Category Archives: Case Report

SARS-CoV2 Infection in a Multiple Sclerosis Patient Treated with Natalizumab – A Case Presentation

Georgiana Șerban, Rodica Bălașa

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2020-0022

Introduction: The novel coronavirus, SARS-CoV2, has rapidly spread worldwide and led to an intense collaboration among both physicians and researchers in order to stop its dissemination. Little is yet known about how this virus behaves, but recent studies have suggested the role of integrins in the viral penetration of target cells. Natalizumab is an anti-α4-β1 integrin monoclonal antibody used in the treatment of multiple sclerosis (MS), a neurodegenerative auto-immune disease affecting primarily young adults. MS patients have a greater susceptibility to develop severe infections especially enhanced by the disease-modifying therapies (DMTs) which are currently recommended for their treatment. Natalizumab is considered the safest high-efficacy DMT in times of COVID-19 outbreak.
Case presentation: We hereby describe the first case from Romania of a MS patient treated with Natalizumab who subsequently acquired SARS-CoV2 infection and whose recovery was excellent, with no functional neurological or respiratory sequelae.
Conclusion: The favourable evolution of our patient supports the potential therapeutic effect Natalizumab might have in SARS-CoV2 treatment by specifically blocking integrins and by its immunosuppressant characteristics.

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Ambulatory Treatment of Pressure Sores in a Patient without Neurological Lesions

Anca Cighir, Paul Antoniu Adrian Boțan

George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania

DOI: 10.2478/amma-2020-0021

Introduction: Pressure sores have been defined as areas of localized soft tissue ischemic necrosis caused by prolonged pressure related to posture, which usually occur over a bony prominence. The most affected areas are those that undergo a lot of tension such as trochanters, sacrum, malleoli, heels and occiput. Most people that are affected by pressure sores have an underlying pathology that makes them immobile, confining them to chairs or bed for longer periods of time. Pressure ulcers may have direct causes (pressure, shear, friction, immobility, loss of sensation) or indirect causes.
Case presentation: This paper will present the case of a 53-year-old male. After about 3 weeks of being immobilized in bed in dorsal decubitus due to an acute respiratory distress which required intubation and mechanical ventilation, the patient developed very large pressure sores on the left sacral and buttock area and left sole. He was treated in the outpatient department using multiple therapeutic protocols based on the alternation of antibiotic creams and modern absorbent dressings.
Conclusions: The evolution of this patient was long but favorable, the left sacral and buttock area eschar closing completely while the sole eschar had a good evolution, but is still undergoing treatment.

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Asymptomatic Myxomatous Degeneration of the Mitral Valve, in a Young Male

Carmen Opris1, Horatiu Suciu1,2, Catalin Satala3, Cosmin Banceu2, Cosmin Opris1, Alexandra Stoica2, Tudor Capilna2, Simona Gurzu3,4

1. Department of Adult and Children Cardiovascular Recovery, Emergency Institute for Cardio-Vascular Diseases and Transplantation, Targu Mures, Romania
2. Department of Surgery, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
3. Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
4. Research Center (CCAMF), George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania

DOI: 10.2478/amma-2020-0018

Background: In young patients, the most common cause of mitral valve regurgitation is prolapse or flail of the valve, which is morphologically reflected by myxomatous degeneration. In rare cases, such this presented in this paper, this lesion might be incidentally identified, in young people.
Case presentation: A 43-year-old male, with familial history of hypertension, presented in our Department of Cardiology for a routine check-up. Despite of lack of symptoms, an intense murmur was detected at mitral auscultation area. The echocardiography revealed a severe mitral regurgitation caused by flail of posterior mitral valve. The patient was transferred to the Cardiac Surgery Department for surgical intervention consisting in mitral valve repair. The histopathological examination revealed severe myxomatous degeneration of the spongiosa and fibrosa layers. The recovery after surgery was very good with no postoperative complications. The patient was discharged seven days after surgery, with no significant mitral regurgitation at the three-month follow-up.
Conclusions: In young, asymptomatic patients, the proper time for mitral valve repair should be decided by an interdisciplinary team. For a better understanding of myxomatous degeneration particularities, histopathological assessment should be done in any replaced valve. Certification of such lesions, under microscope, might be an indicator for familial cardiovascular screening, in first degree relatives.

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Necrobiosis Lipoidica Diabeticorum

Anca Cighir, Paul Antoniu Adrian Boțan

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2020-0013

Introduction: Necrobiosis lipoidica diabeticorum is a rare complication occuring mostly in diabetic patients appearing as a skin redness that soon transforms into an extensive necrosis. The usual aspect of such lesions is a deep ulceration with irregular borders developing especially on the lower limbs.
Case presentations: This paper intends to present two cases of necrobiosis lipoidica diabeticorum focusing on the clinical aspect of this disease and the original treatment applied in the Plastic Surgery Department of the Clinical County Hospital of Targu Mures. Both patients suffered from type II insulin-requiring diabetes. The first case is a 63 year old female with different stages of necrobiosis lipoidica diabeticorum lesions developed on the anterior aspect of both legs. This patient was treated using only conservative methods. The second case is a 64 year old male who developed an extensive full-thickness necrosis on the right dorsal aspect of the hand and forearm. The lesions required conservative treatment and the surgical debridement of the extensive necrotic tissues.
Conclusions: Necrobiosis lipoidica diabeticorum is a dramatic condition requiring a well informed approach in order to save the healthy tissues as much as possible. In both cases, the wounds healed spontaneously after a long period of time.

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Urinary Retention in Female after Augmentation Gluteoplasty: A Case Report

Veronica Maria Ghirca1, Anna E Frunda2, Daniel Porav-Hodade1, Călin Chibelean1,
Ciprian Todea-Moga1, Oliver Vida1, Orsolya Mártha1

1. Urology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2. Pediatric Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2020-0011

Introduction: There are many well-known complications after gluteal augmentation surgery, such as: seroma, hematoma, capsular contracture, retraction, wound dehiscence etc., but there are some due to nervous damage (especially submuscular pockets with large implants) insufficiently recognized. The aim of this case report is to highlight a rare complication (urinary retention) after gluteal augmentation surgery with use of solid silicone implants in case of 41-year-old female. Woman aged 41 with a buttock augmentation with silicone implant (submuscular pocket, 300cc) performed 2 months before at plastic surgery service in Madrid, was admitted in our service, the Clinic of Urology from Tg. Mures, with permanent bladder catheter inserted for urinary retention.
Outcome: At the admission, two months after the surgery the clinical examination revealed a permeable urinary catheter with clear urine and a fistulisated wound infection localized in the superior 1/3 of the incision in the intergluteal sulcus. Neither neurological or gynecological examination identified any pathology. After the removal of the catheter, next day the abdominal ultrasonography showed a distended bladder, with a postvoid residual urine volume of 320 ml. Urodynamic investigations (uroflowmetry, pressure flow studies) revealed a reduced Qmax. 7,6 ml/sec, underactive detrusor with a reduced BCI value of 60 (bladder contractility index), requiring self-intermittent catheterization, associated with alpha-blockers.
Conclusions: Buttock implantation is a frequently used plastic surgery procedure with rather high rate of complications, some of them not well identified, unknown such as detrusor underactivity leading to urinary retention.

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Genetic Investigation and Clinical Aspects in a Romanian Treacher Collins Syndrome Family – A Case Report

Mădălina Anciuc1, Florin Tripon2,3, Carmen Duicu1,3, Carmen Gliga1, Claudia Bănescu1,2,3

1. Emergency Clinical County Hospital, Targu Mures, Romania
2. Genetics Laboratory, Center for Advanced Medical and Pharmaceutical Research, Targu Mures, Romania
3. George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2019-0026

Introduction: In approximately 96% of probands, the diagnosis of Treacher Collins Syndrome (TCS) is confirmed by molecular genetic tests. These tests can detect heterozygous mutation of TCOF1 gene (coding treacle protein) and variants of POLR1D gene (coding RNA polymerase I subunit D) with autosomal dominant inheritance, or biallelic variants of POLR1C gene (coding RNA polymerase I subunit C) and POLR1D with autosomal recessive inheritance. Case presentation: We present a neonate proband with family history of clinical features suggestive for TCS. Our patient was investigated for copy number changes (CNCs) of TCOF1 gene using SALSA MLPA P310-B3 TCOF1 probemix to perform Multiplex Ligation-dependent Probe Amplification (MLPA), the results being normal. Dysmorphic features revealed “bird-like” face with trigonocephaly, craniosynostosis, hypoplastic supraorbital rims, underdeveloped zygomas, mandibular hypoplasia and retrognathia (mandibulofacial dysostosis). Other clinical features, like abnormal position and structure of the external ears (microtia, with a bilateral low-set ears, crumpled and malformed pinnae and aural atresia), were also observed. Conclusion: Taking into account our results, and also data found in literature, we consider that all TCS cases, but in particular patients with specific TCS features and without CNCs, require additional investigations using sequencing techniques.

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Silent Ischemic Stroke Was Revealed after Screening for Cognitive Dysfunction in a Hypertensive Patient with New Onset Atrial Fibrillation – Case Report

Tünde Pál1, Zoltan Preg2, Enikő Nemes-Nagy2, Robert Gabriel Tripon2, Beáta Baróti2,
Márta Germán-Salló2

1. Emergency County Hospital Targu Mures, Romania
2. University of Medicine and Pharmacy Science and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2019-0018

Introduction: Hypertension is one of the most important modifiable risk factor related to cognitive decline and dementia. However, screening for cognitive dysfunction is not part of the routine clinical assessment.
Case presentation: In this report, we present the case of a 75 year old hypertensive male patient with new-onset atrial fibrillation, admitted to the Cardiovascular Rehabilitation Clinic Târgu Mureș. Apart from the routine clinical assessment, the evaluation of cognitive functions was performed with three different screening instruments which identified cognitive dysfunction. Depressive state was assessed with the shortened 13 items form of the Beck Depression Inventory BDI-13 (BDI-13) and it showed moderate depression which could influence the results of cognitive tests. Detection of cognitive impairment was followed by magnetic resonance imaging, which revealed not only hypertension specific microvascular impairment but also a sequelae of a former stroke in the territory of the left middle cerebral artery and a possible meningioma.
Conclusion: Screening for cognitive dysfunction in high-risk hypertensive patients can be easily performed and in several cases like ours, can unmask silent cerebrovascular pathologies, leading to prognostic and therapeutic consequences.

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Postoperative Lymphorrhagia – a Possible Complication Following Cephalic Duodenopancreatectomy

Adrian Tudor1,2, Marian Botoncea1, Cedric Kwizera1, Bianca Cornelia Tudor3,4, Cosmin Nicolescu1,2, Călin Molnar1,5

1. First Surgical Department, Emergency Clinical County Hospital of Târgu Mures, Mures, Romania
2. Anatomy and Embryology Department, University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania
3. Lab Medicine, Clinical County Hospital of Târgu Mureș, Romania
4. Microbiology, virology and parasitology Department, University of Medicine, Pharmacy, Sciences and Techology of Târgu Mureș, Romania
5. Surgery I Department, University of Medicine, Pharmacy, Sciences and Technology of Târgu Mures, Romania

DOI: 10.2478/amma-2019-0013

Surgery associated with lymphadenectomy may sometimes result in a lymphorrhagia, which usually resolves spontaneously within a few days, sometimes becoming a refractory complication to the treatment. In the case of large flows, particular attention should be paid to hydroelectrolytic and protein losses. We present the case of a patient with persistent lymphorrhagia after a cephalic duodenopancreatectomy for a pancreatic head tumor. From the 5th postoperative day, the patient had a milky-like secretion on the subhepatic drainage tube. The discharge rate was variable, between 500 and 1500 ml per day, requiring parenteral administration of amino acids, plasma and electrolyte solutions. The postoperative progression was slowly favorable, with the patient discharge on the 25th day following surgery. There are several treatment options for a lymphorrhagia following an extended lymphadenectomy, from intensive parenteral therapy to peritoneal-venous shunt or ligation of the lymphatic vessel responsible for the production of lymphorrhagia. In this case the conservative treatment had a favorable result.

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Case Presentation: Unusual Association Between Possible Bilateral Intraventricular Xanthogranulomas, Postero-inferior Cerebellar Artery Aneurysm and Thrombophilia

Sebastian Razvan Andone1, Andreea Romaniuc1, Zoltan Bajko1,2, Smaranda Maier1,2, Laura Barcutean2, Rodica Bălaşa1,2

1. Mures County Emergency Clinical Hospital, Târgu Mureş, Romania
2. University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania

DOI: 10.2478/amma-2018-0027

Introduction: Xanthogranulomas are rare, benign, usually asymptomatic, cutaneous tumors most frequently seen in children (juvenile xanthogranulomas). Some lesions can be found accidentally at randomly performed cerebral computer tomography (CT) or magnetic resonance imaging (MRI) or even on autopsy.
Case report: We present the case of a 44 year-old woman, known with a thrombophilic disorder (PAI-1 gene mutation, MTHFR C677T and A1298C) on chronic anticoagulant treatment. The onset of symptoms was in 2010, when she presented paresthesia and lower limbs weakness. Two years later the patient presents with severe intermittent headache and left hemicrania and a cerebral angio-MRI is performed showing a left postero-inferior cerebellar artery aneurysm and two choroid plexus intraventricular masses in the lateral ventricles. The patient developed a new symptom, dysarthria in 2014 and in 2015 has multiple episodes of loss of consciousness, interpreted as epileptic seizures. Routine blood tests were within normal range, except for a high cholesterol level. The patient was tested for autoimmune, infectious, endocrine and metabolic diseases that were negative. Surgical treatment and biopsy from the lesion was proposed, however the patient refused both procedures.
Conclusions: There is an association between xanthogranulomas localization and the choroid plexus, the most frequent CNS origin being in the trigon of the lateral ventricle. Our case does not resemble with any other case published, mostly because the unusual presentation, symptomatology and the association between xanthogranulomas, thrombophilia and postero-inferior cerebellar artery aneurysm which were never reported before in other cases of xanthogranulomas from the literature.

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Uncommon Finding of a Gastrointestinal Stromal Tumor in a Patient with Hyperechoic Liver Lesions – Case Report

Adina Maria Roman1, Daniela Dobru1,2, Crina Fofiu2, Alina Boeriu1,2

1. Mures County Clinical Hospital, Târgu Mureş, Romania
2. University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania

DOI: 10.2478/amma-2018-0026

Introduction: Hyperechoic liver lesions identified by conventional ultrasonography are diverse in underlying pathology and most of the time require further investigations. Gastrointestinal stromal tumors (GIST) are rare neoplasms of the gastrointestinal tract which are uncommonly found in metastatic stages at first presentation.
Case report: We present the case of a 51 years old woman with nonspecific symptoms in which conventional ultrasonography showed hyperechoic lesions in the right lobe of the liver with a diameter up to 40 mm. Esophagogastroduodenoscopy revealed a submucosal tumor on the small curvature of the stomach, on the anterior wall, with central ulceration, with normal narrow band imaging (NBI) mucosal pattern and negative gastric biopsy. Contrast enhanced ultrasonography was performed, describing multiple lesions with inhomogeneous enhancement in the arterial phase and rapid washout at the end of arterial phase. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) biopsy examination was definitive for the final diagnosis of epithelioid gastric gastrointestinal stromal tumor. The patient was diagnosed with T2N0M1 epithelioid gastric GIST, stage IV, and is currently under treatment with tyrosine kinase inhibitors.
Conclusions: GIST represent a diagnostic challenge in medical practice because of its size, unusual location in the submucosal layer and lack of symptoms. The role of EUS-FNA is of paramount importance in increasing the accuracy of diagnosis in the case of GIST. The particularity in our case consists of the unusual presentation with the lack of specific symptoms and signs associated with the presence of metastatic lesions at the moment of the diagnosis of GIST.

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