Category Archives: Case Report

Transthoracic 3D Echocardiographic Imaging of Type A Aortic Dissection – Case Presentation

István Adorján Szabó, Ildikó Kocsis, Zoltán Fogarasi, Boglárka Belényi, Attila Frigy

Clinical County Hospital Mures, Romania

DOI: 10.1515/amma-2017-0027

In type A aortic dissection (AoD) an early and accurate diagnosis is essential to improve survival, by applying urgent surgical repair. 3D transthoracic echocardiography (3D-TTE), an advanced noninvasive imaging technique, could offer a comprehensive evaluation of the ascending aorta and aortic arch in this regard. Both modalities of real-time 3D imaging – live 3D and full-volume aquisition – proved to be useful in evaluating the localization and extent of AoD. Our case illustrates the utility of 3D-TTE in the complex assessment AoD. By providing the proper anatomical dataset, 3D-TTE could facilitate considerably the diagnosis of type A AoD.

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Practical Advantages of CBCT in the Surgical Treatment of Impacted Lower Third Molar

Alina Ormenișan, Alina Iacob, Daniel Szava, Balint Bogozi, Adina Coșarcă

University of Medicine and Pharmacy Tirgu Mures, Romania

 

DOI: 10.1515/amma-2017-0006

Introduction: The imaging method of cone beam is an improved, extremely accurate computed tomography applicable in the whole field of dentistry. Due to its ability to locate the exact position of the impacted teeth, CBCT software has an important role in the management of difficult cases of impacted third molar. In some situations, the lower third molar is quite near to the inferior alveolar nerve that the surgical extraction can present a high risk of post-operative sensitive impairs of the skin and mucosa of the lower lip and chin on the same side.
Presentation of case series: Our study tried to assess the contribution of CBCT in the pre-operative evaluation and further treatment of patients with impacted third molars in mandibular bone with high risk of inferior alveolar nerve injury. The paper presents three clinical cases showing positive signs on standard OPG, which exhibit indicators of a potential contact between the inferior alveolar nerve and the impacted lower third molars. For an improved exploration Dental CT Scan, DICOM image acquisition program, and 3D reconstruction with a special software were used. Conclusions: The study showed that compared with panoramic radiography, CBCT improve the evaluation of the surgical risk and allow a more accurate planning of surgery.

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An Uncommon Severe Case of Pulmonary Hypertension – From Genetic Testing to Benefits of Home Anticoagulation Monitoring

Varga Andreea1, Țilea Ioan1*, Lazar Erzsebet1, Negovan Anca Elena2, Banescu Claudia3, Tatar Maria Cristina2

1 Family Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Internal Medicine III, University of Medicine and Pharmacy Tirgu Mures, Romania
3 Genetics, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0050

A 62 year-old caucasian male was admitted in our pulmonary hypertension expert center with initial diagnosis of pulmonary veno-occlusive disease for validation and specific treatment approach. Routine examinations revealed no apparent cause of pulmonary hypertension. Patient was referred for a thorax contrast enhanced multi-slice computed tomography which revealed extensive bilateral thrombi in pulmonary lower lobe arteries, pleading for chronic post embolic lesions. A right heart catheterization and pulmonary angiography confirmed the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). Following the local regulations, the patient underwent thrombophilia screening including molecular genetic testing, with positive findings for heterozygous for VCORK1 -1639G>A gene single nucleotide polymorphism, PAI-1 4G/5G and factor II G20210A gene. With heterozygous genetic profile of 3 mutations he has a genetic predisposition for developing a thrombophilic disease which could be involved in the etiology of CTEPH. Familial screening was extended to descendants; the unique son was tested with positive results for the same three genes. Supportive pulmonary hypertension drug therapy was initiated together with patient self-monitoring management of oral anticoagulation therapy. For optimal control of targeted anticoagulation due to a very high risk of thrombotic state the patient used a point-of-care device (CoaguChek®XS System, Roche Diagnostics) for coagulation self-monitoring.

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Case Report: Endoscopic Management of Sleeve Gastrectomy Fistula

Roşu Alexandra Floriana1*, Ferreira Carlos Noronha2, Ribeiro Luis Carrilho2, Velosa José2, Zlatian Ovidiu Mircea3

1 Gastroenterology Department, County Clinical Emergency Hospital, Craiova, Romania
2 Gastroenterology and Hepatology Department, University Hospital Santa Maria, Lisbon, Portugal
3 Microbiology department, University of Medicine and Pharmacy of Craiova, Romania

DOI: 10.1515/amma-2016-0049

Background. Morbid obesity is an important cause of morbidity and mortality. Bariatric surgery is the best option to manage obesity. Vertical gastrectomy is safe and effective but sometimes complicate with hemorrhage, fistulas and stenosis. Fistulas can be solved by conventional surgery or interventional endoscopy.
Case presentation. We describe a morbidly obese patient with vertical gastrectomy who developed complications after surgery. Immediately after surgery the patient developed sepsis. Upper gastrointestinal endoscopy excluded fistula. One month later a peri-gastric abscess developed due to a fistula orifice in the distal esophagus, treated with argon plasma and two double pigtail plastic stents placed endoscopically to drain the abscess. The stents were removed two weeks later and was placed a covered metallic stent in the distal esophagus. Six weeks later the metallic stent was removed and the orifice closed. Four months later the patient developed sepsis. Computer tomography revealed a subdiaphragmatic abscess and endoscopy revealed a 2 mm fistula orifice at the previous site, treated with argon plasma and two trough-the-scope clips that closed it. There were no further incidents after two years of follow-up.
Conclusions. Early diagnosis and endoscopic approach can resolve these complications without the morbidity and increased mortality risk of surgical re-interventions.

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Metastatic Prostate Cancer with Highest Reported PSA Level

Martha Orsolya, Tilinca Mariana*, Tataru Octavian Sabin, Chiujdea Sever, Balan Daniel, Vartolomei Mihai Dorin

University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0044

Introduction: Prostate cancer is the sixth most common cancer in the world, the second most common cancer among men, and the most common cancer in men in Europe. Metastatic prostate cancer among young patients represents the rarest of the newly diagnosed prostate cancer, with few reports of cases with a longer survival.
Case presentation: We present the case of a 59 year-old male who was referred with back pain over the last month. Digital rectal examination highlighted an enlarged and totally indurated prostate of 4×4.5 cm, while abdomino-pelvic X-rays showed osteoblastic metastases in the spine and pelvis bones. Laboratory examinations revealed a Prostate Specific Antigen level of 7941 ng/ml. Prostate biopsy histology showed a bilateral prostate cancer with a Gleason score of 8. Androgen deprivation therapy and daily administration of biphosphonates were prescribed. After two years of treatment, the Prostate Specific Antigen level decreases to 8 ng/ml.
Conclusions: We reported the highest Prostate Specific Antigen level in a patient under 60 years old with metastatic prostate cancer. Prostate cancer remains an important public health problem due to the aggressiveness of the disease and advanced stage upon diagnosis. Prostate Specific Antigen is mandatory to evaluate, to have a reference level in order to prevent metastatic prostate cancer in young patients at diagnosis.

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A Rare Chromosomal Disorder – 14q Interstitial Deletion Syndrome

Boglis Alina*, Rac Corina Dana, Moldovan Elena, Duicu Carmen, Bănescu Claudia

University of Medicine and Pharmacy, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2016-0041

Introduction: Interstitial deletions of the long arm of chromosome 14q (OMIM 613457) are very rare conditions.
Case presentation: We present a 3-month-old male patient with dysmorphic features and congenital heart defect associated with a small interstitial deletion of chromosome 14q, identified by cytogenetic analysis as 46,XY,del(14)(q11q12). Dysmorphic features included microcephaly, broad nasal bridge, micrognathia, large and poorly folded auricular lobes and long digits. He also present rectus abdominis diastasis and umbilical hernia. The cranial computer tomography showed partial agenesis of the corpus callosum and ventriculomegaly.
Conclusions: Cytogenetic analysis or molecular techniques are necessary to establish the correct diagnosis in patients with multiple congenital anomalies in association with proximal or distal interstitial 14q deletion.

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Left Sided Gallbladder – Case Report

Török Árpád, Kantor Tibor*, Borz Cristian, Márton István Dénes, Mureșan Mircea

University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0042

Left sided gallbladder is a rare anomaly that is often associated with other abnormal anatomy in the hepatobiliary system. One left positioned gallbladder was found in a consecutive series of 3290 patients undergoing laparoscopic cholecystectomy for gallstone disease in the Mure County Emergency Hospital’s 2nd Surgery Clinic between 2005 and 2015, a prevalence of 0.03 per cent. In case of left sided gallbladder the cystic artery always crosses in front of the common bile duct from right to left. The cystic duct may open on the left or right side of the common hepatic duct. Anterograde cholecystectomy is the best choice for precise exploration of the cystic duct and cystic artery.

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Lyme Meningoradiculitis: Case Reports and Literature Review

Smaranda Maier1,2, Nicoleta Stirbu1,2*, Zoltan Bajko1,2, Anca Moţăţăianu1,2, Brânduşa Ţilea1,2, Adrian Alexandrescu1,2, Rodica Bălaşa1,2

1 University of Medicine and Pharmacy Tirgu Mures, Romania
2 Mures County Clinical Emergency Hospital, Romania

DOI: 10.1515/amma-2016-0033

The clinical manifestations of Lyme disease are protean. The meningoradiculitis is a common and well-recognized complication of neuroborreliosis but can be easily misdiagnosed without a high degree of clinical suspicion, mainly if the tick bite is not present in the medical history. We report two cases of Lyme meningoradiculitis with excellent outcome after appropriate antibiotic therapy. In an endemic area in case of neurological manifestations suggestive for neuroborreliosis the serological testing for B. burgdorferi in serum and cerebrospinal fluid is imperative for the correct diagnosis.

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To Be or Not to Be … Acute Coronary Syndrome

Irina Pintilie, Alina Scridon, Răzvan Constantin Șerban

Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureș, Romania, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2016-0029

Introduction: The association between ST segment abnormalities, elevated cardiac enzymes, and chest pain is usually a marker of acute coronary injury. However, certain other pathologies can sometimes mimic acute coronary syndromes.
Case report: A 40-year-old Caucasian male, former smoker, with no other cardiovascular risk factors, presented to the Emergency Department for typical ischemic, prolonged chest pain. The ECG demonstrated inverted T waves in leads I, II, aVL, and V3 to V6. The patient presented high cardiac necrosis markers (troponin I 2.65 ng/ml). Based on these findings, the case was interpreted as non-ST segment elevation myocardial infarction, but coronary angiography excluded the presence of significant coronary lesions. The ventriculography showed an efficient left ventricle, with mild hypokinesia of the two apical thirds of the anterior left ventricular wall. Cardiac magnetic resonance imaging demonstrated areas of hypersignal on the T2-weighted imaging sequence in the left ventricular myocardium, suggestive for acute myocarditis. The patient was started on antiplatelet, beta-blocker, and angiotensin converting enzyme inhibitor, with favorable evolution.
Conclusion: This case underlines the polymorphic appearance of acute myocarditis, which can often mimic an acute coronary event.

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Pulmonary and Cerebral Infarcts Due to Secondary Thrombosis Risk of a Genetic Mutation: Life-threating Methylentetrahydrofolate Reductase (MTHFR) Deficiency with Early Onset

Edith Simona Ianosi, Simona Szasz, Roxana Nemes, Gabriela Jimborean

University of Medicine and Pharmacy, Targu Mures, Romania

DOI: 10.1515/amma-2016-0026

Methylentetrahydrofolate reductase (MTHFR) is a key enzymatic component of the folate cycle, converting 5,10-methylentetrahydrofolate into 5-methylentetrahydrofolate. Severe MTHFR deficiency is a rare recessive disease leading to major hyperhomocysteinemia, homocystinuria, and progressive neurological distress within the two first decades of life.
We present the case of a young, 21 years old female patient who was admitted and treated in Clinic of Pneumology Tirgu Mures for a postero-basal left pneumonia without favourable radiologic evolution under antibiotic and symptomatic treatment. Thoracotomy was recommended in order to elucidate the diagnosis. The histopatological examination revealed the zone of pulmonary infarction. After 12 weeks from surgical intervention, the patient was admitted in Department of Neurology for stroke attack. The complex laboratory investigations reveal deficiency of methylentrahydrofolate reductase (MTHFR) caused by a genetic mutation.

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