Clinical Case Studies

[Michael Scally MD]

Pigac B, Masic S. Colonic Perforation in a Young Tetraplegic Male Caused by Zucchini. Medical Archives 2016;70(5):395-7. Colonic Perforation in a Young Tetraplegic Male Caused by Zucchini

INTRODUCTION: Colonic perforation is a clinical condition which occurs due to variety of reasons, such as intrinsic disorders of the intestine, extrinsic causes, but also due to presence of foreign bodies. Foreign objects enter gastrointestinal tract by oral or transanal introduction.

CASE REPORT: We present an uncommon case of a 26- year-old tetraplegic male, whose death was a consequence of a widespread purulent peritonitis provoked by colonic perforation inflicted by an unusual foreign body, transanally introduced 28 centimeters long zucchini (Cucurbita pepo L.).

CONCLUSIONS: We share our experience in order to emphasize the importance of consideration and early recognition of foreign body presence in the alimentary tract as possible diagnosis.

 

[Michael Scally MD]

Virilisation In Siblings Secondary To Transdermal 'Bioidentical' Testosterone Exposure.

Precocious puberty is the development of secondary sexual characteristics before the age of 8 years in girls (onset of thelarche) and 9 years in boys (increase in testicular volume). Clinical and biochemical assessment is directed at determining whether the underlying process is gonadotrophin-dependent (central precocious puberty (CPP)), associated with activation of the hypothalamic-pituitary-gonadal (HPG) axis, or gonadotrophinindependent (peripheral precocious puberty (PPP)) which is characterised by elevated sex steroids but low gonadotrophin levels.

The siblings were a 5-year 9-month old boy (Patient 1, PT1) and his 4-year 6-month old sister (Patient 2, PT2). PT1 was referred for concerns regarding increasing aggression and onset of masturbatory behaviour. There had also been gradual phallic enlargement, development of pubic and axillary hair and acceleration in growth velocity over a period of 18 months.

On examination, PT1 had no cutaneous stigmata or increased pigmentation, his blood pressure was within the age-specific range, there were no abdominal or pelvic masses, and his neurological examination was unremarkable. His height was >97th percentile, weight >97th percentile. He had Tanner stage 3 genital (G3) development with increased scrotal size and rugosity, and a stretch penile length of 8.5 cm (>90th percentile) (Fig. 1). He had Tanner stage 2–3 pubic hair (PH2–3), and some early axillary hair (A1–2). His testicular volumes were pre-pubertal (2 mL on the left and 2–3 mL on the right).

During the consultation, the parents revealed that PT2 had also developed emotional lability and onset of pubic hair development. Her examination revealed Tanner stage 2 pubic hair (PH2), no axillary hair (A1) and obvious clitoral enlargement.

Both children had elevated testosterone concentrations (PT1 2.2 nmol/L and PT2 4.2 nmol/L), pre-pubertal gonadotrophin levels, negative tumour markers (hCG and AFP) and normal baseline 17-hydroxyprogesterone (17-OHP) levels.

A diagnosis of virilisation secondary to exogenous testosterone exposure was made.

The father subsequently admitted to using transdermal 15% liposomal testosterone cream, a bioT prepared by a local compounding service specialising in complementary medicines, for the past 2.5 years.

This had been prescribed by his general practitioner, unbeknownst to his wife, for decreased energy levels and declining libido. There had been no biochemical assessment for andropause prior to commencement of the bioT. He denied having been warned about the importance of washing his hands after applying the bioT, and avoiding skin-to-skin contact with others – either by his general practitioner or the compounding service. His testosterone concentration measured in the late afternoon, approximately 3 h before the nightly application of bioT cream, was 45.9 nmol/L (11.0–40.0).

The parents were advised of the importance of ensuring no further exposure to the bioT cream. Over the subsequent months, both children experienced a normalisation of their behaviour and measured testosterone concentrations were within the prepubertal ranges.

Huynh T, Stewart CI. Virilisation in siblings secondary to transdermal 'bioidentical' testosterone exposure. J Paediatr Child Health. Virilisation in siblings secondary to transdermal ‘bioidentical’ testosterone exposure

 

[Michael Scally MD]

[OA] Management Of Screwdriver-Induced Penetrating Brain Injury

BACKGROUND: Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with long and electric screwdriver is a peculiar accident and is relatively rare. Because of its rarity, the treatments of such injury are complex and nonstandardized.

CASE PRESENTATION: We presented a case of a 54-year-old female who was stabbed with a screwdriver in her head and accompanied by loss of consciousness for 1 h. Computer tomography (CT) demonstrated that the screwdriver passed through the right zygomatic bone to posterior cranial fossa. Early foreign body removal and hematoma evacuation were performed and the patient had a good postoperative recovery.

CONCLUSIONS: In this study, we discussed the clinical presentation and successful management of such a unique injury caused by a screwdriver. Our goal is to demonstrate certain general management principles which can improve patient outcomes.

Shi J, Mao Y, Cao J, Dong B. Management of screwdriver-induced penetrating brain injury: a case report. BMC Surg 2017;17(1):3. Management of screwdriver-induced penetrating brain injury: a case report

a. Clinical picture showing a screwdriver penetrating the right cheekbone.
b. Computed tomogram (CT) of brain showing the metallic foreign body with metal artefacts.
c-d. CT of head-brain window showing a metallic foreign body passed through the right cheekbone to posterior cranial fossa.
e-f. CT scan showing left cerebellar hematoma and subarachnoid hemorrhage

 

[CdnGuy]

Interesting....

https://www.sciencedaily.com/releases/2017/01/170125145900.htm

 

[Michael Scally MD]

Baber Y, Bott E. Natural death in the setting of autoerotic practice. Forensic Sci Med Pathol ;12(2):174-7. Natural death in the setting of autoerotic practice

Deaths in an autoerotic setting are usually due to accidental asphyxia, in which the individual accidently hangs or strangles themselves while inducing hypoxia for the purpose of heightened arousal.

Death occurs when the level of hypoxia causes the individual to lose consciousness and is thus unable to prevent the neck compression from becoming lethal.

In some cases there is an "escape" mechanism incorporated into the set-up which may fail. In rare cases, death is not as an immediate result of the autoerotic activity and is as a result of natural causes, which may or may not be related to the process.

This case demonstrates the death of a 69 year old male which has occurred in the setting of a complex autoerotic environment, not as a result of asphyxiation, but rather as a result of natural causes which is likely to have been brought about by repeated similar activity.

The autopsy revealed pulmonary emboli and lower limb deep vein thrombosis. There was no other natural disease of note and no features considered typical of asphyxiation.

 

[Michael Scally MD]

Rose G, Costa V, Drake A, Siadecki SD, Saul T. Ultrasound-guided dorsal penile nerve block performed in a case of zipper entrapment injury. J Clin Ultrasound. Ultrasound‐guided dorsal penile nerve block performed in a case of zipper entrapment injury

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure.

 

[ronin17]

Pigac B, Masic S. Colonic Perforation in a Young Tetraplegic Male Caused by Zucchini. Medical Archives 2016;70(5):395-7. Colonic Perforation in a Young Tetraplegic Male Caused by Zucchini

INTRODUCTION: Colonic perforation is a clinical condition which occurs due to variety of reasons, such as intrinsic disorders of the intestine, extrinsic causes, but also due to presence of foreign bodies. Foreign objects enter gastrointestinal tract by oral or transanal introduction.

CASE REPORT: We present an uncommon case of a 26- year-old tetraplegic male, whose death was a consequence of a widespread purulent peritonitis provoked by colonic perforation inflicted by an unusual foreign body, transanally introduced 28 centimeters long zucchini (Cucurbita pepo L.).

CONCLUSIONS: We share our experience in order to emphasize the importance of consideration and early recognition of foreign body presence in the alimentary tract as possible diagnosis.

This one is kind of sad being he was in a wheelchair. I would of paid for the guys time with an escort.

At least he was consuming his vegetables ha ha.

 

[BBC3]

Looks like a REAL John Bobbet.. But she did not toss the driver in the FIELD.. CrAZY BITHCHEZ....

take yer dik when its a cumin to ya> pos cuntz...!

[OA] Management Of Screwdriver-Induced Penetrating Brain Injury

BACKGROUND: Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with long and electric screwdriver is a peculiar accident and is relatively rare. Because of its rarity, the treatments of such injury are complex and nonstandardized.

CASE PRESENTATION: We presented a case of a 54-year-old female who was stabbed with a screwdriver in her head and accompanied by loss of consciousness for 1 h. Computer tomography (CT) demonstrated that the screwdriver passed through the right zygomatic bone to posterior cranial fossa. Early foreign body removal and hematoma evacuation were performed and the patient had a good postoperative recovery.

CONCLUSIONS: In this study, we discussed the clinical presentation and successful management of such a unique injury caused by a screwdriver. Our goal is to demonstrate certain general management principles which can improve patient outcomes.

Shi J, Mao Y, Cao J, Dong B. Management of screwdriver-induced penetrating brain injury: a case report. BMC Surg 2017;17(1):3. Management of screwdriver-induced penetrating brain injury: a case report

a. Clinical picture showing a screwdriver penetrating the right cheekbone.
b. Computed tomogram (CT) of brain showing the metallic foreign body with metal artefacts.
c-d. CT of head-brain window showing a metallic foreign body passed through the right cheekbone to posterior cranial fossa.
e-f. CT scan showing left cerebellar hematoma and subarachnoid hemorrhage

View attachment 59300

 

[BBC3]

SO HE LITERALLY JACKED-HEEMSELF-SENSELESS-&-WITH-AN-ASSIST...!?!?!?

LOOK - I found a whopper of a VIBRATOR in my mom's dresser droor theother day and she's 75... Yea imagine my SURPRISE.......!

If I ever DIE oddly. There are a few chosen folks that know what should be writtin on my cock and forehead,, LOL Else send DEXTER>...

Baber Y, Bott E. Natural death in the setting of autoerotic practice. Forensic Sci Med Pathol ;12(2):174-7. Natural death in the setting of autoerotic practice

Deaths in an autoerotic setting are usually due to accidental asphyxia, in which the individual accidently hangs or strangles themselves while inducing hypoxia for the purpose of heightened arousal.

Death occurs when the level of hypoxia causes the individual to lose consciousness and is thus unable to prevent the neck compression from becoming lethal.

In some cases there is an "escape" mechanism incorporated into the set-up which may fail. In rare cases, death is not as an immediate result of the autoerotic activity and is as a result of natural causes, which may or may not be related to the process.

This case demonstrates the death of a 69 year old male which has occurred in the setting of a complex autoerotic environment, not as a result of asphyxiation, but rather as a result of natural causes which is likely to have been brought about by repeated similar activity.

The autopsy revealed pulmonary emboli and lower limb deep vein thrombosis. There was no other natural disease of note and no features considered typical of asphyxiation.

 

[BBC3]

OH GOWD DAMNB...! Just knock the MOFO out and PULL that fuckin zipper back apart....

Rose G, Costa V, Drake A, Siadecki SD, Saul T. Ultrasound-guided dorsal penile nerve block performed in a case of zipper entrapment injury. J Clin Ultrasound. Ultrasound‐guided dorsal penile nerve block performed in a case of zipper entrapment injury

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure.

 

[Michael Scally MD]

Gynecomastia: Look Beyond The Obvious [Low Grade Superficial Urothelial Carcinoma Of The Bladder]

A 29-year-old man was referred to our clinic with a 4-week history of a tender predominant left breast enlargement without nipple discharge. He had been practicing bodybuilding regularly since years, but denied taking anabolic androgenic steroids. His past medical history was unremarkable apart from surgical treatment of undescended testes in childhood. His sexual desire and erectile function were normal. He had no family history of breast or testicular cancer.

Physical examination confirmed small palpable masses of tissue predominantly in the left breast.

Ultrasound of the breast and mammography showed the typical appearance of gynecomastia without features of malignancy. Serum chemistry and complete blood count were all in normal range. Hormonal studies showed normal plasma levels of prolactin, thyroid-stimulating hormone (TSH) and cortisol. Testosterone was in the high-normal range and his estradiol was elevated, while the gonadotropins were suppressed.

The tumor marker α-fetoprotein was normal, human chorionic gonadotropin (hCG) was elevated.

Pusl T, Stoemmer P. Gynecomastia: look beyond the obvious. Am J Med. http://www.amjmed.com/article/S0002-9343(17)30489-8/abstract

 

[Michael Scally MD]

[OA] Beta-Human Chorionic Gonadotropin-Secreting Intracranial Germ-Cell Tumor Associated with High Testosterone

A 38-year-old male patient presented with general weakness, polydipsia and a body weight loss of 10 kg in two years. Hypopituitarism with central hypothyroidism and central adrenal insufficiency were noted at Taipei City Hospital (Taipei, Taiwan). However, HYPOGONADOTROPIC HYPERGONADISM was also observed.

The patient was diagnosed with an intracranial beta-human chorionic gonadotropin (beta-hCG) secreting germ-cell tumor, and brain magnetic resonance imaging revealed that the tumor involved the pineal gland, stalk, posterior pituitary gland, right basal ganglion, hypothalamus, corpus callosum and posterior hippocampus.

The cerebrospinal fluid (CSF) beta-hCG level was 1936 IU/l, while the alpha-fetoprotein (AFP) level was <0.24 ng/ml. The serum AFP level of the patient was 3.28 ng/ml, and the beta-hCG level was 178 IU/l with a CSF:serum beta-hCG ratio >2:1.

The patient was successfully treated with chemotherapy and radiotherapy, as demonstrated by a marked decrease in size of the tumor and in the serum beta-hCG levels.

Intracranial beta-hCG secreting germ-cell tumors are rare in adults and manifest differently compared with patients of early pubertal age. In contrast with the precocious puberty frequently observed in young patients, the diagnosis of adult patients is often delayed and the symptoms are associated with tumor size and location.

The present case report described an adult male with an intracranial beta-hCG secreting GCT, demonstrating hypopituitarism and asymptomatic hyperandrogenemia, and reviews and discusses the literature relevant to the case.

Yang WP, Chien HY, Lin YC. beta-human chorionic gonadotropin-secreting intracranial germ-cell tumor associated with high testosterone in an adult man: A case report. Oncol Lett 2017;14(1):1129-32. https://www.spandidos-publications.com/10.3892/ol.2017.6213

 

[Michael Scally MD]

[OA] A Case of Male Osteoporosis: A 37-Year-Old Man with Multiple Vertebral Compression Fractures

While the contributing role of testosterone to bone health is rather modest compared to other factors such as estradiol levels, male hypogonadism is associated with low bone mass and fragility fractures.

Along with stimulating physical puberty by achieving virilization and a normal muscle mass and improving psychosocial wellbeing, the goals of testosterone replacement therapy in male hypogonadism also include attainment of age-specific bone mineral density.

We report on a 37-year-old man who presented with multiple vertebral compression fractures several years following termination of testosterone replacement therapy for presumed constitutional delay in growth and puberty.

Here, we discuss the management of congenital hypogonadotropic hypogonadism with hyposmia (Kallmann syndrome), with which the patient was ultimately diagnosed, the role of androgens in the acquisition of bone mass during puberty and its maintenance thereafter, and outline specific management strategies for patients with hypogonadism and high risk for fragility fractures.

Radi S, Karaplis AC. A Case of Male Osteoporosis: A 37-Year-Old Man with Multiple Vertebral Compression Fractures. Case Rep Endocrinol. https://www.hindawi.com/journals/crie/2017/6328524/

 

[Michael Scally MD]

[OA] Female with 46, XY Karyotype

Disorders of sex development (DSD) are congenital conditions characterized by atypical development of chromosomal, gonadal, and phenotypic sex.

46, XY DSD can result from disorders of testicular development or disorders of androgen synthesis/action.

Prophylactic gonadectomy should be considered in patients with 46, XY DSD because of the increased risk of gonadal malignancy.

We report two rare cases of 46, XY DSD, including XY pure gonadal dysgenesis and complete androgen insensitivity syndrome, who underwent a prophylactic gonadectomy.

Jung EJ, Im DH, Park YH, et al. Female with 46, XY karyotype. Obstetrics & Gynecology Science. 2017;60(4):378-82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547087/

 

[Michael Scally MD]

Liu Z, Hou X, Fan X, Hu Y, Liu G. Car Windshield Wiper in the Brain: Case Report. Surg J (N Y) 2016;2(2):e42-e5. https://www.thieme-connect.de/products/ejournals/html/10.1055/s-0036-1584170

Background Transorbital intracranial penetrating injury is rare. Damage caused by a huge metallic foreign body is very critical and life-threatening.

Method We report an extremely rare case of transorbital intracranial penetrating metal strip (a car windshield wiper), which has not previously been reported in the literature.

Results Emergency craniotomy was performed; the object was removed successfully, and the patient's life was saved [in a vegetative state!].

Conclusion With the life-threatening penetrating brain injury caused by a huge foreign body, prompt surgical treatment and comprehensive postoperative treatment are important to save patients' lives.

 

[grey]

Results Emergency craniotomy was performed; the object was removed successfully, and the patient's life was saved [in a vegetative state!]

Not sure I would count being able to keep the meat sack itself rolling without brain function as a win in this one...

 

[Michael Scally MD]

Nguyen SM, Ko Ko N, Sattar AS, et al. Pulmonary Embolism Secondary to Testosterone-Enhancing Herbal Supplement Use. Cureus 2017;9(8):31545. http://assets.cureus.com/uploads/case_report/pdf/7068/1503088533-20170818-4-hik5t8.pdf

Decreased testosterone levels in men are often a normal sign of aging. Testosterone replacement therapy (TRT) is a well-established option for those with symptomatic hypogonadism related to low testosterone levels. Conversely, designer herbal supplements in the context of testosterone supplementation are poorly studied, yet remain popular among aging men who seek the well-known, often enhancing, effects of testosterone that involve muscle mass and sexual function/drive.

In 2014, the Food and Drug Administration (FDA) issued a warning about the significant risk of venous clots secondary to testosterone product use. Testosterone-induced polycythemia is one of the proposed mechanisms for this increased clotting propensity. Increased thromboxane A2 receptor density on platelets and increased platelet aggregation have also been linked to testosterone treatment in men.

Fenugreek extract is a common active ingredient in commercially available herbal supplements that are often marketed as testosterone enhancers. It is thought that certain fenugreek compounds inhibit aromatase and 5-alpha-reductase activity, leading to diminished testosterone breakdown. However, the efficacy and safety profile of this agent in its use for boosting testosterone levels are unclear.

In this case report, we present a patient with new-onset, bilateral pulmonary embolism possibly associated with the daily use of fenugreek-containing testosterone supplements.

 

[Michael Scally MD]

[OA] Induction of Puberty with Human Chorionic Gonadotropin (hCG) Followed by Reversal of Hypogonadotropic Hypogonadism in Kallmann Syndrome

INTRODUCTION: Kallmann syndrome (KS) is a rare, congenital disorder combining hypogonadotropic hypogonadism (HH) due to GnRH-deficiency with anosmia. Traditionally thought to require lifelong therapy it turns out to be a reversible condition in some patients.

CASE REPORT: We present a case of a 22-year old man with absent puberty due to KS, in whom genetic testing revealed heterozygosity for a mutation in the PROK2 gene. Pubertal development and virilisation was achieved by using human chorionic gonadotropin (hCG) injections followed by testosterone replacement.

Treatment with hCG (Pregnyl®) was started with a weekly dose of 1000 IU s.c., administered as 500 IU twice weekly, gradually increased up to 7000 IU per week, resulting in a gradual increase of testosterone level as well as pubertal development. After 40 weeks of hCG treatment a satisfactory effect on virilisation and a 44% increase in combined testicular volume were achieved.

During the follow-up we observed reversal of hypogonadism allowing discontinuation of testosterone treatment. Normalisation of testicular volume as well as gonadotropin and inhibin B levels through a 2-year postreversal period was seen.

CONCLUSIONS: Treatment with hCG is effective in inducing pubertal development and may have advantage over testosterone replacement due to a potential of gonadal maturation. A regular assessment of testicular volume and biochemical surveillance including measuring of serum inhibin B and gonadotropins are necessary for a timely detection of reversal of GnRH deficiency.

Pierzchlewska, M. M., M. G. Robaczyk, et al. "Induction of puberty with human chorionic gonadotropin (hCG) followed by reversal of hypogonadotropic hypogonadism in Kallmann syndrome." Endokrynol Pol. Induction of puberty with human chorionic gonadotropin (hCG) followed by reversal of hypogonadotropic hypogonadism in Kallmann syndrome. | Pierzchlewska | Endokrynologia Polska

 

[Michael Scally MD]

[OA] Hypertestosteronemia and primary infertility from a mediastinal extragonadal germ cell tumor
http://www.endocrine-abstracts.org/ea/0050/eposters/ea0050ep061_eposter.pdf

Extragonadal germ cell tumors (EGCTs) are tumors of gonadal origin representing < 5 % of germ cell malignancies that form outside gonads. These are typically found in the mediastinum, retroperitoneum or pineal gland.

Clinical Presentation - A 26-year-old male presented to the Reproductive Endocrinology outpatient clinic, in January 2016 with a two year history of infertility. He had known hypertrophic cardiomyopathy due to MYH 7 sarcomere mutation, treated with implantable cardioverter - defibrilator while his partner was healthy.

Initial investigations performed by their GP, showed hypertestosteronemia (52.9 nmol/L, normal range 9.0 - 26.0 nmol/L) and azoospermia (0 sperm per 20ml of ejaculate). During consultation, he reported hoarseness of voice, hypersexuality, and increased hair distribution on torso and extremities over the past 3 years. He denied having used anabolic steroids or any supplements and was only on amiodarone to ameliorate arrhythmias from his hypertrophic cardiomyopathy.

On examination he had normal stature, was hirsute with bilaterally small testes (<10cc each) but no evidence of any masses during palpation. A testicular/scrotal U/S was unremarkable. Subsequent investigations revealed consistently elevated testosterone (52.9 nmol/L), β -hCG (900IU/L, normal range: < 1IU/L), oestradiol (738pmol/L, normal range: 36.7 -147pmol/L) and suppressed FSH and LH (< 1IU/L, normal FSH: 2 - 9IU/L, LH: 2 -12IU/L) while remaining tests were normal.

 

[Michael Scally MD]

[OA] An Unusual Foreign Body in the Heart [How Did It Get There!!!]

Penetrating foreign bodies in the heart is rare and may lead to life-threatening complications. Early diagnosis and removal are crucial for these rare cases. We report a case of accidental penetrating sewing needle in the right ventricle. The needle was successfully removed without open heart surgery and cardiopulmonary bypass (CPB), after accurate localization using transthoracic echocardiography (TTE).


A 14-year-old male was consulted to our department with a history of accidental sewing needle penetration through his chest. An exploration surgery had been performed 6 days before admission in the previous rural hospital without knowing the exact location of the needle, thus end as a failure. Vital signs were normal.

A simple chest X-ray displayed a needle in the chest (Fig. 1). The needle was demonstrated in the right ventricle using TTE (Fig. 2). One end of the needle was seen embedded into the lateral wall of the right ventricle and the other end was embedded into the interventricular septum, near to the apex.

Furthermore, a median sternotomy was performed. The needle ends were not visible on the cardiac surface. Nevertheless, the needle was palpated in the right ventricular wall. We gently pushed the needle without incising the muscle, grasped with an anatomical forceps, and pulled out from the apex (Fig. 3). Postoperative TTE showed no abnormality and the patient was discharged from the hospital 4 days after the surgery.

Darmawan H. An Unusual Foreign Body in the Heart: A Case Report. Ann Thorac Cardiovasc Surg. An Unusual Foreign Body in the Heart: A Case Report