by Merina Khan, Nida Saleem, Syed Nayer Mahmud and Muhammad Haneef
Case Report
Primary hyperparathyroidism (PHPT) is characterized by the overproduction of parathyroid hormone (PTH) due to parathyroid gland hyperplasia, adenoma, or carcinoma, resulting in hypercalcemia and raised or inappropriately normal PTH levels. Primary hyperparathyroidism is rare in pregnancy, with a reported incidence of one percent. There is a direct relationship between the degree of severity of hypercalcemia and miscarriage risk, with higher rates being reported in those patients, whose serum calcium levels are greater than 11.4 mg/dL (2.85mmol/L). After taking written informed consent, we report a case of 32 years old female in the third trimester of pregnancy, who presented with recurrent symptomatic hypercalcemic episodes. A successful parathyroidectomy was performed during the third trimester of pregnancy. The patient responded dramatically with no subsequent post-operative feto-maternal complications and normal post-operative serum calcium levels. During pregnancy, the diagnosis of primary hyperparathyroidism can be difficult due to physiological changes of pregnancy. Besides this, a precise radiological diagnosis of the overactive parathyroid gland is not possible due to the risk of radiation injury to the fetus. This can lead to persistent hypercalcemia associated with numerous dreadful feto-maternal complications. In literature, there is conflicting data regarding the management of gestational hyperparathyroidism, especially during the third trimester of pregnancy. From this case, it is concluded that in a patient with recurrent symptomatic hypercalcemic episodes, even during the third trimester of pregnancy, emergency parathyroidectomy can be considered regardless of gestational age.
American Journal of Medical Case Reports. 2022, 10(6), 183-185. DOI: 10.12691/ajmcr-10-6-6
Pub. Date: June 23, 2022
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by Anuraag Sah, Hardik Fichadiya, Muhammed Atif Masood Noori, Arshan Khan, Harshil Fichadiya, Asnia Latif, Maria Khazaei and Michael Zaboski
Original Research
Immune-mediated necrotizing myopathy (IMNM) is an inflammatory myopathy characterized by proximal muscle weakness and significantly elevated creatinine kinase levels. IMNM occurs primarily in adults and is usually rapidly progressive in nature. It can be seronegative or associated with antibodies against signal recognition peptide (SRP) or hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Scarce and rare cases of Immune-mediated necrotizing myopathy have recently been observed in muscle biopsy of COVID-19 patients with similar histological and clinical features of other IMNM with profound proximal muscle weakness and elevated CPK levels. We present a very interesting case of an atypical presentation of IMNM in the presence of COVID-19 infection. Treatment with Remdesivir and dexamethasone resulted in improvement of her symptoms.
American Journal of Medical Case Reports. 2022, 10(6), 180-182. DOI: 10.12691/ajmcr-10-6-5
Pub. Date: June 19, 2022
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by Oadi N. Shrateh, Mariam Thalji, Samer Barahmeh, Muayad Salman, Haneen Owienah, Ayman Altarifi, Iyas Tanib, Lyudmila Hamarsheh and Rabee Adwan
Case Report
Introduction: Fistula is defined as abnormal communication between two epithelium-lined surfaces. Among all types of uterine fistulae, the utero-cutaneous one is infrequently encountered, especially following a lower uterine segment cesarean section. The classic presentation of patients with utero-cutaneous fistula is cyclical hemorrhage from the incision site of previous CS. Surgical intervention is considered the most effective therapeutic option. Clinical report: A 34-year-old female patient came to our attention complaining of abdominal pain and bloody discharge from the incisional site 2 months after a lower uterine segment cesarean section (LUCS). Utero-cutaneous fistula was detected by using Pelvic MRI. Patient had successful surgical resection of the fistula. Conclusion: Although it’s extremely rare, utero-cutaneous fistula should be included in the differential diagnosis of cyclical abdominopelvic pain and/or discharge after lower uterine segment cesarean section (LUCS).
American Journal of Medical Case Reports. 2022, 10(6), 176-179. DOI: 10.12691/ajmcr-10-6-4
Pub. Date: June 13, 2022
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by Shawn Philip, Muhammad Farhan Ashraf, Mary Strader, Hala Abdelwahab and Asra Batool
Case Report
Sevelamer is phosphate lowering oral agent used in chronic kidney disease (CKD) to decrease oral phosphate absorption. Sevelamer has been shown to cause crystalline induced colitis. This can manifest as abdominal pain or gastrointestinal bleeding. We present a case with chronic kidney disease and Moyamoya syndrome that presented with abdominal pain and anemia. Colonoscopy revealed a single circumferential cratered ulcer in the transverse colon. Pathology showed crystalline induced colitis. Sevelamer was discontinued and the patient`s symptoms improved.
American Journal of Medical Case Reports. 2022, 10(6), 173-175. DOI: 10.12691/ajmcr-10-6-3
Pub. Date: June 06, 2022
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by Walaa Hammad, Qirat Jawed, Islam Younes, Ana Romero, Jesus Romero, Asnia Latif and Fareeha Abid
Case Report
Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a clinical entity recognized as a biliary manifestation within the spectrum of the systemic disorder known as IgG4-related disease (IgG4-RD). The prevalence of this disease is frequently underestimated since it can be misdiagnosed as cholangiocarcinoma or primary sclerosing cholangitis. 90% of patients present with coexistent autoimmune pancreatitis (AIP), while only 10% of the patients present with isolated biliary involvement. Here, we present a rare case of a 54-year-old gentleman who presented to our hospital with abdominal pain and cholestatic liver injury found to have IgG4-SC in the absence of pancreatitis. IgG4-SC represents a chronic inflammatory state which is usually seen in the fifth and sixth decades of life. These patients frequently present with symptoms characterized by obstructive jaundice, pruritus, and abdominal discomfort. Approximately 90% of the patients will have an elevation of serum IgG4 levels (≥140 mg/dL). Characteristic imagining findings include thickening of common bile duct wall, narrowing of the long segments and dilation of the upstream biliary system, and no evidence of biliary masses. Although it is frequently associated with autoimmune pancreatitis, it can present as an isolated disease. Hence, IgG4 sclerosing cholangitis should be part of the differential diagnosis of patients presenting with biliary strictures. It is of utmost importance to differentiate IgG4-SC from its frequent mimickers such as primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and pancreato-biliary malignancies since therapeutic strategies and outcomes differ significantly between these clinical entities. Glucocorticoids are the first-line treatment and immunomodulatory drugs are used in patients with disease relapse after steroid therapy, which is seen in 50-60% of cases.
American Journal of Medical Case Reports. 2022, 10(6), 170-172. DOI: 10.12691/ajmcr-10-6-2
Pub. Date: June 01, 2022
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by Ken-ichi Muramatsu, Hiroki Nagasawa, Ikuto Takeuchi and Youichi Yanagawa
Case Report
The patient was a 62-year-old woman who was found in an unconscious. She had paroxysmal atrial fibrillation, dyslipidemia and anxiety neurosis. On arrival, she was in a state of deep coma with hypotension and hypoxia. She underwent tracheal intubation and continuous infusion of noradrenalin. Her serum cholinesterase (butylcholinesterase) level was 2 IU/L. Organophosphate poisoning was suspected. On day three, she regained clear consciousness and accepted that she had intentionally ingested a bottle of fenitrothion with suicidal intent. On the 3rd day, her serum cholinesterase level decreased to 0 U/L, and remained at this level until the 7th day. Prolonged artificial ventilation was required due to weak respiration. On the 14th day, she presented shock, a deterioration of consciousness, a distended abdomen with the peritoneal stimulation sign. She was diagnosed with paralytic ileus with septic shock. Her general condition gradually improved with supportive therapy. At the end of treatment in our hospital, she barely could walk and feed for herself and was transferred to another hospital for rehabilitation. To our knowledge, this is the first reported case of delayed paralytic ileus after prolonged transient hypocholinesterasemia induced by fenitrothion poisoning, in which atropine was not used as treatment. Physicians should pay attention to the complication of paralytic ileus when a patient with organophosphate poisoning shows prolonged hypocholinesterasemia.
American Journal of Medical Case Reports. 2022, 10(6), 167-169. DOI: 10.12691/ajmcr-10-6-1
Pub. Date: May 29, 2022
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