 61-year-old woman with metastatic malignant melanoma of the left great toe presented to us with symptoms of severe left hypochondrium pain associated with high-grade fever, gross abdominal distension and recurrent vomiting. Two months earlier, metastasis was observed to have spread to the stomach and inguinal lymph nodes. At this stage, the patient opted for traditional medication instead of definitive surgery and chemotherapy. Radiological imaging revealed an emphysematous change to the stomach which was radiologically consistent with gastric malignant melanoma. Unfortunately, the patient succumbed to this rare condition.
Leydig cell tumours (LCTs) of the ovary are rare ovarian tumours that usually present with hyperandrogenism. Conventional radiological imagings are helpful in localising these tumours. However, some tumours may be too small to be localised before curative surgical removal. It is important to identify these androgen-secreting neoplasms which originate mostly from adrenals or ovaries because they are potentially malignant and require specific treatment. When conventional imagings are unrevealing, selective ovarian and adrenal venous sampling (SOAVS) is the next option. We report a case of LCT that was localised by SOAVS after results from other imaging modalities remained inconclusive.
Melioidosis is a protean disease which is endemic to Southeast Asia and northern Australia. Here, we report a case of infected aortic aneurysm due to Burkholderia pseudomallei in an immunocompetent man 6 months after a trip to northern Malaysia. This patient initially received inappropriate surgical and antibiotic treatment, leading to a peri-prosthetic aortic infection with lumbar spondylitis and contiguous psoas muscle abscess. This case highlights the difficulty of diagnosing melioidosis given its diverse clinical manifestations and the limits of routine microbiological methods to identify B. pseudomallei Melioidosis should be considered a possible diagnosis in individuals with unexplained fever subsequent to travel in an endemic area.
Pseudoaneurysm of the ankle involving the posterior tibial artery is a rare presentation with only four paediatric cases previously reported in English literature. We report a new case following blunt trauma with the clinical presentation and management strategy. A 6-year-old boy presented with a pulsatile swelling at the medial aspect of ankle following a history of blunt trauma 3 weeks ago. Imaging confirmed pseudoaneurysm involving the distal posterior tibial artery. Excision of the pseudoaneurysm was performed without any complication.
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.
Anaesthesia for patients with severe lung fibrosis post COVID-19 infection requires special consideration. This is due to its propensity to cause perioperative anaesthetic catastrophe and possibility of cross infection among healthcare workers if not properly managed. This interesting article elaborates in detail the anaesthetic and surgical challenges in a morbidly obese patient who had a severe COVID-19 infection presenting for an elective spine surgery.
Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) is rarely caused by a phaeochromocytoma. We report a case of a 51-year-old woman with an 8-year history of severe constipation who underwent extensive investigations including gastroscopy, colonoscopy, ultrasonography, colonic transit studies and isotope defeacography, which did not reveal any pathology other than slow colonic transit time. The unifying diagnosis of ectopic ACTH and phaeochromocytoma was made after the case was initially investigated for an adrenal incidentaloma. Multiple challenges had to be overcome prior to surgery for the functioning adrenal adenoma including management of refractory hypokalaemia, poor nutritional status, persistent hyperglycaemia, labile blood pressure and florid hypercortisolaemia driving the metabolic derangements. She underwent an uneventful left-sided adrenalectomy and required no medication thereafter with normal blood pressure, blood glucose and serum potassium and resolution of constipation and abdominal symptoms. In conclusion, patients with EAS related to phaeochromocytoma are rare and present with distinctive diagnostic and management challenges but if diagnosed successfully and managed intensively, they are curable.
We reported a case of a woman with no past medical illness who presented with a few days' history of fever, myalgia, arthralgia, hypochromic microcytic anaemia and thrombocytopaenia and who was nonstructural protein 1 antigen (NS1Ag)-positive. Haemolytic anaemia including full blood picture work-up revealed high reticulocyte count and haemolysis with positive direct Coombs test. She was started on prednisolone and was discharged well.
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 report a term newborn who presented on day 3 of life with unilateral, tender scrotal swelling with skin discolouration, which was subsequently diagnosed as haemophilia A at about 6 months of age. He received intramuscular vitamin K and hepatitis B vaccine at birth uneventfully. The scrotal swelling was treated as an infected hydrocoele, considering the absence of a family history of bleeding disorder and other risks of bleeding tendency, as well as the ultrasonographic features. He also had congenital pneumonia requiring venepuncture, non-invasive oxygen supplementation and intravenous antibiotics, without any complication. The swelling slowly improved over 2 months. He later developed post-trial vaccine injection haematoma at 4 months of age, and multiple non-traumatic bruises when he was 6 months old, leading to the diagnosis. This case demonstrates an uncommon, but a possible, early manifestation of haemophilia A at birth with a unilateral scrotal haematoma.
Kodamaea ohmeri keratitis is an opportunistic pathogen seen in patients who have undergone invasive procedures and immunocompromised state. It has been identified in septicemia patients, resulting in mortality. To the best of our knowledge, we identified the first case of K. ohmeri keratitis following an injury with vegetative material. A 57-year-old woman with underlying, poorly controlled diabetes mellitus was gardening when a tree leaf accidentally poked her in the eye. Two weeks later, the patient presented with right eye pain, redness and progressive blurring of vision due to a traumatised right cornea. Slit-lamp examination showed a small inferior paracentral corneal stromal infiltrate with overlying epithelial defect. A corneal scraping sample yielded K. ohmeri from Analytical Profile Index (API) 20C yeast identification system. She was treated with intensive topical amphotericin B and fluconazole. After 6 weeks of treatment, the keratitis resolved with faint scar tissue, and her visual acuity improved.
Recurrent laryngeal nerve (RLN) injury is one of the main complications of total thyroidectomy. If the injury is bilateral, total airway obstruction, aphonia and hoarseness of voice could be precipitated. Hence, it is wise for the operating surgeon to be guided by neural monitoring during thyroidectomy. We present a valuable experience handling a middle-aged man with a huge papillary thyroid carcinoma . He needed an urgent thyroidectomy due to obstructive symptoms. We highlight our intraoperative dexterity in handling his surgery in the context of continuous monitoring of RLN using electromyography.
We report a case of COVID-19 in a 29-week preterm infant. This child is the youngest reported case of SARS-CoV-2 infection in Malaysia, and to the best of our knowledge, one of the youngest documented cases of established vertical transmission of SARS-CoV-2 reported in literature. Our report highlights the clinical course, timelines of viral shedding by real-time reverse transcription-PCR and antibody seroconversion in a premature infant infected with SARS-CoV-2. In addition, we discuss the challenges faced in managing a preterm infant infected with SARS-CoV-2 and the knowledge gaps that need to be explored.