Category Archives: Case Report

Acute Pulmonary Embolism in a Teenage Female – A Case Report

DOI: 10.2478/jccm-2018-0015

Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage.

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Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report

DOI: 10.2478/jccm-2018-0013

Background: Elizabethkingia meningoseptica are Gram-negative rod bacteria which are commonly found in the environment. The bacteria have also been associated with nosocomial infections, having been isolated on contaminated medical equipment, especially in neonatal wards.
Case report: Here, we present the case of a premature female infant born at 33 weeks’ gestational age, with neonatal meningitis. The onset was marked by fever, in the 5th day of life, while in the Neonatal Intensive Care Unit. The patient was commenced on Gentamicin and Ampicillin, but her clinical condition worsened. Psychomotor agitation and food refusal developed in the 10th day of life, and a diagnosis of bacterial meningitis was made based on clinical and cerebrospinal fluid findings. A strain of Elizabethkingia meningoseptica sensitive to Vancomycin, Rifampicin and Clarithromycin was isolated from cerebrospinal fluid. First-line antibiotic therapy with Meropenem and Vancomycin was adjusted by replacing Meronem with Piperacillin/Tazobactam and Rifampicin. The patient’s clinical condition improved, although some isolated febrile episodes were still present. The cerebrospinal fluid was normalized after 6 weeks of antibiotic treatment, although periventriculitis and tetraventricular hydrocephalus were revealed by imaging studies. Neurosurgical drainage was necessary.
Conclusion: Elizabethkingia meningoseptica can cause severe infection, with high risk of mortality and neurological sequelae in neonates. Intensive care and multidisciplinary interventions are crucial for case management.

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Incidental Finding of a Left Atrial Myxoma while Characterising an Autoimmune Disease

DOI: 10.2478/jccm-2018-0009

Although cardiac tumours are uncommon, cardiac myxomas account for more than fifty percent of all cases and are the most frequent primary cardiac tumour. They have a broad clinical spectrum, usually related to cardiac symptoms, peripheral embolic events or systemic manifestations. We present a case report of a 68-year-old man who presented with systemic symptoms and analytical features suggestive of an autoimmune disease. In the ensuing diagnostic procedures, a cardiac myxoma was found, and after surgical resection, both the systemic manifestations and the analytical abnormalities disappeared.

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Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report

DOI: 10.2478/jccm-2018-0008

Introduction: Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur.
Case presentation: The case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome.
Conclusions: NBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.

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Post-Pneumonectomy ARDS and Ogilvie Syndrome – A Case Report

DOI: 10.2478/jccm-2018-0007

Introduction: The Acute Respiratory Distress Syndrome (ARDS) is a severe hypoxemic acute lung injury that may complicate lung resections. Reported mortality is very high, up to 50%. This report covers an ARDS case occurring post left pneumonectomy, with a favorable outcome, despite association with an acute colonic pseudo-obstruction syndrome (Ogilvie syndrome) that required abdominal surgery for decompression.
Case report: A 60-year old Caucasian male, diagnosed with a stage IIIA left lung tumor underwent a left pneumonectomy. On the second postoperative day, the patient developed ARDS, requiring ventilatory support. Two days later, as the multiple organ dysfunction worsened, a bowel obstruction occurred. With an acute colonic pseudo-obstruction diagnosis, the decision was to perform laparotomy and a temporary cecostomy. A subsequent improvement in the respiratory parameters and vital functions resulted in weaning from ventilator 8 days after the onset of the ARDS and transfer to the surgery ward 14 days after pneumonectomy.

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Serratia marcescens Sepsis in a Child with Deep Venous Thrombosis – A Case Report

DOI: 10.2478/jccm-2018-0004

Introduction: Venous thromboembolism is a rare condition in paediatrics that included both deep venous thrombosis and pulmonary embolism. Serratia marcescens is a gram-negative bacterium that belongs to the Enterobacteriaceae family and tends to affect immunocompromised hosts.
Case report: We report the case of an 11-year-old boy, admitted in the Pediatric Clinic I from Emergency County Hospital Tîrgu Mureș, Romania with intense pain, swelling, cyanosis and claudication of the left foot. His personal history revealed a recent appendectomy. A close family was reported to have had a deep venous thrombosis. The laboratory tests, performed on the day of admission, revealed increased inflammatory biomarkers and D-dimer. Coagulation tests gave a low activated partial thromboplastin time (APTT). Doppler venous ultrasound and CT-exam established a diagnosis of deep venous thrombosis. Anticoagulant therapy was initiated, but on the tenth day of admission, the patient developed signs and symptoms of sepsis, and the blood culture revealed Serratia marcescens. After antibiotic and anticoagulant therapy, the patient progressed favourably. The patient was a carrier of the heterozygous form of Factor V Leiden.
Conclusions: The association between deep venous thrombosis and Serratia marcescens sepsis can compromise a condition in pediatric patients.

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Stroke Secondary to Traumatic Carotid Artery Injury – A Case Report

DOI: 10.2478/jccm-2018-0003

Introduction: Lesions of the carotid and vertebral arteries secondary to direct trauma, called blunt cerebrovascular injuries (BCVI) are relatively rare and are markedly different from spontaneous dissections. Ischaemic stroke is a significant complication, with high morbidity and mortality rates. The basis of a diagnosis relies on appropriate, high sensitivity imaging screening.
Case report: We present the case of a 31 years old male patient with polytraumatism secondary to a motor vehicle accident, who was admitted to an orthopaedic clinic for multiple lower extremity fractures. His fractures were treated surgically. He developed in the 3rd day after the admission left sided hemiparesis secondary to ischaemic stroke. The diagnosis of traumatic carotid artery injury (TCAI) was based on duplex ultrasound and angio CT scans. The outcome was favourable despite the severe carotid lesions presenting with occlusion secondary to dissection.
Conclusions: In the majority of BCVI cases there is a variable latent period between the time of injury and the development of stroke. The management of cases is challenging because in the majority of cases there are multiple associated injuries. Although antithrombotics are widely used in the treatment, there is no consensus regarding the type of agent, the optimal dose or treatment duration.

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Severe Austrian Syndrome in an Immunocompromised Adult Patient – A Case Report

DOI: 10.1515/jccm-2017-0025

Background: Known also as Osler’s triad, Austrian syndrome is a complex pathology which consists of pneumonia, meningitis and endocarditis, all caused by the haematogenous dissemination of Streptococcus pneumoniae. The multivalvular lesions are responsible for a severe and potential lethal outcome.
Case report: The case of a 51-year-old female patient, with a past medical history of splenectomy, is presented. She developed bronchopneumonia, acute meningitis and infective endocarditis as a result of Streptococcus pneumoniae infection and subsequently developed multiple organ dysfunction syndromes which led to a fatal outcome. Bacteriological tests did not reveal the etiological agent. The histopathological examination showed a severe multivalvular endocarditis, while a PCR based molecular analysis from formalin fixed valvular tissue identified Streptococcus pneumoniae as the etiologic agent.
Conclusions: The presented case shows a rare syndrome with a high risk of morbidity and mortality. Following the broad-spectrum treatment and intensive therapeutic support, the patient made unfavourable progress which raised differential diagnosis problems. In this case, the post-mortem diagnosis demonstrated multiple valvular lesions occurred as a result of endocarditis.

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Neutropenia and T-Wave Inversion as Toxin-Mediated Complications of a Streptococcal Infection

DOI: 10.1515/jccm-2017-0030

Introduction: Streptococcal infection can be responsible for multiple complications, such as toxic, septic or allergic disorders. Toxin-mediated complications (TMC) can appear during the acute phase of disease and can involve any organ, causing carditis, arthritis, nephritis, hepatitis etc.
Case presentation: The case of a young woman without a history of recurrent streptococcal tonsillitis, admitted to “Matei Balş” National Institute for Infectious Diseases, Bucharest, Romania, presenting with fever, sore throat and exudative tonsillitis, is detailed. The initial test for Streptococcus pyogenes was negative. The patient had leukopenia with severe neutropenia, high values of inflammatory biomarkers and electrocardiographic (ECG) changes with inverted T waves in leads V1-4 and flattened T waves in V5-6. There were no other cardiac signs or symptoms. The patient received cefuroxime for two days. On admission, the patient was prescribed Penicillin G and dexamethasone which resulted in a rapid recovery. The leucocytes count returned to normal as did the ECG abnormalities. At the time of discharge, the antistreptolysin O titre was high.
Conclusions: The case highlights the toxin-mediated complications (TMC) of streptococcal infection which occur from the outset of the disease.

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Lethal Subarachnoid and Intracerebral Haemorrhage Associated with Temporal Arteritis. A Case Report

DOI: 10.1515/jccm-2017-0028

Giant cell arteritis is a systemic inflammatory vasculitis, typically involving the superficial temporal arteries, but with possible ischemic and hemorrhagic cerebrovascular complications.
The case is reported of a patient with a clinical picture of giant cell arteritis, who had multiple occupational exposures to various infectious agents.
His initial favourable progress was followed by an atypical outcome. Despite immunosuppressive treatment, he developed fatal subarachnoid and intracerebral haemorrhages, possibly due to rupture of a microaneurysm of the posterior cerebral artery.

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