Category Archives: Case Report

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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Surgical Strategy in Bouveret’s Syndrome. A Case Report

Márton István Dénes, Árpád Török, Etele Éltes, Levente Kucserik, Zsolt András, Bogdan Borz, Cristian Borz*

University of Medicine and Pharmacy Targu Mures, Romania

DOI: 10.1515/amma-2016-0017

Bouveret’s syndrome is a high mechanical obstruction due to impaction of a gallstone into the duodenum, through a cholecystoduodenal fistula. It belongs to a larger group of gallstone ileus, a disease which occurs after developing a fistula between the gallbladder and the gastrointestinal tract. This is a rare complication of gallstones but because it appears in elderly people, it has a high morbidity and mortality. Patients have various symptoms and the treatment is individualized. We present here a case of a 67 years old patient, admitted in emergency, presenting symptoms of high bowel obstruction, with onset 5 days before admission. Abdominal ultrasound reveals a 5 cm stone that seems to be in the gallbladder, gastric stasis and at gastroscopy appears a foreign body impacted in the duodenum. After a short preparation the patient underwent surgery. We found a dilated stomach and a large cholecystoduodenal fistula with an impacted gallstone in the duodenum. We performed one stage surgery: cholecystectomy, extraction of the stone and suturing of the fistula. We reestablished the continuity of the intestinal tract. We performed also an ileostomy for feeding the patient and protecting the anastomoses. The postoperative evolution was favorable.
We consider that one stage surgical treatment in gallstone ileus is an option, if the patient is in good condition and we have an adequate postoperative intensive care management.

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Deep Venous Thrombosis Associated With Inferior Vena Cava Abnormalities And Hypoplastic Kidney In Siblings

Duicu Carmen*, Bucur Gabriela, Simu Iunius, Tripon Florin, Marginean Oana

University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0011

Congenital inferior vena cava anomalies have a reduced frequency in general population, many times being an asymptomatic finding. Patients caring such anomalies are at risk to develop deep vein thrombosis. In this paper, we present 2 siblings with deep venous thrombosis and inferior vena cava abnormalities, with a symptomatic onset at similar age. The inferior vena cava abnormality was documented by an angio-CT in each case. The thrombophilic workup was negative. Patients were treated with conservative therapy: low molecular weight heparin anticoagulants converted later to oral anticoagulant with resolution of symptoms and disappearance of the thrombus. Finally, in the absence of any risk factor in a young patient admitted with deep vein thrombosis investigations to exclude inferior vena cava anomalies are mandatory.

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Endocrine dysfunction in neurofibromatosis type 1 – an update

Pop Raluca-Monica1,2, Radu Mircea Neagoe3, Kolcsar Melinda4*, Paşcanu Ionela5

1 Research Methodology Department, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Endocrinology Outpatient Clinic, Emergency Mureş County Hospital, Tirgu-Mures, Romania
3 Surgery Department, University of Medicine and Pharmacy Tirgu Mures, Tirgu-Mures, Romania
4 Pharmacology and Clinical Pharmacy Department, University of Medicine and Pharmacy Tirgu Mures, Tirgu-Mures, Romania
5 Endocrinology Department, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2016-0003

Background: Neurofibromatosis type 1 is an autosomal dominant disorder associated with multiple neoplasms particularly those of ectodermal origin. Various endocrine pathologies are often present, among them, hyperparathyroidism and follicular thyroid lesion are very rare described and their coincidence in the same patient has not been described in the literature reviewed.
Subject: A 59-years-old woman with clinical manifestation of neurofibromatosis type 1 developed dysphagia, dysphonia, choking sensation. Physical and imagistic examination revealed a multinodular goiter with microfollicular lesion on fine needle aspiration biopsy (FNAB), elevated parathormone levels and severe osteoporosis. The surgically removed thyroid contained a nodule with follicular architecture of uncertain malignant potential; the parathyroid tissue appeared normal.
Discussion and conclusion: This case serves as a reminder to look for non-neurogenic tumors in patients with neurofibromatosis. Clinicians must be aware of the diverse clinical features of this genetic disorder.

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Volemic resuscitation in a patient with multiple traumas and haemorrhagic shock. Anti-oxidative therapy management in critical patients. A Case Report

Bedreag Ovidiu Horea1,2, Rogobete Alexandru Florin1,2*, Sarandan Mirela3, Cradigati Alina Carmen3, Nartita Radu1, Sandesc Dorel1,2, Papurica Marius1,2

1 Clinic of Anaesthesia and Intensive Care, Emergency County Hospital ”Pius Brinzeu”, Timisoara, Romania
2 Faculty of Medicine, ”Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
3 Clinic of Anaesthesia and Intensive Care ”Casa Austria”, Emergency County Hospital ”Pius Brinzeu”, Timisoara, Romania

DOI: 10.1515/amma-2016-0002

A patient with multiple traumas is usually found in severe haemorrhagic shock. In 40% of the cases, the patient with multiple traumas and haemorrhagic shock cannot recover due to secondary injuries and complications associated with the shock. In this paper we present the case of a male patient 30 years old, who suffered a car accident. The patient is admitted in our hospital with haemorrhagic shock due to femur fracture, acute cranial-cerebral trauma and severe thoracic trauma with bleeding scalp wound, associated with lethal triad of trauma. The clinical and biological parameters demand massive transfusion with packed red blood cells (PRBCs), fresh frozen plasma (FFP), cryoprecipitate (CRY) and colloidal solution (CO) sustained with vassopresor for the haemodynamic stabilisation. During his stay in the ICU, the patient benefits from anti-oxidative therapy with Vitamin C, Vitamin E and Vitamin B1. After 14 days the clinical state of the patient improves and he is transferred in Polytrauma Department.

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Particular Aspects of a Pancreatic Insulinoma Case

Motoc R1,2, Albu C2, Munteanu Irina2, Dirtu Oana2, Motoc Crina2, Tilea I3,2

1 Internal Medicine Clinic III, Dept. M3, Faculty of Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Tirgu Mures Emergency Clinical County Hospital, Tirgu Mures, Romania
3 Family Medicine, Dept. M3, Faculty of Medicine, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/amma-2015-0130

With a very low incidence (1-4 cases per 1 million per year), characterized by insulin hypersecretion, independent of the glycemia control system, insulinoma is a rare endocrine tumor, clinical with accentuated neuropsychological symptoms that hampers clinical diagnosis. We present a case of a 33 years old patient with no notable personal history, active lifestyle, non-smoker, a work environment that doesn’t involve professional toxicity; a remarkable family history of a brother with type 1 diabetes mellitus and grandmother with liver adenocarcinoma was noticed; in this particular case Whipple triad was strongly suggestive, gastrointestinal upper-ultrasonography endoscopy with tissue puncture as a tumor diagnostic tool was used and laparotomy was used successfully for removing the tumor, with favorable follow-up.

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Coronary Artery Dissection in the Left Main Treated with Stenting in a Patient with Multiple Re-infarction – Case Report

Nyulas Tiberiu1, Blendea Ciprian1,2, Barcan Andreea1, Bajka Balazs1,2, Korodi Szilamer1, Rat Nora1

1 University of Medicine and Pharmacy of Tîrgu Mureș, Clinic of Cardiology, Tîrgu Mureș, Romania
2 Cardio Med Medical Center, Department of Advanced Multimodal Imaging, Tîrgu Mureș, Romania

DOI: 10.1515/amma-2015-0129

Introduction: In complex cases of multiple coronary artery stenosis, revascularization strategy could be essential for improving the life expectancy andqualityof life. However, major complications are sometimes encountered during interventions, such as rupture of the atheromatous plaque with consequent dissection of the coronary artery, causing an acute coronary syndrome which requires immediate intervention from the operator. In the absence of an experienced interventional cardiologist a complication like this can be fatal. Case presentation: We present the case of a 67-years old patient, male, with a known history of cardiovascular disease, who presented in our service complaining of chest pain with tightening character, irradiation in the shoulder and left arm, respectively shortness of breath and fatigue. The patient presented a history of multiple infarctions, intervention and stenting on RCA and circumflex artery. Computed Tomographic Coronary Angiography provided detailed information on the location of the target lesions and was followed by a revascularization procedure. However, despite the complex pre-interventional assessment, while trying to engage the guide in the emergence ofthe circumflex artery, atherosclerotic plaque rupture occurred, causing a dissection of the coronary wall which extended retrogradely into the left main, requiring a rapid response from the operator. A coronary stent was implanted into the left coronary artery trunk, treating the dissection. Conclusions: Coronary artery dissection is a very serious complication that can occur during a complex revascularization procedure, requiring immediate intervention in order to save the patient’s life.

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