American Journal of Medical Case Reports

Background: New target specific anticoagulants (TSOACs) are convenient to use and effective management in the prophylaxis against thromboembolic sequela of atrial fibrillation (AF). However, without a test to monitor therapeutic efficacy, non-responders may not be detected until they suffer complications. We present a case where one year of dabigatran treatment failed to prevent development of a left atrial clot in the setting of AF. Case: An 84-year-old male with persistent atrial fibrillation presented with anemia of unknown etiology. Workup revealed no acute sources of bleeding, but he was on oral anticoagulation with dabigatran for greater than one year. Anticoagulation had to be discontinued for planned endoscopy. Thus, patient was electrically cardioverted to sinus rhythm. However, 3 days later he presented with a clot in the left femoral artery requiring embolectomy and was back in atrial fibrillation. He was switched to rivaroxaban for anticoagulation. Transesophageal echocardiogram (TEE) 4 weeks later revealed no clot. He was started on the antiarrhythmic amiodarone, then electrically cardioverted to sinus rhythm without complication. Discussion: TEE should be performed prior to electrical cardioversion for patients on TSOACs in case patient is a non-responder. Non-responders, should be placed on a TSOAC with an alternative mechanism of action. Conclusion: Switching TSOACs may be effective management for certain patients with failure of anticoagulation.

American Journal of Medical Case Reports. 2015, 3(5), 153-154. DOI: 10.12691/ajmcr-3-5-10
Pub. Date: May 14, 2015

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Central Retinal Artery Occlusion in a Young Female with Fibromuscular Dysplasia

by Rajan Paul and Dai Barr

Case Report

Fibromuscular dysplasia (FMD) is a rare non-arteriosclerotic, non-inflammatory arterial disease affecting the large arteries e.g renal, carotid, mesenteric and coronary. We describe a case of Central retinal artery occlusion with embolus reorientation in a patient with FMD.

American Journal of Medical Case Reports. 2015, 3(5), 148-152. DOI: 10.12691/ajmcr-3-5-9
Pub. Date: May 05, 2015

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Tuberculosis - An Atypical Presentation

by A Elmorsy, A. Clark-Morgan and G. Shergill

Case Report

Although endemic to the United Kingdom in the 19th and 20th centuries, cases of Tuberculosis have increased in the last twenty years making it an important differential diagnosis to consider. The recurrence of this almost extinct disease is thought to be a result of increasing prevalence of immune system deficiency, particularly Acquired Immunodeficiency Syndrome (AIDS). Musculoskeletal tuberculosis, particularly of a joint, remains a rare condition - accounting for less than 5% of cases of tuberculosis. Symptoms are mild and/or non-specific, making delayed or missed diagnosis a common problem. Here we present the unusual case of tuberculosis of the elbow to maintain consideration of tuberculosis as a differential diagnosis, even in cases with no strong suggestive medical history.

American Journal of Medical Case Reports. 2015, 3(5), 146-147. DOI: 10.12691/ajmcr-3-5-8
Pub. Date: April 30, 2015

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Facial Herpes Simplex Virus Type 1 Infection in a Patient with Multiple Sclerosis on Fingolimod

by Racosta Juan Manuel, McEwan Lynn, Kremenchutzky Marcelo Carlos and Morrow Sarah Anne

Original Research

Fingolimod is an oral disease-modifying therapy for relapsing multiple sclerosis widely used in Canada as a second-line therapy. Fingolimod increases the risk of infections given its dose-dependent reduction of peripheral lymphocytes, due to the reversible sequestration in lymphoid tissues. We present a case of disseminated facial Herpes Simplex Virus type I infection in a patient using fingolimod, with an atypical distribution of the eruption, likely due to the concomitant exposure to sunlight and application of sunscreen. This case report provides insight about a novel mechanism of disseminationof Herpes Simplex Virus type I, which generally enters damaged epithelium or mucosal surfaces secondary to abrasions or trauma. Since Herpes Simplex Virus type I infection tends to disseminate and is accompanied by visceral involvement in immunosuppressed patients, close surveillance of viral infections and the prompt administration of full-dose antiviral therapy in this population is advised.

American Journal of Medical Case Reports. 2015, 3(5), 144-145. DOI: 10.12691/ajmcr-3-5-7
Pub. Date: April 30, 2015

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Hepatocellular Carcinoma in Acute Intermittent Porphyria: Incidental or Expected?

by Mary Mathews, Lauren Paish, Abhishek Kumar, Nazia Khan and Michael Maroules

Case Report

Acute intermittent porphyria (AIP) is a rare genetic disorder involving an insufficiency of the enzyme porphobilinogen deaminase of the heme biosynthesis pathway. Clinically, this manifests as acute attacks of abdominal pain and neuropsychiatric dysfunction, at times these attacks can be life threatening. Despite an autosomal dominant pattern of inheritance, only a minority develop acute attacks due to poor penetrance, thus representing the manifest and latent type of AIP. A unique association between AIP and Hepatocellular carcinoma (HCC) has been reported by some studies recommended screening recommendations for AIP gene carriers over the age of 50. We report a case of 55 year old Slovakian female with a past medical history of acute intermittent porphyria. She presented to the emergency room complaining of persistent, sharp, right upper quadrant pain with intractable nausea and vomiting. A diagnosis of acute episode of AIP was made, along with incidental finding of hepatocellular carcinoma.

American Journal of Medical Case Reports. 2015, 3(5), 141-143. DOI: 10.12691/ajmcr-3-5-6
Pub. Date: April 30, 2015

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Reactivation of Spinal Tuberculosis in a Patient with Rheumatoid Arthritis on Low-dose Methotrexate

by Narjust Duma MD, Jaime Mittal MD and Sobia Nizami

Case Report

42 year old Hispanic woman with rheumatoid arthritis who has been taking methotrexate for 24 weeks was admitted for severe, sharp lumbar back pain for 3 weeks. The pain radiated to both legs, worsened with walking or standing and improved at rest. It was accompanied by low grade fevers, anorexia and generalized fatigue. The patient denied cough or shortness of breath. MRI of the spine showed an L4 pathologic deformity with abnormal marrow infiltration and a ring-enhancing lesion within the left psoas muscle suspicious for abscess. CT-guided biopsy of the psoas showed necrotic debris and neutrophilic infiltrates. PPD test was reported negative. Bacterial and fungal cultures were negative after 5 days. She was discharged with an empiric 30-day regimen of intravenous ceftriaxone and oral linezolid due to high suspicion for a bacterial etiology. Twenty-six days later, the patient returned due to worsening of her back pain, she was unable to ambulate, and had a 15 pound interval weight loss. Previous biopsy cultures were positive for acid-fast bacilli and repeat MRI showed pathologic collapse of L4 with a retropulsive fracture, superimposed phlegmons bilaterally, severe spinal stenosis, and compression of the cauda equina. Three sputum specimens for AFB smears were negative. The patient recalled having had a BCG vaccine and a negative PPD in 1995; she denied exposure to TB or international travel for the past 21 years. The patient was placed on a 6 months regimen of isoniazid, rifampin, pyrazinamide, ethambutol, and pyridoxine. Two months after her presentation, she required an L4 corpectomy with a vertebral replacement cage, an L2-L4 laminectomy, and L3-L5 fusion due severe back pain and spine instability.

American Journal of Medical Case Reports. 2015, 3(5), 137-140. DOI: 10.12691/ajmcr-3-5-5
Pub. Date: April 24, 2015

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Late Onset Ornithine Transcarbamylase Deficiency Accompanying Severe HyperammonemiaAfter Cesarean Section: Case Report

by Birsen Dogu, Nezir Yılmaz, Sabriye Ozcekic and Hafize Oksuz

Case Report

Hyperammonemia is one of the common complications of porto-systemic shunt or liver failure. In patients without liver failure or porto-systemic shunt, hyperammonemia can be caused by urea cycle disorders. Nitrogen excretion pathway or enzyme deficiency disorder can result in any hyperammonemia, coma, or death that may cause severe clinical encephalopathy presenting with neurological symptoms. The most common cause of genetic disorders in the urea cycle is ornithine carbamoyltransferase deficiency. In this article, 28-year-old female patient who had late-onset ornithine carbamoyltransferase deficiency with severe acute hyperammonemia resulting coma and death after cesarian section is described. In addition, treatment of hyperammonemia including sodium benzoate, arginine, and hemodialysis were discussed.

American Journal of Medical Case Reports. 2015, 3(5), 133-136. DOI: 10.12691/ajmcr-3-5-4
Pub. Date: April 23, 2015

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Rheumatoid Arthritis: An Exceptional Complication of Chemotherapy in a Patient with Lung Cancer

by Tse-Hao Lee, Rong-Hsin Yang and Yum-Kung Chu

Case Report

A 63-year-old non-smoker, without previous history of arthritis, developed inflammatory arthritis while being treated with pemetrexed/cisplatin combination for advanced lung cancer. Clinical features and serology fulfilled the 2010 ACR/EULAR criteria for the diagnosis of rheumatoid arthritis (RA). RA is an autoimmune disease that primarily attacks joint tissues, causing inflammation of the joint lining. Although the relationship between these anticancer agents and the presence of RA remains unclear, this unprecedented adverse effect can be corrected by changing therapeutic strategies. Our case report might open a medical debate about chemotherapy side effect in cancer patients.

American Journal of Medical Case Reports. 2015, 3(5), 130-132. DOI: 10.12691/ajmcr-3-5-3
Pub. Date: April 22, 2015

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Gallstone Ileus-A Case Report with Review of the Literature

by Christos Konstantinidis, Aleksandros Hamzin and Ioannis Stefanidis

Case Report

A 64 years-old female patientreferred to our hospital for further treatmentof gallstone ileusdiagnosed at another hospital. She had a past medical history of thyroidectomy and mild heart failure. After four days of conservative treatment she underwent scheduled laparotomy with enterolithotomy and stone extraction. Although the operation was uneventful, immediately after that in the recovery room the patient presented severe ARDS with pulmonal edema and acute renal failure. The patientdeceased two days later.

American Journal of Medical Case Reports. 2015, 3(5), 126-129. DOI: 10.12691/ajmcr-3-5-2
Pub. Date: April 22, 2015

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Successful Treatment of Nocardia Farcinica Prosthetic Valvular Endocarditis without Valvular Replacement

by Margret Jona Einarsdottir, Hildur Gudmundsdottir, Bjarni Torfason, Anna Thorisdottir, Karl Andersen, Thordis Jona Hrafnkelsdottir and Sigurdur Gudmundsson

Case Report

We report a case of prosthetic valve nocardia endocarditis. A 43 year old farmer underwent aortic valve replacement with a bioprosthetic valve. The immediate post-operative course was uneventful but 2 weeks later he developed fever. A trans-oesophageal echocardiogram (TEE) showed a string like structure attached to the prosthetic valve. Blood cultures grew N. farcinica. He was initially treated with trimethoprim/sulfamethoxazole (TMP/SMZ), but due to eosinophilia and leucopenia his treatment was changed to imipenem and amikacin. He developed a rash, presumed to be due to imipenem, which was then substituted with linezolid. He completed a 6 week course of intravenous (i.v.) antibiotics. Desensitization with amoxicillin/clavulanic acid was successful and the patient received oral amoxicillin/clavulanic acid for 6 months. At present, 12 months from diagnosis, he is afebrile and TEE is normal. To our knowledge, this case is the fifth reported case of successful treatment of prosthetic valve nocardia endocarditis treated without surgery.

American Journal of Medical Case Reports. 2015, 3(5), 121-125. DOI: 10.12691/ajmcr-3-5-1
Pub. Date: April 21, 2015

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