Clinical Case Studies

[Michael Scally MD]

Syed F, Mena-Gutierrez A, Ghaffar U. A Case of Iced-Tea Nephropathy. New England Journal of Medicine. 2015;372(14):1377-8. http://www.nejm.org/doi/full/10.1056/NEJMc1414481

A 56-year-old man presented to the hospital in May 2014 with weakness, fatigue, body aches, and an elevated serum creatinine level (4.5 mg per deciliter [400 μmol per liter]). Review of his medical record indicated previous creatinine levels of 1.2 mg per deciliter (110 μmol per liter) in October 2013 and 2.5 mg per deciliter (220 μmol per liter) in February 2014. He had no proteinuria or hematuria.

The urine sediment was remarkable for the presence of abundant calcium oxalate crystals. He did not have a personal history of kidney stones or any family history of kidney disease. He reported not consuming ethylene glycol. He had no malabsorptive symptoms or history of gastric surgery.

On further questioning, the patient admitted to drinking sixteen 8-oz glasses of iced tea daily. Worsening renal failure with uremic symptoms necessitated the initiation of dialysis.

Owing to the rapidly progressive nature of the patient's renal failure yet normal kidney size on ultrasonography, a renal biopsy was performed, which showed many oxalate crystals, interstitial inflammation with eosinophils, and interstitial edema consistent with a diagnosis of oxalate nephropathy. The urinary oxalate excretion was elevated, at 99 mg (1100 μmol) in 24 hours (normal, 7 to 44 mg [80 to 490 μmol]).

Cases of acute oxalate nephropathy have been reported with Averrhoa carambola (star fruit), A. bilimbi (cucumber tree fruit), rhubarb, and peanuts. Our patient had none of the factors that have previously been associated with hyperoxaluria, such as gastric bypass surgery, overingestion of ascorbic acid, the use of “juicing,” or ethylene glycol poisoning.

The average daily intake of oxalate in the United States is 152 to 511 mg per day, which is higher than that recommended by the Academy of Nutrition and Dietetics (<40 to 50 mg per day).

Black tea is a rich source of oxalate, containing 50 to 100 mg per 100 ml, a level that is similar to or higher than that in many foods considered to be rich in oxalate. About 84% of tea consumed in the United States is black tea.

With 16 cups of tea daily, the patient's daily consumption of oxalate was more than 1500 mg — a level that is higher than the average American intake by a factor of approximately 3 to 10.

We speculate that oxalate nephropathy may be an underrecognized cause of renal failure. In cases of unexplained renal failure in which proteinuria is absent and abundant oxalate crystals are present in urine sediment, a thorough dietary history should be obtained, because the kidney dysfunction could be a manifestation of oxalate nephropathy from an oxalate-rich diet.

The case presented here was almost certainly due to excessive consumption of iced tea.

 

[BBC3]

SO his guts were crytalized and swollen up from tea?! While the study presents some indications which appear to correlate, THEY do NOT appear to discuss the WATER which he was mixing it with. And any potential reaction of any potential contaminates. In the south, there are quite a few folks drinking a shit load of tea in a day - although i will say that even on gluttonous days about a half gallon will tend to put you off it.... Funny world we live in now ain't it... Sounds like he did not get his share of greens... LOL

STILL - Very interesting information about TEA, and when it has been marketed an an antioxidant Holy Grail as of late.

Now go and drink just a half gallon of crystal light and prepare to wake up the next day with an AXE planted in the middle of thy skull... I must say though, I did not check the water either. Come to think, they actually shut down one of those public water sources in P'Cola a couple of years back after determining a radon contamination... That must be why I stick to BEER... LOL

Syed F, Mena-Gutierrez A, Ghaffar U. A Case of Iced-Tea Nephropathy. New England Journal of Medicine. 2015;372(14):1377-8. http://www.nejm.org/doi/full/10.1056/NEJMc1414481

A 56-year-old man presented to the hospital in May 2014 with weakness, fatigue, body aches, and an elevated serum creatinine level (4.5 mg per deciliter [400 μmol per liter]). Review of his medical record indicated previous creatinine levels of 1.2 mg per deciliter (110 μmol per liter) in October 2013 and 2.5 mg per deciliter (220 μmol per liter) in February 2014. He had no proteinuria or hematuria.

The urine sediment was remarkable for the presence of abundant calcium oxalate crystals. He did not have a personal history of kidney stones or any family history of kidney disease. He reported not consuming ethylene glycol. He had no malabsorptive symptoms or history of gastric surgery.

On further questioning, the patient admitted to drinking sixteen 8-oz glasses of iced tea daily. Worsening renal failure with uremic symptoms necessitated the initiation of dialysis.

Owing to the rapidly progressive nature of the patient's renal failure yet normal kidney size on ultrasonography, a renal biopsy was performed, which showed many oxalate crystals, interstitial inflammation with eosinophils, and interstitial edema consistent with a diagnosis of oxalate nephropathy. The urinary oxalate excretion was elevated, at 99 mg (1100 μmol) in 24 hours (normal, 7 to 44 mg [80 to 490 μmol]).

Cases of acute oxalate nephropathy have been reported with Averrhoa carambola (star fruit), A. bilimbi (cucumber tree fruit), rhubarb, and peanuts. Our patient had none of the factors that have previously been associated with hyperoxaluria, such as gastric bypass surgery, overingestion of ascorbic acid, the use of “juicing,” or ethylene glycol poisoning.

The average daily intake of oxalate in the United States is 152 to 511 mg per day, which is higher than that recommended by the Academy of Nutrition and Dietetics (<40 to 50 mg per day).

Black tea is a rich source of oxalate, containing 50 to 100 mg per 100 ml, a level that is similar to or higher than that in many foods considered to be rich in oxalate. About 84% of tea consumed in the United States is black tea.

With 16 cups of tea daily, the patient's daily consumption of oxalate was more than 1500 mg — a level that is higher than the average American intake by a factor of approximately 3 to 10.

We speculate that oxalate nephropathy may be an underrecognized cause of renal failure. In cases of unexplained renal failure in which proteinuria is absent and abundant oxalate crystals are present in urine sediment, a thorough dietary history should be obtained, because the kidney dysfunction could be a manifestation of oxalate nephropathy from an oxalate-rich diet.

The case presented here was almost certainly due to excessive consumption of iced tea.

 

[kawilt]

Love that expresso. With spring water of course.

 

[BBC3]

I would be wary of spring water FYI. It is my experience you are better off going with distilled even from walmart. You can always give it the freeze test and see if it spikes it concerned. But it has proven in quite a bit of testing for me...

I mean and what a joke legally. "Hey man, we told you it was from a spring, we can't help it that an alien shit in it last night..".. LOL

Of course, if you find Ponce's fountain of youth, bottle me some up...

AND FYI - I MEANT "THOU" in THY post above. I can't stand fucking errors any more. Life is just no fun... Not that I am correct. Just that I LIKE TO PRETEND I AM...

Love that expresso. With spring water of course.

 

[kawilt]

BBC...distilled water is dead. You know that!

 

[Michael Scally MD]

Badal J, Ramasamy R, Hakky T, Chandrashekar A, Lipshultz L. Case Report: Persistent erectile dysfunction in a man with prolactinoma. F1000Res. 2015;4:13. http://f1000research.com/articles/4-13/v1

Erectile dysfunction has been explored as a condition secondary to elevated prolactin; however, the mechanisms by which elevated prolactin levels cause erectile dysfunction have not yet been clearly established.

We here present a patient with a history of prolactinoma who suffered from persistent erectile dysfunction despite testosterone supplementation and pharmacological and surgical treatment for the prolactinoma.

Patients who have had both prolactinemia and erectile dysfunction have been reported in the literature, but we find no report of a patient with persistent erectile dysfunction in the setting of testosterone supplementation and persistent hyperprolactinemia refractory to treatment.

This case provides evidence supporting the idea that suppression of erectile function occurs in both the central and peripheral nervous systems independent of the hypothalamic-pituitary-gonadal axis.

 

[BBC3]

This is a good article you post right after some BPA information pertaining to "Xenoestrogens" in the other thread on BPA. It seems to me that I recall that while prolactin seems present in active Gyno, IT ALWAYS TAKES ELEVATED ESTROGEN to build the basic (breast tissue) physical manifestations in the breast tissue in men??

MY PROOF - I NEVER had a problem with Prolactin PRIOR to INDUCING a problem with elevated estrogens...

I have heard that before around here from others. And you USUALLY see situations where men are using steroids which CLEARLY ELEVATE ESTROGEN prior to any prolactin/gyno type issues.

I noted in YOUR PRIMER that no mention of DOPAMINE MASTERY to the potential Prolactin situation was mentioned, however, they do go there in the article and study.

1. The notion of prolactin for prolactin, or even Dopamine, and possible Serotonin imbalance is interesting. I do see where the article primes to indicate that this could be an issues OUTSIDE the involvement or influence of the HPTA.! I have seen tale in past of big believers in the notion that a Dopamine/Serotonin imbalance is the root of my misfired erection attempts. But if so even - would it be CAUSE or EFFECT...!?!

2. But is it, would it be really? You have to wonder the CHICKEN OR EGG, and would the physical manifestation of prolactin type tissue from temporary conditions CAUSE the brain to change its operating profile as an adjustment to new physical conditions. WE MUST GIVE CREDENCE to the possibility that the while the brain may inspire new cellular growth - IT MAY NOT BE SO EASY FOR IT TO TAKE IT AWAY... Thus it would have to adjust.

3. An just as above, when you INDUCE a physical world in which you brain is kinda baffled as to HOW it came to be, you MUST again consider BPA's and other estrogen mimicking contaminants in our world today. As if there is any truth to the problem what so ever, it would be like applying the SICKEST FILTHIEST ESTROGEN BASED CYCLE a man could have a nightmare about.

There is either a cover-up or general failure to "Look at the big picture" as ESTROGEN APPEARS to underlie and PRECEDE prolactin type tissue and activity.

Badal J, Ramasamy R, Hakky T, Chandrashekar A, Lipshultz L. Case Report: Persistent erectile dysfunction in a man with prolactinoma. F1000Res. 2015;4:13. http://f1000research.com/articles/4-13/v1

Erectile dysfunction has been explored as a condition secondary to elevated prolactin; however, the mechanisms by which elevated prolactin levels cause erectile dysfunction have not yet been clearly established.

We here present a patient with a history of prolactinoma who suffered from persistent erectile dysfunction despite testosterone supplementation and pharmacological and surgical treatment for the prolactinoma.

Patients who have had both prolactinemia and erectile dysfunction have been reported in the literature, but we find no report of a patient with persistent erectile dysfunction in the setting of testosterone supplementation and persistent hyperprolactinemia refractory to treatment.

This case provides evidence supporting the idea that suppression of erectile function occurs in both the central and peripheral nervous systems independent of the hypothalamic-pituitary-gonadal axis.

 

[Michael Scally MD]

Evolving Paradigm of Illnesses Presented To Medical Intensive Care Unit in Body Builders

Garg SK. Evolving paradigm of illnesses presented to medical Intensive Care Unit in body builders: Cases from tertiary care center. Indian J Crit Care Med. 2015;19(4):227-9. http://www.ijccm.org/article.asp?issn=0972-5229;year=2015;volume=19;issue=4;spage=227;epage=229;aulast=Garg

Bodybuilding is the use of progressive resistance exercise to control and develop one's musculature. With the rise in number of persons adopting this activity, there is evolving paradigm of illnesses presented to intensive care in this population subset. Strict adherence to details of bodybuilding and avoidance of unsupervised medications are essential to prevent untoward effects.

» Introduction

Bodybuilding is the use of progressive resistance exercise, and it involves drastic reductions in body fat while maintaining muscle mass. There is a tendency to think that there is a magic powder or supplement that will give you the physique of your dreams, but there is no substitute for hard work, commitment, and good diet. It requires continuous hard effort for years. It has beneficial effects also in terms of lower long-term disease risk but doing unscrupulously can be harmful and may lead to more severe illnesses, injury and even mortality.

» Case Reports

Case 1

A 35-year-old male who presented to us with a history of severe pain in both thigh and unable to walk for last around 3 days after having strenuous exercise activity in the gym. He also had vomiting and decrease oral in take thereafter. Though he was a regular visitor to the gym but he did a new exercise in the form of more than 500 sit-ups. Before visiting us, he took consultation outside and received analgesics but little relief in pain. On admission, he was conscious, maintaining vitals and having pain and tenderness in both thigh. Laboratory evaluation at time of admission showed hemoglobin (Hb) 14.8 g/dL, total leukocyte count 12,400, urea 128 mg/dL, serum creatinine 4.8 mg/dL, sodium 133 mmol/L, potassium 4.55 mmol/L, calcium 7.8 mg/dL, creatine phosphokinase (CPK) 87,000 U/L, total bilirubin 1.2 mg/dL, serum glutamic oxaloacetic transaminase (SGOT) 1160 U/L, serum glutamic pyruvic transaminase (SGPT) 404. He was passing adequate amount of urine after fluid resuscitation in the hospital. Diagnosis of rhabdomyolysis due to strenuous exercise leading to acute kidney injury was made based on the temporal profile, clinical presentation, lab reports and ruling out other common causes like severe sepsis. He required multiple sessions of dialysis during his 11 days stay in our hospital. Though he was improving, but he opted to shift to some other hospital of his nearby area.

Case 2

A 28-year-old male who was regular at the gym for bodybuilding presented to us with 1-day history of epigastric pain radiating to back, recurrent vomiting and abdominal distension. On admission his heart rate was 160 per min regular, respiratory rate was around 40 per min, blood pressure 100/80 mmHg, abdomen was diffusely distended and mildly tender. Initial lab evaluation showed Hb 18.7 g/dL, total leukocycte count 6200, serum creatinine 0.8 mg/dL, urea 34 mg/dL, sodium 138, potassium 4.3 mmol/L, total protein 6.1 g/dL, albumin 3.7 g/dL, SGOT 29, SGPT 26, alkaline phosphatase 145, lipase 104, serum amylase 760 U/L, prothrombin time (international normalized ratio) 1.23, activated partial thromboplastin time 38 s, serum calcium 9.4 mg/dL, serum triglyceride 148 mg/dL. Arterial blood gas analysis reveal pH 7.33, pCO 2 35, pO 2 80 mmHg on oxygen through face mask at 8 L/min, lactate 3.7 mmol/L. On Ultrasonography abdomen, pancreas was swollen with mild peritoneal collection, diffuses inflammatory changes with no evidence of gall stones or biliary sludge.

On detailed history including alcohol intake and examination we could not find obvious reason of acute pancreatitis other than his history of taking androgenic anabolic steroids (AAS) and protein supplements for body building since other less common causes which includes hypercalcemia, hypertriglyceridemia or post-endoscopic retrograde cholangiopancreatography was also not there and corticosteroids are known etiological agent for acute pancreatitis.

After initial improvement over the period of 5-7 days patient's condition start worsening again, and he was shifted to bigger center where he died after 2-3 days.

Case 3

An 18-year-old male presented to us with a history of 1-day of stiffness of jaw, neck, back and difficulty in swallowing. There was also associated history of sweating over face and neck. Over the next few hours, he developed frequent sudden jerky movement of the body. As he developed spasm and hypoxia, he was intubated and kept on mechanical ventilation. He was requiring paralyzing agent in addition to diazepam infusion because of severe and frequent tetanic spasm. There was no history of fever, no evidence of poisoning or trauma, but he was on self-medication as part of body building and taking regular intramuscular injection of anabolic steroid. In the absence of any other clue, we attributed tetanus due to intramuscular injections. He improved and discharged after around 6 weeks of hospitalization. He remained on a ventilator with a paralyzing medication for more than 4 weeks with daily interruption of paralysis to observe for tetanic spasm.

» Discussion

Our first case was patient of rhabdomyolysis leading to acute kidney injury. It was suspected on the basis of high-intensity exercise in otherwise routine gym visitor, followed by pain in both thigh with tenderness, deranged lab reports which include very high level of CPK, alanine and aspartate aminotransferases, low level of calcium and after exclusion of other common causes including severe sepsis.

Rhabdomyolysis may develop in an individual after strenuous activity even who are athlete as it was in our patient. He did more than 500 sit-ups at stretch that too first time along with his daily gym activity. Moreover, he took analgesics for muscle pain, which in association with poor oral intake worsens acute kidney damage. Exertional rhabdomyolysis is more likely to occur when strenuous exercise is performed under high temperatures and humidity. Other factors include improper hydration, inadequate recovery between bouts of exercise, intense physical training, and inadequate fitness levels for beginning high-intensity workouts. As he did his activity in the gym, high temperature seems to be unlikely contributor. Intense physical training and inadequate fitness level for beginning high-intensity workouts appear to be more logical explanation for rhabdomyolysis in our patient.

Rhabdomyolysis is an important cause of acute renal failure (ARF), and main pathophysiological mechanisms are renal vasoconstriction, intraluminal cast formation, and direct myoglobin toxicity. [1],[2] Around 33% of the episodes of rhabdomyolysis lead to ARF. [3] Daher Ede et al. reported a similar case of rhabdomyolysis leading to acute kidney injury after strenuous exercise. [4]

Our second patient was a case of acute pancreatitis. It was diagnosed on the basis of raised amylase level with ultrasonographic findings of swollen pancreas with inflammatory changes in patient of epigastric pain, which was later confirmed on computed tomography scan.

Androgenic anabolic steroids have grown in popularity amongst athletics and bodybuilders due to their ability to enhance performance, muscle mass, and aesthetic reasons. They are easily available and perceived to be safe. Recent estimates place AAS use in the USA at 1% of the population. These agents have numerous side effects. Pancreatitis as a complication of AAS is not much reported but of corticosteroids is well documented. The usual causes of pancreatitis were excluded in our patient on the basis of history, lab reports, and ultrasonography. Researchers have recently discovered evidences that suggest anabolic steroids may demonstrate potentially new and serious adverse consequences.

Evidence obtained from a clinical trial suggests that acute pancreatitis and acute kidney injury can be caused by the use of anabolic steroids like methandrostenolone. Rosenfeld et al. reported a case of 50-year- old man who develop acute pancreatitis and acute kidney injury which was attributed to AAS. [5]

Samaha et al. described a case report of multi-organ damage after the use of anabolic steroids. They suspected anabolic steroid causes hypercalcemia. They also suspected that besides hypercalcemia, acute pancreatitis have resulted from overuse of amino acid supplements. [6] Though hypercalcemia was not present in our patient but he was on protein supplements. Arginine was shown to be a potent secretagogue for anabolic hormones in addition to inducing pancreatic acinar damage. [7],[8]

Our third case was a patient of tetanus. It was diagnosed on the basis of typical clinical picture consisting of the jaw, neck, back stiffness and difficulty in swallowing. There was also associated history of sweating over face and neck. Later on, he developed typical recurrent tetanic spasms, for which he was intubated and kept on mechanical ventilation. Diazepam along with the atracurium infusion was given.

He was regularly taking AAS intramuscular injection as a self-prescribed and self-injected medication, as part of bodybuilding activity. There was no evidence of mode of transmission for tetanus other than intramuscular injection. This mode of transmission for tetanus is well reported in the literature. [9] Our patient required mechanical ventilation for about 5 weeks with continuous diazepam infusion. He also required continuous infusion of the paralyzing agent for almost 4 weeks. There was complete recovery.

As the people engaged in bodybuilding are on a continuous rise, with more data collection or planning an observational study will help to better understand this population subset.

 

[Michael Scally MD]

Gonadotrophin Secreting Pituitary Adenoma with Hypersecretion of Testosterone and Testicular Enlargement
http://www.endocrine-abstracts.org/ea/0037/ea0037ep1167.htm

Gonadotroph pituitary adenomas are common but majority of them are classified as non-functional as they do not lead to features of hormonal excess. Functional gonadotroph adenomas are rare and there are only few small series or individual case reports about these.

Case report: 45-year-old gentleman presented with headaches, progressive visual failure and complaint of excessive tiredness. He had normal libido and had an 8-year-old child.

On examination, he had bitemporal hemianopia and bilaterally enlarged testes (>40 ml bilaterally). His MRI showed a large pituitary macroadenoma (35×29×26 mm) with suprasellar extension and displacing the optic chiasma.

His blood results showed high normal haemoglobin of 180 g/l (130–180) with borderline high haematocrit of 0.51 l/l (0.40–0.50).

Sex hormone profile was as follows: LH: 10.5 IU/l (3.0–13); FSH: 15.7 IU/l (1.3–9.2); Testosterone: 43.4 nmol/l (9–25); free Testosterone 1257 pmol/l (215–760); Sex Hormone Binding Globulin 26 nmol/l (15–48). Alpha sub-unit was also elevated at 2.55 IU/l (NR<1.0).

His thyroid functions were as follows: TSH: 7.61 mU/l (0.3–4.7), FT4: 6.0 pmol/l (9.5–21.5); FT3: 2.7 pmol/l (3.5–6.5). Prolactin was mildly high at 982 mIU/l (0–450). GH and IGF1 were normal at 0.13 μg/l and 14 nmol/l (7–28) respectively. His baseline cortisol was low at 75 nmol/l.

He was started on Dexamethasone and Levothyroxine and underwent trans-sphenoidal pituitary adenomectomy. He made an uneventful recovery apart from transient diabetes insipidus.

The histology was consistent with pituitary adenoma with scattered FSH positive cells and very rare LH positive cell.

In the post-operative period, his LH, FSH & Testosterone levels were 0.7 IU/l, 3.0 IU/l and <1.0 nmol/l respectively.

His visual fields also improved significantly.

He is continuing on steroids and levothyroxine.

The patients reported earlier had either high testosterone levels or testicular enlargement. The authors could not find any case report of a patient with both, high testosterone level and testicular enlargement, secondary to functional gonadotrophinoma.

 

[Michael Scally MD]

Rocha FL, Hara C. Compulsive Masturbation With Pramipexole for Antidepressant Augmentation in Major Depression: A Case Report. J Clin Psychopharmacol. http://journals.lww.com/psychopharm..._Masturbation_With_Pramipexole_for.99238.aspx

Pramipexole is an amino-benzothiazole derivative agonist, with selective and specific affinity for dopamine (DA) receptors of the D2 subfamily, particularly the D3 receptor subtype, and without significant effects on adrenergic or serotonergic receptor sites.

It is approved for the treatment of Parkinson disease (PD) and restless legs syndrome (RLS).

In psychiatry, pramipexole has been studied in bipolar and unipolar depression because of its dopaminergic and neuroprotective effects.

Case reports with patients experiencing PD raised concerns about the potential for compulsive behaviors to arise during the treatment with the drug.

In this article, we describe a patient with refractory major depression who developed compulsive masturbation with pramipexole augmentation of the antidepressant treatment.

 

[Michael Scally MD]

Gerstein NS, Deriy LB. Neck Impalement during Mountain Biking. New England Journal of Medicine. 2015;373(4):366-. http://www.nejm.org/doi/full/10.1056/NEJMicm1412571

A previously well 40-year-old man was riding a mountain bike off-road when he fell and impaled his neck on a branch that was 2 cm in diameter. The patient did not attempt to remove the branch, and he transported himself to our emergency department.

A computed tomographic angiogram showed the foreign body in the soft tissues of the left side of the neck at the level of the superior thyroid cartilage, extending through the platysma muscle, to the anterior margin of the sternocleidomastoid muscle (Panel A, arrow). The branch extended approximately 1.6 cm deep into the neck from the skin surface, with no evidence of vascular or airway injury (Panel A).

Penetrating neck injuries can be associated with vascular, airway, cervical spine, or nerve injuries. The foreign body may be providing tamponade if a major vascular structure is injured; hence, there is a possible benefit to leaving the foreign body in place until radiologic and surgical evaluations are performed.

In the operating room, the foreign body (Panel B) was removed, and the wound was explored, irrigated, and closed. The patient had an uneventful postoperative course.

 

[BBC3]

In short = IF YA GET STUCK GOOD WITH SOMETHING. - DON'T PULL IT OUT OR YER A DUMBASS....

View attachment 27482

Gerstein NS, Deriy LB. Neck Impalement during Mountain Biking. New England Journal of Medicine. 2015;373(4):366-. http://www.nejm.org/doi/full/10.1056/NEJMicm1412571

A previously well 40-year-old man was riding a mountain bike off-road when he fell and impaled his neck on a branch that was 2 cm in diameter. The patient did not attempt to remove the branch, and he transported himself to our emergency department.

A computed tomographic angiogram showed the foreign body in the soft tissues of the left side of the neck at the level of the superior thyroid cartilage, extending through the platysma muscle, to the anterior margin of the sternocleidomastoid muscle (Panel A, arrow). The branch extended approximately 1.6 cm deep into the neck from the skin surface, with no evidence of vascular or airway injury (Panel A).

Penetrating neck injuries can be associated with vascular, airway, cervical spine, or nerve injuries. The foreign body may be providing tamponade if a major vascular structure is injured; hence, there is a possible benefit to leaving the foreign body in place until radiologic and surgical evaluations are performed.

In the operating room, the foreign body (Panel B) was removed, and the wound was explored, irrigated, and closed. The patient had an uneventful postoperative course.

 

[Michael Scally MD]

Insertion of foreign bodies into the genitourinary system is a pathological action believed to increase sexual gratification usually for psychiatric patients and mentally retarded cases especially during masturbation.

In this report, we represented a male case who is inserted a 195 cm cannula by himself into the bladder through the urethra because of his psychiatric disorder.

Sokmen D, Torer BD, Kargi T, Yavuzsan AH, Sahin S, et al. Unusual foreign body in the vesico-urethral; 195 cm liquid pipe. Turk J Urol. 2014;40(4):248-50. http://www.turkurolojidergisi.com/eng/ozet/2826/156/Abstract

 

[Michael Scally MD]

Removal of a Sex Toy under General Anaesthesia Using a Bimanual-Technique and Magill’s Forceps

Highlights
· A case of a 68-year-old male with large bowel obstruction due to the presence of a phallic object in the rectum is presented.
· Removal of the phallic object was achieved using a pair of Magill’s forceps and bi-manual manipulation under general anaesthesia.
· This case demonstrates the use of Magill’s forceps to aid removal of a foreign body in the rectum.
· Laparotomy and open removal may, therefore, be rarely necessary.

Obinwa O, Robertson I, Stokes M. Removal of a sex toy under general anaesthesia using a bimanual-technique and Magill’s forceps: A case report. International Journal of Surgery Case Reports. 2014;15:96-8. http://www.casereports.com/article/S2210-2612(15)00360-0/fulltext

Introduction - Phallic objects may cause large bowel obstruction if not promptly removed. A bi-manual technique with the aid of a Magill’s forceps is presented here.

Presentation of Case - A 68-year-old man presented to the emergency department with severe lower abdominal discomfort, distension and inability to pass urine, flatus or bowel motions. He had inserted a phallic object in the rectum 10 hours prior to presentation and had been unable to remove same.

Abdominal examination was remarkable for distension with tenderness also elicited suprapubically and in the left iliac fossa. The foreign body was barely palpable per rectum. Plain radiographs showed prominent left-sided colonic segments.

Following the trial of a manual attempt at removal in the emergency department, a decision was made to remove this under anaesthesia due to worsening symptoms. The phallic object was successfully removed under general anaesthesia using bi-manual manipulation assisted by a pair of Magill’s forceps.

Discussion - The method of removal of phallic objects varies from one individual case to another. In the presence of obstruction, a quick decision must be made for removal under general anaesthesia and the patient will also need to be consented for laparotomy. Previous literature described a “cork-in-bottle” technique using myomectomy screws as well as use of single-incision laparoscopic surgery (SILS) ports for removal of phallic objects.

Conclusion - Extraction of phallic objects requires ingenuity. We describe another minimally invasive technique of removal that adds to the literature, thereby limiting the need for laparotomy and open removal of foreign bodies.

 

[Michael Scally MD]

Hussain T, Jan RA. A Viper Bite. New England Journal of Medicine. 2015;373(11):1059-. http://www.nejm.org/doi/full/10.1056/NEJMicm1410237

A 46-year-old farmer presented to the emergency department 3 hours after his penis was bitten by a snake while he was urinating in an open field.

The snake was identified by the patient as “gunas,” which is the local name of the Levantine viper (Macrovipera lebetina).

Physical examination revealed stable vital signs, with a grossly swollen penis and formation of hemorrhagic bullae at the puncture sites (Panel A).

Laboratory investigations showed an initial prothrombin time of 17 seconds (reference value, <12), an activated partial-thromboplastin time of 34 seconds (reference value, <24), and a fibrinogen level of 80 mg per deciliter (reference range, 200 to 400).

Venous and arterial Doppler ultrasonography revealed normal flow in the cavernosal and dorsal vessels of the penis.

The patient received polyvalent anti–snake venom (a snake antivenom serum that neutralizes the venom of the cobra, common krait, and viper) with no adverse effects.

At 36 hours after the initiation of treatment, the patient’s coagulopathy had resolved and he was discharged home.

The swelling subsided 4 days after discharge, with the formation of necrotic tissue at the puncture sites (Panel B). The patient had recovered completely at 2-week follow-up.

 

[Michael Scally MD]

Surgery? No Thanks!!!



A 22-year-old man presented to the hospital after a motor vehicle collision in which his head struck the windshield of a bus.

Initial observations and the physical and neurologic examinations were normal, but the injury warranted computed tomographic (CT) scanning.

A CT scan of the brain (Panel A) showed an incidental finding of grossly dilated occipital and temporal horns of the right lateral ventricle.

Magnetic resonance imaging (Panel B) confirmed the presence of a large cystic lesion extending from the temporal and posterior horns of the right lateral ventricle (axial size, 11 cm by 7 cm), with a mild midline shift of the third ventricle, and compression of the midbrain and brain stem with thinning of the temporal and occipital cortexes.

A large, asymptomatic, intraventricular arachnoid cyst was diagnosed. Arachnoid cysts — collections of cerebrospinal fluid within the layers of the arachnoid membrane — occur infrequently.

Most are congenital, but they can also be acquired after trauma or infection through the entrapment of cerebrospinal fluid within arachnoid adhesions.

Neurosurgery was recommended in this case, but the patient discharged himself from the hospital and there was no further follow-up.

Valluru B, Raj R. Arachnoid Cyst. New England Journal of Medicine. 2015;373(11):e13-e.http://l.facebook.com/l.php?u=http%3A%2F%2Fwww.nejm.org%2Fdoi%2Ffull%2F10.1056%2FNEJMicm1413067&h=JAQEdSnLGAQHafcNJrKPi1CWvF0VQPqBVOCsuUrZdin4nug&enc=AZPALV7e6RDEdrEay4XmpdTEpIS0AXWe_n5v2FMxGOBNd44zYmFGQ3oAu_eKRhtJNiVC11voiuf8p7Mlug5joozYvMghXD6_JnWc5UnrA8eKZXvuEqo9QQtrb9whjvVEIWMbyeVeJ73hG_cfpphAzGix6oHgrCc5-1D71mgm9lBcIeaRA4FW_87AFg7BboMQmCjxjsU4nDKlzkYBYpQzg0ND&s=1 (http://www.nejm.org/doi/full/10.1056/NEJMicm1413067)

 

[CensoredBoardsSuck]

N Engl J Med. 2015 Nov 5;373(19):1845-1852.
Malignant Transformation of Hymenolepis nana in a Human Host.
Muehlenbachs A1, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA, Frace MA, Ito A, Metcalfe MG, Rollin DC, Visvesvara GS, Pham CD, Jones TL, Greer PW, Vélez Hoyos A, Olson PD, Diazgranados LR, Zaki SR.

Abstract
Neoplasms occur naturally in invertebrates but are not known to develop in tapeworms. We observed nests of monomorphic, undifferentiated cells in samples from lymph-node and lung biopsies in a man infected with the human immunodeficiency virus (HIV). The morphologic features and invasive behavior of the cells were characteristic of cancer, but their small size suggested a nonhuman origin. A polymerase-chain-reaction (PCR) assay targeting eukaryotes identified Hymenolepis nana DNA. Although the cells were unrecognizable as tapeworm tissue, immunohistochemical staining and probe hybridization labeled the cells in situ. Comparative deep sequencing identified H. nana structural genomic variants that are compatible with mutations described in cancer. Invasion of human tissue by abnormal, proliferating, genetically altered tapeworm cells is a novel disease mechanism that links infection and cancer.


http://www.nejm.org/action/showMedi...EJMoa1505892&aid=NEJMoa1505892_attach_1&area=

 

[Michael Scally MD]

Lukasik-Glebocka M, Sommerfeld K, Tezyk A, Zielinska-Psuja B, Panienski P, Zaba C. Flubromazolam - A new life-threatening designer benzodiazepine. Clin Toxicol (Phila). http://www.tandfonline.com/doi/full/10.3109/15563650.2015.1112907#abstract

CONTEXT: In addition to designer benzodiazepines such as etizolam, deschloroetizolam, pyrazolam, diclazepam, nifoxipam, or clonazolam, a new psychoactive substance like flubromazolam, triazole of flubromazepam has become available.

Flubromazolam is currently not marketed as a medication but rather as a research chemical and recreational drug. It mostly causes sedative effects but also has moderate anti-anxiety and muscle relaxant effects. A case of a severe intoxication of flubromazolam has been reported.

CASE DETAILS: A 27-year-old man, presented with deep coma, bilateral pinpoint unreactive pupils, acute respiratory failure and hypotension, complicated by hypoxic ischemic changes in the central nervous system.

A positive result of a urine screening test confirmed the presence of benzodiazepines, which resulted in administration of flumazenil and improved patient consciousness. Quantitative method of liquid chromatography indicated flubromazolam in the patient's serum at 59 ng/mL and urine at 105 ng/mL about 19 h after ingestion of 3 mg dose. On admission, serum creatine kinase was 15 960 U/L.

The patient was treated with mechanical ventilation, intravenous fluids, flumazenil and continuous infusion of norepinephrine at a dose of 0.12 microg/kg/min. The patient survived and on the ninth day of hospitalization he was transferred to the Department of Neurology.

DISCUSSION: Flubromazolam is a new designer drug. Recreational use may be a cause of prolonged, severe intoxication associated with coma, hypotension, and rhabdomyolysis.

 

[Michael Scally MD]

[Open Access] Post Coital Penile Ring Entrapment: A Report of a Non-Surgical Extrication Method

Highlights
· Removal of an entrapped penile ring where possible should be done in a simple non-invasive way.
· Milking the oedematous penis through the thick metallic ring in a slippery field complemented by levering with a blunt end paediatric bone lever, was the technique used to remove the ring.
· The ring was extricated without any morbidity and the patient went home on the same day.

The patient is a 26 year old male who presented in a specialist orthopaedic & trauma centre on the 17th of September, 2015 with a painful engorged penis, 13 hours after sexual intercourse.

He complained of weak and poorly sustained erections.

During foreplay he removed his thick completely circular ring from his finger, put it on the glans and slid it all the way to the root of his penis.

He and his partner tried to remove the ring afterwards.

In the agitation and manipulation, he noticed that the penis continued to engorge and pain ensued.

He saw a doctor 10 hours later who tried to remove it without anaesthesia before referral to our centre.

On examination, he was anxious and distressed.

The penile shaft was grossly oedematous, mildly tender, cold, sensate, engorged but not turgid. The glans was also oedematous, cyanosed, cold and sensate.


The circumference of the penis at the widest point was 16 cm (measured with a strip of gauze thread intra-operatively and cross-checked with a measuring tape afterwards).

A thick stainless steel ring, 6.5 cm in circumference (measured after extrication) was seen at the root of the penis.

Under general anaesthesia …. [go to link]

Agu TC, Obiechina NJA. Post coital penile ring entrapment: A report of a non-surgical extrication method. International Journal of Surgery Case Reports 2015;18:15-7. https://www.sciencedirect.com/science/article/pii/S221026121500499X

This case report shows how a simple but painstaking method of milking and levering in a slippery field was used to remove a thick metallic ring entrapped at the root of the penis after sexual intercourse.

A ring can be removed easily from an organ if the inter-phase is made slippery.

However this must be weighed against the handling difficulties posed by a wet slippery surface.

With perseverance and the use of unconventional instrument, the ring was successfully extricated as a day case and without a surgical incision.

 

[Michael Scally MD]

Tikka T, Mistry N, Janjua A. Acute unilateral sensorineural hearing loss associated with anabolic steroids and polycythaemia: case report. J Laryngol Otol 2015:1-5. Acute unilateral sensorineural hearing loss associated with anabolic steroids and polycythaemia: case report

BACKGROUND: Unilateral sudden sensorineural hearing loss due to an infarct in the vertebrobasilar system has been widely reported. Most patients have a background of traditional coronary risk factors related to these cerebrovascular episodes.

CASE REPORT: A 32-year-old male, a regular user of anabolic steroids, presented to the emergency department with unilateral sensorineural hearing loss and symptoms suggestive of an infarct of the anterior inferior cerebellar artery but in the absence of risk factors for ischaemic stroke.

RESULTS: Magnetic resonance imaging confirmed the presence of infarction in the region supplied by the anterior inferior cerebellar artery. Polycythaemia was found on haematological analysis, which we believe was secondary to the use of anabolic steroids. The patient was commenced on aspirin as per the stroke management protocol. There was resolution of neurological symptomatology six weeks after the episode, but no improvement in hearing.

CONCLUSION: To our knowledge, this is the first case report of unilateral sensorineural hearing loss secondary to the use of anabolic steroids causing polycythaemia. This cause should be considered in the differential diagnosis of patients presenting with sensorineural hearing loss, especially in young males, when no other risk factors can be identified.