BMJ Case Reports

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ISSN / EISSN : 1757-790X / 1757-790X
Published by: BMJ (10.1136)
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, Enrico Battistella, Luca Bonariol, Marco Massani
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-244737

Abstract:
Mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs) are rare tumours of gastrointestinal tract, extremely rare in anal canal. We report a case of misdiagnosed MiNEN in a 38-year-old woman initially conservatively treated for a supposed anal fistula. In a second proctological evaluation, biopsy of the anal neoformation was performed and the histological specimen diagnosed a MiNEN. The complete staging showed a disseminate disease and the patient started a chemotherapy schedule. After 6 months, stable disease was revealed at the last imaging performed and radical surgery was offered to the patient that is actually on oncological follow-up without recurrence at 1 year.
Akihiro Fujimoto, Yoshimasa Kosaka, Takahiro Hasebe, Toshiaki Saeki
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-242742

Abstract:
The main concern after breast augmentation with silicone injection is that silicone granulomas make it difficult to detect breast cancer. A case of breast cancer was diagnosed using colour Doppler ultrasound (CD) to detect an non-palpable mass not presenting as a hypoechoic mass lesion. An 83-year-old woman was incidentally found to have a lesion in her right breast, which was injected with silicone, showing 18F-fluorodeoxyglucose (FDG) uptake; the lesion was suspected to be breast cancer or silicone granuloma. A mass at the FDG uptake site was not detected on ultrasonography (US); however, observation using CD revealed a slightly hypoechoic area with hypervascularity. Core needle biopsy showed invasive ductal carcinoma. Patients in whom US does not reveal lesions after breast augmentation with silicone injection should undergo CD to detect hypervascularised tissue. To prevent false-negative biopsy results, CD is essential to detect cancer at suspected sites.
Tomislav Mestrovic, Mario Sviben, Sanja Zember, Domagoj Drenjancevic
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-243618

Abstract:
Genital warts (also known as condylomata acuminata) caused by the human papillomavirus (HPV) represent one of the most common sexually transmitted infections. Although they are usually found in the outer genital region, a small proportion of men can present with (often unrecognised) intraurethral warts, generally limited to the distal urethra and urethral meatus. This poses a treatment challenge not adequately addressed by the current guidelines. Here, we present two cases of low-risk HPV-positive patients with protruding and non-protruding condylomata acuminata of the distal urethra, which were treated successfully by using two different topical regimens (ie, a combination of policresulen and imiquimod for one patient and 5-fluorouracil monotherapy for the other). Although this type of management results in lower rates of tissue destruction and complications and may be given preference as an initial therapeutic option, additional prospective comparative clinical studies are needed to elucidate its potential in similar cases.
Jagannath Kamath, Harshit Bhaskar Shetty, Arkesh Madegowda, Anusha S Bhatt
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2020-240007

Abstract:
Intraosseous schwannoma is extremely rare that it is not often considered among differential diagnosis for an osteolytic lesion, especially in long bones of the extremities. Amounting to less than 0.2% of all primary bone tumours and less than 200 cases reported so far, with only 3 cases involving the humerus, we hereby report the fourth case. In addition to its rarity, this was the only case of an intraosseous schwannoma involving the humerus bone which presented with a pathological fracture in a 45-year-old woman after sustaining a trivial trauma. Radiological examination revealed a geographic type of osteolytic lesion in distal shaft region of the left humerus. Only a histopathological examination helped in revealing and confirming the diagnosis of an intraosseous schwannoma. Treatment of the tumour with complete excision with bone graft reconstruction and osteosynthesis yields good results with very low risk of recurrence.
, Taha Alrifai, Ira J Miller, Melissa L Larson
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-245350

Abstract:
We present a unique case of a patient with a long-standing history of indolent chronic lymphocytic leukaemia (CLL) who suddenly developed autoimmune haemolytic anaemia after starting immune checkpoint inhibitor therapy for bladder cancer. He had no clear indication to start CLL-directed treatment based on current clinical practice guidelines; however, targeted treatment of CLL with ibrutinib proved to be effective in treating the haemolytic anaemia.
Rasads Misirovs, Avinash Kumar Kanodia, Christopher McDonald, Richard Green
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-245103

Abstract:
Mesiodens is the most common type of supernumerary tooth, located between the maxillary central incisors in close relation to the nasopalatine canal. A 20-year-old man presented with right-sided nasal blockage, nasal discharge and collapsed nose without history of trauma. Imaging revealed a calcified mass in the inferior meatus extending into dilated nasopalatine canal. Endoscopic removal of the mass revealed tuberculate appearance of an incompletely developed tooth, consistent with mesiodens. Based on the history of septal cartilage collapse with right-sided mucopurulent discharge, endoscopic findings of the right inferior turbinate being adherent to the septal cartilage and the underlying mesiodens, we believe that the patient developed a septal abscess secondary to infection in nasal mucosa surrounding the mesiodens causing collapse of septal cartilage. While a tooth or tooth-like mass causing nasal passage air-flow obstruction is uncommon, we believe that this is the first reported case of mesiodens presenting with septal cartilage collapse.
Kevin Green, Stephanie Rothweiler, Barrett Attarha, Vandana Kavita Seeram
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-245833

Abstract:
Purulent pericarditis is a rare infection of the pericardial space defined by the presence of gross pus or microscopic purulence. Here, we present a case of Streptococcus anginosus purulent pericarditis, leading to obstructive and septic shock. After prompt pericardial drainage, the patient experienced rapid improvement in symptoms. However, due to the presence of a loculated effusion and concern for development of constrictive pericarditis, a pericardial window was performed. Although purulent pericarditis is often fatal, this case illustrates the reduced morbidity following prompt recognition and drainage.
Shraddha Murali, Srinivas Vinayak Shenoy, Ravindra Attur Prabhu, Shankar Prasad Nagaraju
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-242471

Abstract:
Intracranial abscesses are uncommon, serious and life-threatening infections. A brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant Staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arteriovenous grafts. However, intracranial abscess formation due to MRSA is rare. Here, we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors. Intracranial abscesses are uncommon, serious, and life-threatening infections. A Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arterio-venous grafts. However intracranial abscess formation due to MRSA is rare. Here we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors. A 46-year-old male with chronic kidney disease (CKD) secondary to chronic glomerulonephritis, on haemodialysis for 4 years through a left brachio-cephalic AVF developed an episode of generalised tonic-clonic seizures lasting 2 min during his scheduled dialysis session. He reported no complaints before entry to the dialysis. On clinical examination, he was drowsy with the absence of any focal motor deficits. His blood pressure was recorded to be 200/120 mm Hg. He was managed in the intensive care unit with mechanical ventilation, intravenous nitroglycerine for blood pressure control, levetiracetam for seizures and empirical vancomycin. Radiological evaluation showed a brain abscess in the midline involving bosth basi-frontal lobes. After medical optimization, the abscess was drained surgically, and the pus cultured. As culture grew Methicillin Resistant Staphylococcus aureus, he was treated with intravenous vancomycin for 6 weeks. On follow up, the abscess had resolved and the patient recovered without any neurological deficits.
Sudarshan Khokhar, Saumya Kumar, Deeksha Rani, Aayush Majumdar
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-245570

Abstract:
A 58-year-old woman presented to us with sudden onset diminution of vision for 10 days following trauma while using mobile phone. Patient had a history of posterior iris claw implantation 3 years ago. On examination, the patient was aphakic and intraocular lens (IOL) was seen enclaved on nasal side and disenclaved on temporal side on ultrasound biomicroscopy. Patient underwent surgery for re-enclavation of temporal haptic by lifting the IOL using 23-gauge pars plana trocar. Patient had a postoperative uncorrected visual acuity of 6/9 and best-corrected visual acuity of 6/6 with refraction. Re-enclavation of partially disenclaved posterior iris claw lens is a minimally invasive technique to restore visual acuity in such cases.
Piriyanga Kesavan, Shivani Joshi, Yüksel Gercek
Published: 21 September 2021
by BMJ
BMJ Case Reports, Volume 14; https://doi.org/10.1136/bcr-2021-243229

Abstract:
Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.
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