BMJ case reports
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A 63-year-old man underwent endoscopic evaluation of the rectal stump for rectal bleeding and suffered a massive cerebral air embolism with severe neurological impairment and subsequent death. The patient underwent a Hartmann's procedure 9 month previously for ischaemic bowel and was noted to have portal hypertension at laparotomy. We hypothesise that air entered the venous plexus around rectum and entered the azygos vein via a porto-systemic shunt and travelled retrogradely via the superior vena cava to the venous sinuses of the brain.
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A teenage boy with vertically acquired-HIV presented with bone pain of 6 months duration. His antiretroviral therapy (ART) consisted of tenofovir disoproxil fumarate (TDF), emtricitabine and ritonavir-boosted lopinavir. Plain X-rays showed stress fractures of metatarsals bilaterally. ⋯ This case uniquely features renal and skeletal toxicities with resultant metatarsal stress fractures. Children and adolescents on combined ART which include tenofovir should be screened for the early detection of proximal tubulopathy, with the measurement of renal function, phosphate, vitamin D and urinary phosphate excretion. Although uncommon and mostly reversible, recognition of tenofovir-related effects is paramount as prolonged exposure may lead to persistent renal tubular damage and osteomalacia.
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Benign goitres have the potential to reach massive sizes if neglected, but most have a protracted course that may or may not present with compressive symptoms. We report the case of a 57-year-old man who presented with a rapidly enlarging nodular goitre resulting in acute respiratory failure. Endotracheal intubation and emergency total thyroidectomy were performed, revealing massive thyroid nodules with minimal intrathoracic extension and tracheal erosion. ⋯ Several cases of benign goitres necessitating endotracheal intubation have been reported. Airway compromise was attributed to a significant intrathoracic component, or inciting events such as thyroid haemorrhage, pregnancy, radioiodine uptake or major surgery. Obstructive symptoms may not correlate well with objective measures of upper airway obstruction such as radiographs or flow volume loops.
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We describe two patients with laryngeal cyst who underwent microlaryngeal surgery. Peroral rigid laryngoscopy, as an indirect endoscopy, performed via the transoral route, was evaluated as a routine screening tool of the difficult airway in patients with laryngeal neoplasm, in our hospital preoperatively. ⋯ As we saw in these two cases, endoscopic examination alone was inadequate for the assessment of a difficult airway, which may also lack the predictive sensitivity or may cause a high false positive. Usage of video laryngoscopy combined with intubating stylet will improve the intubation success in patients with huge epiglottic cyst.
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Pulmonary embolism (PE) remains one of the leading causes of cardiovascular mortality. The safety and efficacy of thrombolytic therapy using tissue-type plasminogen activator (tPA) for acute PE in clinical practice remain unclear. We describe a case of life-threatening submassive PE causing extreme refractory hypoxaemia, where thrombolysis was successfully administered. ⋯ Patients, not in shock however, but with evidence of right-ventricular (RV) dysfunction echocardiographically, that is, submassive PE may also benefit. Serum troponin and brain-type natriuretic peptide have been suggested as biomarkers of RV injury that may identify a subset of submassive PE patients who may particularly benefit from thrombolytic therapy. The clinical response of this patient to thrombolysis is important, as it may identify a subgroup of patients with submassive PE who warrant this intervention.