Zeitschrift für klinische Fallberichte

Large clinical trials have established the superiority of carotid endarterectomy for stroke prevention in patients with symptomatic critical carotid artery stenosis. Although postoperative complications are commonly ischemic, cerebral hyperperfusion syndrome represents a rare but potentially treatable diagnosis. Outcomes are contingent on early identification, prevention and management of precipitating factors. Herein, we report the case of a patient who presented with altered mentation, hemiparesis, aphasia and seizures, nine days after left carotid endarterectomy. The underlying pathophysiological mechanism, associated risk factors, screening, prevention and management of cerebral hyperperfusion syndrome are discussed.

HIV-Associated Dementia has since the 1980’s been identified as a part of the AIDS complex. While it was once a common finding in AIDS patients, it has been infrequently diagnosed in developed nations since the introduction of highly active anti-retroviral therapy (HAART). We present a case of a 28-year-old man with an 11-year history of poorly controlled HIV who was found to have HIV-Associated Dementia.

Tetanus is a life-threatening disease caused by the anaerobic spore-forming bacterium, Clostridium tetani, which produces a potent neurotoxin responsible for symptoms upon entering a susceptible host. Herein, we present a 5-day-old male neonate, delivered by spontaneous vaginal delivery who presented with a three-day history of provoked episodes of spasms associated with refusal to breastfeed and excessive crying. He was born to an 18-year old first-time mother who did not receive tetanus toxoid containing vaccines (TTCV) during her antenatal care visits. He had active spasms and his oxygen saturation was at 98% on 1 litre of oxygen/min via nasal prongs. The umbilical cord stump had purulent discharge. He was admitted to intensive care unit, initiated on phenobarbital, metronidazole and continued oxygen therapy. He didn’t receive TTCV, tetanus immunoglobulin and eventually expired on day 7 of life. Maternal TTCV immunization, skilled birth attendance and proper umbilical stump care are key in the prevention of neonatal tetanus.

Kaposi’s sarcoma (KS) is the most prevalent malignancy in patients with HIV infection. few reports describe KS in HIV-negative, non-immune compromised patients in the United States, but the incidence of the disease in the area of middle east in non-HIV, Immunocompetent is not well recognized. It affects the endothelial cells of the skin and mucous membranes. The cases seen in HIV-negative men were less aggressive and rapidly progressing than those in people with HIV. However, although, they tended to be more malicious than in the classical type of KS which is seen mostly in men of Mediterranean origin and occurred at an earlier age. We are presenting a rare case of Mucocutaneous KS diagnosed based on histopathology in an 82-year-old Yemeni male patient, who is seronegative HIV, non-immunocompromised with no history of organ nor bone marrow transplantation.

Thromboembolism in patients with nephrotic syndrome is a well-known complication because of a hypercoagulable state. It is rather rare that cerebral venous sinus thrombosis is reported as a complication in nephrotic syndrome, which could have potentially fatal consequences. There is a sub-diagnosis of this disease due to non-specific signs, and symptoms that may be like headache, vomiting, drowsiness, and altered behavior. Considering this, sinus vein thrombosis should always be considered in children with nephrotic syndrome, early clinical suspicion, and early detection, and management with anticoagulants result in satisfying outcomes. Here, we describe the case of a male child, two years and six months year-old, in the background; the child suffers from nephrotic syndrome and has been treated with steroids for four months. He was admitted with weakness, drowsiness, and refusing to eat, after full investigation was done, he was diagnosed with sinus vein thrombosis.

Ziel: Untersuchung der klinischen Merkmale und Herausforderungen bei der Behandlung einer Infektion mit Streptokokken der Gruppe B (GBS) bei Neugeborenen und Säuglingen.

Methoden: Klinische Daten zu Infektionen mit Streptokokken der Gruppe B bei Neugeborenen und Säuglingen (≤ 3 Monate alt), die zwischen Mai 2015 und Januar 2018 im Kinderkrankenhaus der Zhejiang University School of Medicine, Abteilung für Neonatologie, aufgenommen wurden, wurden retrospektiv analysiert. Die klinischen Merkmale der Infektion mit Streptokokken der Gruppe B, die Schwierigkeiten bei ihrer Behandlung und ihre Prognose wurden analysiert.

Ergebnisse: Insgesamt wurden 52 Patienten untersucht, davon 29 Jungen und 23 Mädchen. 39 Neugeborene waren zwischen 0 und 28 Tage alt und 13 Säuglinge zwischen 29 und 90 Tage. Das Erkrankungsalter lag in 15 Fällen unter 7 Tagen und in 37 Fällen über 7 Tagen. Es gab 12 Frühgeborene und 40 voll ausgetragene Säuglinge. Die durchschnittliche Dauer vom Erkrankungsbeginn bis zur Einlieferung ins Krankenhaus betrug zwischen einem halben und einem Tag. Die durchschnittliche Dauer des Krankenhausaufenthalts betrug in der Sepsis- und der Meningitisgruppe 12,45 ± 5,28 bzw. 36,27 ± 17,68 Tage. Die wichtigsten klinischen Manifestationen in der Sepsisgruppe waren Fieber (77,27 %), schlechte Ernährung, vermindertes Schreien und weniger Bewegung (59,09 %) und schließlich Atemnot (27,27 %), während in der Meningitisgruppe Fieber (96,15 %), schlechte Ernährung, vermindertes Schreien und weniger Bewegung (92,31 %), eine Vorwölbung der vorderen Fontanelle oder Krampfanfälle (50 %) auftraten. In 45,83 % der Fälle wurde eine Abnahme der weißen Blutkörperchen (WBC) beobachtet, in 22,92 % der Fälle eine Zunahme und die restlichen 31,25 % lagen im normalen Bereich, die Häufigkeit einer Thrombozytopenie war unter 10,42 % und das C-reaktive Protein war in beiden Gruppen signifikant erhöht. Die Genesungszeit des C-reaktiven Proteins war in der Sepsisgruppe jedoch signifikant kürzer als in der Meningitisgruppe (7,33+3,31 Tage, 14,96+9,55 Tage, P < 0,01). Manifestationen der Zerebrospinalflüssigkeit: Beim Vergleich der kranialen MRT von zerebral verletzten und normalen Patienten wurde ein signifikanter Unterschied in der jeweiligen ZSF-Zellzahl (3964+4279/ul, 1745+2396/uL, P<0,05), dem Zuckerspiegel (0,94+0,9 mmol/l, 1,80+0,999 mmol/l, P<0,01), dem Proteingehalt (5366,0+1486,8 mg/l, 1591,6+860,2 mg/l, P<0,01) und dem positiven Bakterienausstrich (60 %, 7 %, P<0,01) festgestellt. Arzneimittelempfindlichkeit: 52 Fälle von GBs waren zu 100 % empfindlich gegenüber Ampicillin, Penicillin, Vancomycin, Linezolid und Tigecyclin. Alle Patienten waren resistent gegen Clindamycin, 84,61 % gegen Tetracyclin und 23,08 % gegen Levofloxacin oder Ciprofloxacin.

Diskussion: In der Sepsisgruppe wählten 68,2 % (15/22) eine Kombination aus Penicillin oder Ampicillin + Cephalosporin, während in der Meningitisgruppe 73,1 % (19/26) der Kinder eine Kombination aus entweder (a) Penicillin oder Ampicillin + Ceftriaxon oder Cefotaximpalmat oder (b) Vancomycin, Meropenem erhielten. Patienten, bei denen sich die Zerebrospinalflüssigkeit nur langsam erholte oder die zwei Wochen nach der ersten Antibiotikabehandlung wiederkehrendes Fieber hatten, erhielten zusätzlich zu ihrer Basisbehandlung Vancomycin oder Linezolid oder Rifampicin. Zwei Patienten in der Gruppe mit der lokalen Infektion erhielten keine systemischen Antibiotika, und zwei Patienten entschieden sich für eine Monoantibiotikatherapie. 8. Komplikationen und Prognose: Alle Patienten in der Sepsisgruppe erholten sich und erfüllten die Entlassungskriterien, 4/22 erlitten einen Schock, 4/22 ein Atemnotsyndrom, 1/22 hatte eine toxische Enteroparalyse als Komplikation(en). In der Meningitis-Gruppe konnten 92,3 % (24/26) der Patienten das Krankenhaus mit normalen oder verbesserten Ergebnissen in der Zerebrospinalflüssigkeit (31,38 (+19,82 Tage)) verlassen, 1 Kind wurde ohne Genesung entlassen und 1 Kind verstarb bedauerlicherweise; 10/26 von ihnen hatten eine ausgedehnte Hirnverletzung, 6/26 hatten einen subduralen Erguss, 4/26 hatten einen Schock, 3/26 hatten eine Leberverletzung und 2/26 hatten eine Hirnhernie.

Schlussfolgerung: GBS-Infektionen bei Neugeborenen und Säuglingen können Sepsis, Meningitis, Atemnotsyndrom, Harnwegsinfektionen, Haut- und Nabelinfektionen verursachen, die rasch fortschreiten und daher dringend medizinisch behandelt werden müssen. Besonders schwierig ist die Behandlung einer eitrigen Meningitis durch Streptokokken der Gruppe B, die zu einem längeren Krankenhausaufenthalt führt und ein hohes Risiko für schwerwiegende neurologische Komplikationen birgt. Die Autoren sind der Ansicht, dass während der Schwangerschaft und auch während des Stillens auf die Untersuchung der Haut, der Nabelschnur und der Mundhöhle von Neugeborenen auf Streptokokken der Gruppe B (GBs) geachtet werden sollte, um einer Infektion frühzeitig vorzubeugen.

Aim: To report a rare case of valsalva retinopathy in adult following a cardiopulmonary resuscitation.

Case report: A 35-year-old man admitted to intensive care unit for acute exacerbation of bronchial asthma secondary to pneumonia and received cardiopulmonary resuscitation during the admission. Post extubation, he noted bilateral central reduce vision with visual acuity of 6/60 in the right eye and 6/24 in the left eye. Fundus examination showed bilateral pre-macular haemorrhage. Patient was treated conservatively and regain normal vision after six weeks with complete resolution of the pre-retinal haemorrhage.

Conclusion: Valsalva retinopathy is a well-described phenomenon which happen due to increase intrathoracic pressure causing rise in intravenous ocular pressusre leading to rupture of retinal capillaries. A pre-retinal haemorrhage in the macula is the usual finding at presentation. Although it involved the central area of macula, prognosis is good as seen in this case complete anatomical improvement is observed within months.

We reported a case of Wunderlich’s syndrome in a patient with massive retroperitoneal haemorrhage who was admitted to the Emergency Department with acute onset right flank pain that began in the previous 2 days. During the stay in ED, unstable hemodynamics were occurred due to haemorrhagic shock and nephrectomy was planned. In the postoperative period, the patient had good convalescent and no complications were detected. After 10 days of follow-up, the patient was hemodynamically stable, blood laboratory results were normal and the patient was discharged. In addition, no hemorrhage, no metastasis and no recurrence were observed at the end of the 6-months follow-up.

Background: Immune checkpoint inhibitors have emerged as a valuable therapeutic option in many types of advanced cancer, including small cell lung cancer. However, more research and data are still needed to understand how to better combine and sequence immunotherapy with classical chemotherapy agents in order to improve survival. Moreover, identifying and managing immune-related adverse events is still challenging.

Case presentation: We report a case of a recurrent small cell lung cancer. The patient was referred for inclusion in a clinical trial after progression of the disease despite two lines of therapy. After discontinuing both the nivolumab and ipilimumab treatment because of grade 3 hepatitis and grade 2 pneumonitis, and also after progression to a fourth line treatment with chemotherapy, the patient was rechallenged with compassionate use nivolumab monotherapy. This therapy was discontinued due to SOX1-positive dysarthria-clumsy-hand syndrome, which improved with corticosteroid therapy. After almost one year, the tumor remained stable reinforcing the idea that the cause of the complication was an immune-related encephalitis due to anti-PD1. Despite the severe toxicity, the patient achieved a long-term survival of almost four years.

Conclusion: The remarkable long-term survival obtained with immunotherapy rechallenge in this small cell lung cancer patient is promising for its future use in this setting characterized by a poor prognosis. However, immunotherapy rechallenge is not without risks. In fact, this is also the first case report on SOX1-positive autoimmune encephalitis due to anti-PD1. It also highlights the need of a careful diagnosis and therapy monitoring to prevent and mitigate potential irAEs.

Megalencephaly is a neuronal migration disorder characterized by an abnormally large brain. Numerous associated syndromes and various molecular mutations have been identified as an etiology for megalencephaly, however, SCN2A mutations have not been previously described. This report highlights a case of a term male megalencephalic neonate who presents with intractable seizures, who was found to have SCN2A gene variant that has now been identified as pathogenic. This patient expands our knowledge of the phenotypic spectrum of SCN2A mutations by adding consideration for macroscopic brain findings. Currently, we have no direct link between SCN2A mutations and megalencephaly, but our patient highlights the potential overlap in disease processes. It is possible that the biochemical disturbance associated with abnormal neuronal migration also affects the neuronal circuitry, thus increasing the propensity for electrical dysfunction and manifesting as seizures.