Category Archives: Case Report

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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Left Ventricular Non-compaction Cardiomyopathy – A Case Report

Szakacs Xantus Timea, Varga Andreea*, Bocicor Andreea Elena, Tatar R, Tilea I

University of Medicine and Pharmacy Tîrgu-Mures, Romania

DOI: 10.1515/amma-2015-0039

Background: Left non-compaction cardiomyopathy (LVNC) or “spongy myocardium” is a relatively rare primary genetic cardiomyopathy, characterized by prominent wall trabeculations and intertrabecular recesses which communicate with the ventricular cavity. It appears in isolated form or coexists with other congenital heart diseases and/or systemic abnormalities.
Material and method: A 28-year-old woman was admitted with exertional dyspnoea, palpitations, non-specific chest pain and progressive fatigue on exertion. In her family history sudden cardiac-related deaths at young age are present. Cardiovascular system examination revealed tachycardia, intermittent extra beats. The rest EKG showed sinusal tachycardia (105 bpm), negative T-waves in DII, DIII, aVF, V4-V6. Consecutive 24 hours Holter EKG monitoring revealed nonsustained ventricular tachycardia, paroxysmal atrial fibrillation, isolated ventricular extrasystoles. Echocardiography showed left ventricular systolic dysfunction (LVEF:30-35%), slight LV enlargement, normal right ventricle and small left ventricle (LV) trabeculae in the apical area. Cardiac MRI demonstrated dilated LV and the presence of the trabeculations of LV walls suggestive for non-compaction cardiomyopathy. A combined treatment for heart failure and cardiac arrhythmias was initiated with good clinical results. Patient was scheduled for an implantable cardioverter defibrillator “life-saving”. Conclusions: The symptoms of heart failure and cardiac arrhythmias should be considered important in apparently healthy young patients. Besides intensive medical treatment is indicated the implantation of an ICD “life-saving” and in advanced cases heart transplantation. Even if the electrocardiographic findings are non-specific for noncompaction, a complete diagnostic evaluation is important, including sophisticated imaging techniques, a screening of first-degree relatives, and an extensive clinical, and genetic appreciation by a multidisciplinary team.

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Piggy-back Hepatic Transplant Technique and Veno-venous Bypass Without Cardiac Arrest: A Multidisciplinary Approach in Borderline T3b/T3c Renal Tumors

Nechifor-Boila IA1*, Suciu H2, Loghin Andrada3, Borda Angela3, Maier A1, Martha Orsolya1, Chibelean C1

1 Department of Urology, Tîrgu-Mureş University of Medicine and Pharmacy, Tîrgu-Mures, Romania
2 Department of Cardiovascular Surgery, Tîrgu-Mureş University of Medicine and Pharmacy, Tîrgu-Mures, Romania
3 Department of Pathology, Tîrgu-Mureş University of Medicine and Pharmacy, Tîrgu-Mures, Romania

DOI: 10.1515/amma-2015-0038

Surgery for renal cell carcinomas with tumor thrombus extending in the Inferior Vena Cava (IVC) can be particularly challenging, especially in the retrohepatic and intraatrial situations (T3b and T3c). Classically, these tumors require the intraoperative use of cardio-pulmonary by-pass (CPB) and deep hypothermic circulatory arrest (DHCA), that can result in specific complications (stroke, platelet dysfunction), with increased postoperative morbidity rates.
In urological practice, a particular IVC preparation method is currently in use, allowing full control both upon the IVC and its tributaries. It is derived from the “piggy-back” liver transplantation technique and implies the resection of all hepatic ligaments, leaving the hepatic vascular connections intact. This procedure is joined by a form of veno-venous bypass (between the right atrium and the infrarenal IVC) that allows a constant central venous pressure (by assuring blood return), with less bleeding and without the need for CPB and DHCA (avoiding, in this way, their inherent complications). All in all, these recently-introduced procedures can offer better thrombus control, improved oncologic outcomes and smaller complication rates. We aim to present a case of borderline T3b/T3c renal tumor that was successfully treated in our university center using these techniques.

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Relapsing Polychondritis Possibly Caused by Chronic Infection with Borrelia Burgdorferi: Case Report

Morariu SH1, Badea MA1, Cotoi OS2, Vartolomei MD3, Badea Iudita-Maria4, Suciu M5, Buicu F6

1 University of Medicine and Pharmacy of Tirgu-Mures, Romania
2 University of Medicine and Pharmacy of Tirgu-Mures, Romania, Department of Pathophysiology
3 University of Medicine and Pharmacy of Tirgu-Mures, Romania, Department of Molecular and Cell Biology
4 Clinic of Anesthesiology and Intensive Care Medicine, Emergency County Hospital of Tîrgu Mureș, Romania
5 University of Medicine and Pharmacy of Tirgu-Mures, Romania, Department of Prosthetic Dentistry and Oral Rehabilitation
6 University of Medicine and Pharmacy of Tirgu-Mures, Romania, Department of Public Health and Medicines Management

DOI: 10.1515/amma-2015-0018

Introduction: Relapsing polychondritis has been described by Rudolph von Jaksch Warthenhorst in 1923 under the name of polichondropathy. Although the etiology is unknown, an autoimmune mechanism is likely due to formation of autoantibodies to type II collagen in the extracellular matrix of the cartilage with its consequent destruction.
Case report: We present a case with relapsing polychondritis according to McAdam and Damiani criteria and with positive Western blot reaction for Ac IgG anti Borrelia burgdorferi. Serological reaction became negative and the patient presented favorable evolution at 6 months follow-up after corticosteroid therapy and antibiotics.
Conclusion: Chronic infection with Borrelia burgdorferi may play a role in relapsing polychondritis determinism

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