Category Archives: Case Report

Cephalic Duodeno-Pancreatectomy With Pancreatic-Gastric Anastomosis With Double Purse String, in Patient with Lithiasis and Tumoral Jaundice – Case Report

Tudor A, Molnar C, Nicolescu C, Rosca C, Tudor Bianca, Butiurca VO, Copotoiu C

University of Medicine and Pharmacy Tirgu-Mures

DOI: 10.2478/amma-2014-0047

Introduction: One of the most feared complications after cephalic duodeno-pancreatectomy remains pancreatic fistula. In recent years, various methods of pancreatico-digestive reconstruction were performed in order to reduce the rate of pancreatic fistula. One of these methods is pancreatico-gastric reconstruction by using two purse string threads.
Case report: We present in this article a patient with jaundice with mixed etiology: tumoral and lithiasic. Subjectively, the patient accused sclerose-skin-jaundice, right upper quadrant and epigastric pain, nausea and vomiting. Computed tomography revealed dilatation of intra- and extrahepatic bile ducts, a dilated Wirsung duct and a tumor at the biliopancreatic confluence, leading to a suspicion of vaterian ampulom. Upper endoscopy revealed a tumor protruding in the descending duodenal segment. Intraoperatively a tumor suggestive of vaterian ampulom and duct stones was shown. Surgical treatment consisted of coledocolitotomy, cephalic duodeno-pancreatectomy with pancreatic-gastric anastomosis, performed by using two purse string threads. The postoperative evolution was favorable.
Conclusion: Pancreatico-gastric anastomosis using two purse string threads is a simple, safe and quick procedure, avoiding the application of sutures through the pancreatic parenchyma and thus reducing the rate of pancreatic fistula.

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Fanconi Anemia — Case Report of Rare Aplastic Anemia at Child

Deaconu Alina1, Vodă Daniela2, Bulucea D3

1 Children Hospital of Braşov, Romania
2 Department of Medical and Surgical Specialties, Faculty of Medicine, Transilvania University, Braşov, Romania
3 Faculty of Medicine, University Medicine and Pharmacy, Craiova, Romania

DOI: 10.2478/amma-2014-0027

Introduction: Fanconi anemia is an autosomal recessive disease characterized by congenital abnormalities, defective haematopoiesis, and a high risk of developing acute myeloid leukaemia, myelodysplastic syndrome and cancers. FA was first described in 1927 by the Swiss pediatrician Guido Fanconi. The diagnosis is based on morphological abnormalities, hematologic abnormalities (pancytopenia, macrocytic anemia and progressive bone marrow failure) and genetic tests (cariograma).
Case report: We present the case of a child with Fanconi anemia. Although skin and bone morphological abnormalities were present from birth, diagnosis was suspected at 11 years old.
Conclusions: Fanconi anemia is a heterogeneous condition that can present a variety of congenital defects but invariably results in defective haemopoiesis, which is the major cause of morbidity and mortality.

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The Oscar Ramirez Procedure, a Solution for Treating Incisional Hernias with Big Abdominal Wall Defect

Gherghinescu M, Popa D, Panțiru A, Russu C, Roșca C, Benedek Orsolya, Copotoiu C

Surgical Clinic 1, County Emergency Clinical Hospital, Tîrgu Mureș, Romania

DOI: 10.2478/amma-2014-0026

Background: Incisional hernias are important complications of abdominal surgery. Normally they are followed by the growth of the hernia sac and an increase of the abdominal wall defect with loss of domain of the herniated organs.
Case report: We report a case of a 51 year old female, admitted in the 1st Surgical Clinic of the County Emergency Clinical Hospital of Tîrgu Mureș with a large median reducible incisional hernia and a wall defect of 10/12 cm. The abdominoplasty was performed using the Oscar Ramirez technique, which consists of a longitudinal incision along the aponeurosis of the external oblique muscle, at approximately 1–2 cm from the external edge of the rectus abdominis. This procedure allows the abdominal wall closure. This case is part of a lot of 4 patients who received this treatment using the aforementioned procedure in the past 2 months. Postoperative recovery was favorable, bowel movements were present on the second day after the surgery, the subcutaneous drains were shortened on the fifth day and removed on the sixth. There were no immediate postoperative complications or up to a month after the surgery. The patient was discharged on the seventh day.
Conclusions: This technique can be used alone in case of large abdominal wall defects, or prequeling an on-lay mesh procedure addressed to a weak abdominal wall, case in which the functional result is superior to a substitutional mesh.

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An unusual Case of Cardiac Syncope and Acute Coronary Syndrome – A Case Report

Chitu Monica1*, Benedek Theodora1, Condrea S2, Blendea C1, Benedek I1

1 University Of Medicine and Pharmacy of Tîrgu Mures, Department of Internal Medicine
2 Cardiomed Medical Center, Tîrgu Mures, Romania

DOI: 10.1515/amma-2015-0011

Introduction: We aimed to present a case of acute coronary syndrome with unexpected etiology complicated by syncope and arrhythmias, confirmed by imagistic examinations as cardiac parasitosis. Cardiac parasitic diseases are rare diseases, whose diagnosis and therapy should be adapted to each case. Imaging techniques allow precise diagnosis of cardiac echinococcosis, providing essential structural details on the damage degree of heart structures, allowing optimization of complex treatment in these cases.
Case presentation: A 67-year old, obese and diabetic woman presented with cardiac syncope, arrhythmias and acute chest pain. Imagistic examinations excluded intracoronary thrombosis and confirmed a severe structural damage of myocardial tissue, consisting in replacement of the myocardial structure by many cysts caused by parasitic infestation with echinococcus multilocularis and echinoccocus granulosus originating from the liver. CT scan confirmed severe distruction of the left ventricular myocardium by policysts, that led to thinning of inferior and apical left ventricle wall without any possibility of surgical excision. Therefore a specific chemotherapy with albendazole was initiated. Follow up at 2 months indicated a favorable evolution, with serological decrease of echinococcal antibodies and reduction of cysts volume.
Conclusion: In cases of angina and arrhythmias with non-atherosclerotic etiology, imaging techniques can diagnose the anatomopathological substrate of the disease and represent a valuable tool for the follow up.

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The value of Histopathological Diagnosis in Rupoid Psoriasis Accompanied by Fever. A Case Report and a Review of the Literature

Morariu SH1, Badea MA2*, Vartolomei MD3, Badea Iudita Maria4, Cotoi OS5

1 Department of Dermatology, University of Medicine and Pharmacy Tîrgu Mureș, Romania
2 Dermatology Clinic, County Hospital Tîrgu Mureș, Romania
3 Department of Molecular and Cell Biology, University of Medicine and Pharmacy Tîrgu Mureș, Romania
4 Anesthesiology and Intensive Care Medicine Clinic, Emergency County Hospital Tîrgu Mureș, Romania
5 Department of Pathophysiology, University of Medicine and Pharmacy Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0010

Psoriasis is a common dermatosis, however the rupoid type is considered as an exceptional form of this disease. Rupoid scabs are very rare in dermatological daily practice, usually being seen as secondary to syphilis in immunosuppressed patients. Rupoid psoriasis is characterized by thick and multilayered crusts that are resistant to local therapy and present a sudden onset. Severe arthropathy is a common manifestation. We did not found in literature any association of rupoid psoriasis with intermittent fever. We present the case of a patient who exhibited a rush of rupoid boards with severe arthralgia accompanied by intermittent fever. The suspicion of malignant syphilis was raised considering the clinical signs and symptoms and the specific social context of STDs. This suspicion was unconfirmed by TPHA negative reaction and histopathological appearance that showed changes typical of psoriasis. Clinical manifestations were successfully controlled with methotrexate.

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Left Bisegmentectomy for Liver Cirrhosis Associated Primary Hepatic Carcinoma With Preoperative Chemoembolization

Molnar C*, Silaghi C, Rosca C, Marginean L, Butiurca VO, Tudor A, Copotoiu C

University of Medicine and Pharmacy, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0009

Introduction: Hepatocellular carcinoma is the most frequent primary malignant tumor of the liver, being linked in 80% of cases with viral hepatitis ”B” or “C”. Treatment remains a challenge especially in cases with associated hepatic cirrhosis, where preoperative arterial chemoembolization followed by liver resection is recommended.
Case report: We discuss the case of a 64 years old cirrhotic patient, diagnosed by echography, computed tomography, magnetic resonance cholangiography with hepatocellular carcinoma (64x52x46 mm). Preoperative chemoembolization was performed with Lipiodol and 5-FU by supra-selective catheterization of left hepatic artery, followed by favorable radiologic response. Two weeks after embolization, the patient was admitted in Surgical Clinic No. 1 Targu Mures where an atypical resection of the left hepatic lobe (bisegmentectomy II-III) was performed with Harmonic Scalpel. Early and late postoperative evolution was favorable.
Discussions: The principle of arterial chemoembolization is based on the fact that vasculature of primary hepatic tumors is predominantly arterial. Arterial obstruction may lead to ischemic necrosis while tumor embolization combination with a chemotherapeutic agent significantly improves its local concentration. Decrease in tumor size and its vasculature allows for safe hepatic resection especially in the cirrhotic liver.
Conclusion: In case of tumoral cirrhotic liver preoperative chemoembolization decreases intra and postoperative bleeding risk, providing a safe and oncological resection.

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Cardiac Computed Tomography Angiography for Imaging Coronary Arteriovenous Malformation: a Case Report

Suciu Zsuzsanna1, Jakó Beáta2, Benedek Theodora1, Benedek I1

1 Clinic of Cardiology, Discipline of Internal Medicine 6, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
2 Clinic of Cardiology, County Emergency Clinical Hospital, Tîrgu Mureș, Romania

DOI: 10.2478/amma-2014-0006

Background: Coronary arteriovenous malformation is a rare congenital disease consisting mainly in a direct communication between a coronary artery and any one of the four cardiac chambers, coronary sinus, pulmonary arteries or veins. This disease can lead to various cardiovascular events, their severity depending on the degree of the malformation.
Case report: We present the case of a 56-year-old male patient, who was admitted to our institution with dyspnea, palpitation and chest pain, having a history of hypertension and hyperlipidemia, and an abnormal electrocardiogram. Physical examination did not reveal any alterations and the cardiac enzymes were in normal ranges. Cardiac computed tomography was performed before any other invasive studies, with a 64-row scanner (Somatom Sensation multislice 64 equipment, Siemens) after intravenous administration of non-ionic contrast material. CT scan revealed a large (2–2.5 mm) coronary fistula originating from the LAD to the main pulmonary artery, and multiple significant atherosclerotic coronary lesions. Coronary angiography confirmed the arteriovenous malformation between LAD and pulmonary artery, associated with three vascular coronary artery disease.
Conclusions: Cardiac computed tomography angiography can help for a non-invasive diagnosis of the coronary artery malformations, in the same time revealing anatomic details which can be particulary useful for choosing the appropriate management strategy (surgical planning, interventional treatment or optimum medical treatment).

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Is There a Risk Factor More Responsible for Disaster?

Carasca Cosmin1*, Muresan Vasile Adrian2, Tilea Ioan3, Magdas Annamaria4, Carasca Emilian4, Incze Alexandru4

1 County Emergency Clinical Hospital, Tirgu Mures, Romania
2 Surgical Clinic 1, County Emergency Clinical Hospital, Tirgu Mures, Romania
3 Cardiovascular Rehabilitation Clinic, Dept. Family Medicine, Institute of Cardiovascular Diseases and Transplantation Tirgu Mures, Romania,
4 Internal Medical Clinic 4, County Clinical Hospital, Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0054

Background: Risk factors for peripheral arterial disease are generally the same as those responsible for the ischemic heart disease and in both cases are overlapping risk factors involved in the etiology of atherosclerosis, such as smoking, dyslipidemia, diabetes and hypertension.
Case report: We present a case of a 61 years old male, whose ischemic peripheral symptoms began in 2003, at the age of 49, presenting as a Leriche syndrome. The patient was subjected to first revascularization procedure consisting in aortic-bifemoral grafting in the same year. General examination revealed no risk factors except smoking. Only a year after, he returns with critical right lower limb ischemia due to bypass thrombosis, therefore two thrombectomies were performed followed by a right side femoro-popliteal bypassing with Dacron prosthesis. The patient’s condition was good until 2008 when a femoro-popliteal bypass using inverted autologus saphenous vein was imposed due to occlusion of the previous graft. In 2013 the patient was readmitted to hospital with left lower limb critical ischemia. A femoro-popliteal bypass was performed, followed by two thrombectomies and the amputation of the left thigh. Up to this date, the patient kept smoking.
Discussions: Although our patient has a low/medium risk level of atherosclerosis by Framingham score and a minimum Prevent III score, all the surgical revascularization procedures were not able to avoid the amputation.
Conclusions: There are enough reasons to believe that smoking as a single risk factor can strongly influence the unfavorable progression to amputation in patients with peripheral arterial disease.

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Rare Cause of Cephalalgia in a Young Woman – a Case Report

Varga Andreea, Szakacs Xantus Timea*, Gliga Mirela, Podoleanu Cristian Gheorghe Calin, Bocicor Andreea Elena, Carasca Emilian, Tilea Ioan

University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0045

Background: Young adults meeting hypertension diagnostic criteria have a lower prevalence of a hypertension diagnosis. Headache is a rather common symptom among young people. Fibromuscular dysplasia (FMD) is an idiopathic, segmental, nonatherosclerotic and non-inflammatory disease of the muscular tunica of arterial walls, leading to stenosis of small and medium-sized arteries. Fibromuscular dysplasia is much more common than previously thought and is a treatable cause of secondary hypertension.
Case presentation: We present the case of an 18 y.o. young woman, with headache and high blood pressure. “White coat hypertension” was suspected. Clinical history with abrupt onset and increasingly difficult to treat hypertension especially in women, were suggestive for renal artery stenosis. Renal ultrasound and digital subtraction angiography confirmed the aspect of FMD. Sequential percutaneous renal artery angioplasty was later performed with improved evolution both from the clinical point of view and controlled blood pressure below 140/90 mmHg with minimal antihypertensive regimen. Angio CT exam of neck and brain arteries was performed, no other FMD typical lesions were identified.
Conclusions: Medical treatment is first indicated for the hypertensive patient. In this particular case percutaneous renal artery angioplasty showed significant improvement in reduction of antihypertensive treatment in a young patient with secondary hypertension. Further monitoring and management of this patient will include blood pressure measurements at 3-month intervals and renal function measurements annual, as well as non-invasive duplex ultrasonography at 12-month intervals, follow-up is indefinite. It remains challenging whether the patient can be medically managed on antihypertensive medication alone.

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Low Molecular Weight Heparin versus Coumadin-Induced Skin Necrosis in a Patient with Superficial Vein Thrombosis – A Case Report

Sala Nicoleta, Burdun Oana-Cristiana*, Botoman Maria, Rab Andrea, Bancu Ligia Ariana, Ureche Corina

University of Medicine and Pharmacy Tîrgu-Mures, Romania

DOI: 10.1515/amma-2015-0040

Introduction: Coumadin and low molecular weight heparin (LMWH) induced skin necrosis are rare clinical conditions.
Case presentation: A 63-years-old female patient, known with hypertension and right-sided hemiparesis, had presented to the emergency departement with pain and erythema of her internal right thigh. Venous Doppler-echography showed internal safenous vein thrombosis, thus she was started on anticoagulant treatment with Dalteparin and Acenocoumarol. On the 5th day of treatment she developed plantar hematoma on her left leg, followed by the appearance of hematomas, on the lower third of her right calf and on coxofemoral regions. Therefore, we raised the suspicion of heparin or coumadin-induced cutaneous necrosis, we stopped the anticoagulation for 5 days and restarted it with the administration of Rivaroxaban, fresh frozen plasma, antibiotics and local, sterile, saline dressings. After four days the patient presented deep vein thrombosis on her left calf.
Results and Discussion: Coagulation abnormalities were suspected, but infirmed by normal values of specific laboratory tests, such as Protein C (472.2%), protein S (77.10%), lupus anticoagulant (LA1-screening 53, 5s, LA-confirmation 38,0s). Hemogram showed normal platelet values. To exclude a malignancy, abdominal CT scan was performed, which revealed a right adnexal inomogenic cystic lesion, CA-125 (6,5U/ml), requiring further gynecological investigations. For the treatment of skin lesions, the patient required necrectomy and skin graft application.
Conclusion: Particularly, considering that the patient was initially anticoagulated with LMWH and coumadins simultaneously, the etiology of her cutaneous lesions remains uncertain.

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