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Salivary duct carcinoma (SDC) is a rare and highly aggressive salivary gland tumor with rapid growth, distant metastasis, and a high recurrence rate. Moreover, the parotid gland is the most common site with a poor prognosis. A lower frequency of distance metastasis to the liver, skin, and brain has also been reported, although the lungs, bones, and lymph nodes are the most common sites of SDC metastasis. We report a case of nonconvulsive status epilepticus (NCSE) in a 73-year-old male comatose patient having SDC of the parotid gland with an unusual metastasis to the skin and brain diagnosed by frequent cerebrospinal fluid examinations. Meningeal carcinomatosis usually has a poor prognosis, and NCSE is a reversible cause of altered mentation. Clinicians should know the unique set of epilepsy etiologies in patients with malignant tumors.
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Granulomatosis with polyangiitis (GPA) is the systemic vasculitis affecting predominantly small vessels, but vasculitis of medium size artery can be associated. We treated a patient with GPA who had hemorrhagic instability because of a rupture of an aneurysm in the branch of the renal artery; the patient underwent arterial embolization (AE), and hemostasis was successfully achieved. Literature reviews were conducted on the basis of the data available on PubMed, and seven published reports of eight cases with renal artery aneurysms were identified. We concluded that emergency physicians should be aware of the existence of renal artery aneurysms associated with GPA. AE should be considered as one of the treatment choices whenever renal bleeding takes place.
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Objective: Acute pulmonary embolism (PE) is a life-threatening cardiovascular event associated with high mortality and morbidity. The presence of a patent foramen ovale (PFO) in patients with acute PE represents a risk factor for mortality. Furthermore, a thrombus-in-transit via a PFO with impending paradoxical embolism carries a high mortality rate. Case Presentation: An adult patient with ischemic stroke caused by paradoxical embolism following PE underwent mechanical thrombectomy and achieved successful recanalization. Initial CT pulmonary angiography (CTPA) showed not only pulmonary thromboemboli but also bilateral atrial thromboemboli. During hospitalization, transesophageal echocardiography (TEE) revealed the PFO with a right-to-left shunt. Two months after rehabilitation undergone by the patient, PE completely disappeared and PFO closure was conducted to reduce the recurrence risk of ischemic stroke. Conclusion: Not only cardiologists but also interventional neurologists should understand that CTPA can demonstrate the thrombus-in-transit through the PFO and provides a reliable prediction of the sudden onset of ischemic stroke in patients with symptomatic PE. When identified, considering a case-by-case treatment approach by multidisciplinary teams is essential for preventing further life-threatening paradoxical embolization.
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Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is prevalent around the world and is a causative agent of skin and soft tissue infections in healthy individuals. Particularly, Panton-Valentine leukocidin (PVL)-positive CA-MRSA strains occasionally cause life-threatening infections, such as septic pulmonary emboli (SPE) and infectious endocarditis. However, severe infections caused by PVL-positive CA-MRSA strains have rarely been reported in Japan. For the first time, this study reports the case of a 20-year-old Japanese college athlete with life-threatening PVL-positive CA-MRSA USA300 clone infection, including sepsis, SPE, and skin and soft tissue infections with iliofemoral deep venous thrombosis.
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Panton-Valentine leukocidin (PVL)-positive USA300 clone is a highly pathogenic and global epidemic community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone. Athletes are particularly vulnerable to CA-MRSA infection because of the frequency of skin trauma, close-contact situations, and sharing of equipment that is customary in the athletic setting. We experienced a case of Japanese collegiate football player with septic pulmonary emboli secondary to infectious iliofemoral deep venous thrombosis caused by the USA300 clone. Here, we screened the nasal carriage of USA300 clone colonization among asymptomatic teammate of the patient to elucidate the infection route. Among 69 nasal samples, CA-MRSA strains were found in 5.8% (four samples). Molecular epidemiological analyses showed that three of the CA-MRSA strains were USA300 clone. Furthermore, pulsed-field gel electrophoresis revealed that all nasal USA300 clones showed 100% identity with the USA300 clone isolated from their teammate with critical infection. Our findings indicate that nasal colonization of the PVL-positive CA-MRSA, especially USA300 clone, pose a threat among contact sport athletes in Japan likewise other countries. An immediate infection control strategy for contact sport athletes is necessary to prevent outbreaks of PVL-positive CA-MRSA infections.
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Atletas/estadística & datos numéricos , Staphylococcus aureus Resistente a Meticilina/genética , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Nariz/microbiología , Infecciones Estafilocócicas/epidemiología , Antibacterianos/uso terapéutico , Infecciones Asintomáticas/epidemiología , Toxinas Bacterianas/metabolismo , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Electroforesis en Gel de Campo Pulsado , Exotoxinas/metabolismo , Humanos , Japón/epidemiología , Leucocidinas/metabolismo , Masculino , Epidemiología Molecular , Fútbol , Deportes , Infecciones Estafilocócicas/tratamiento farmacológico , Universidades , Adulto JovenAsunto(s)
Mordeduras y Picaduras/epidemiología , Mascotas , Ampicilina/uso terapéutico , Animales , Animales Domésticos , Antibacterianos/uso terapéutico , Mordeduras y Picaduras/tratamiento farmacológico , Mordeduras y Picaduras/mortalidad , Gatos , Maltrato a los Niños/diagnóstico , Maltrato a los Niños/prevención & control , Perros , Servicio de Urgencia en Hospital , Resultado Fatal , Femenino , Paro Cardíaco/epidemiología , Hemorragia/epidemiología , Humanos , Lactante , Japón , Masculino , Factores de Riesgo , Sulbactam/uso terapéutico , Resultado del TratamientoRESUMEN
Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6-24 h after onset. This study investigated the outcomes of thrombectomy performed 6-24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6-24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0-2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476-729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6-24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.
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Trombosis de las Arterias Carótidas/terapia , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Tiempo de Tratamiento , Trombosis de las Arterias Carótidas/diagnóstico , Bases de Datos Factuales , Sistema de Registros , Resultado del TratamientoRESUMEN
Acute infectious endocarditis (IE) is a complex disease that presents as a serious clinical condition associated with a high mortality rate, especially due to intracranial hemorrhaging (ICH). The most common causative organism is Staphylococcus aureus. We herein report a patient with ICH following subacute IE with a positive blood culture for Cardiobacterium hominis. A review of the existing literature revealed that acute IE associated with Cardiobacterium has been reported to cause ICH in only seven previous cases. Prolonged culture-specific antibiotic therapy along with extended surveillance of blood culture is therefore essential for timely intervention.
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Cardiobacterium , Endocarditis Bacteriana/complicaciones , Infecciones por Bacterias Gramnegativas/complicaciones , Hemorragias Intracraneales/microbiología , Adulto , Antibacterianos/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. METHODS: Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. RESULTS: This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. CONCLUSIONS: Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.
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Estenosis Carotídea/cirugía , Toma de Decisiones Clínicas , Imagen de Difusión por Resonancia Magnética , Procedimientos Endovasculares , Infarto de la Arteria Cerebral Media/cirugía , Selección de Paciente , Trombectomía/métodos , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/fisiopatología , Bases de Datos Factuales , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/fisiopatología , Japón , Masculino , Persona de Mediana Edad , Imagen de Perfusión/métodos , Valor Predictivo de las Pruebas , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Programas Informáticos , Trombectomía/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.
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The formation of external carotid artery (ECA) pseudoaneurysms caused by stab wounds is a rare vascular anomaly. Although the surgical exploration of the ECA segment is the standard treatment, endovascular treatment (EVT) can be considered if there is difficulty in identifying the source of bleeding in the injured regions that are difficult to operatively access. Here we treated a young patient who had hemorrhagic instability with hemorrhage-induced coagulopathy caused by a zone III cervical stab wound with a pseudoaneurysm from the main trunk of the ECA; the patient underwent EVT and successful hemostasis. A literature review based on the data available on PubMed was conducted, and 15 published reports of 82 penetrating ECA injuries treated by EVT were identified. We concluded that EVT appears to be an effective surgical alternative for patients with hemorrhage-induced coagulopathy caused by a ruptured ECA pseudoaneurysm after a cervical stab wound.
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Aneurisma Falso/cirugía , Traumatismos de las Arterias Carótidas/cirugía , Arteria Carótida Externa/cirugía , Procedimientos Endovasculares , Heridas Punzantes/cirugía , Adulto , Humanos , MasculinoRESUMEN
PURPOSE: It is difficult for emergency physicians to plan and execute a disaster medical response drill while conducting their daily work activities. Readily available drill preparation manuals are therefore essential, alongside assessment methods to ensure quality. Here, we propose email text analysis as a manual assessment method, and investigate its validity. METHODS: The preparation status of two similar large-scale disaster medical response drills were compared. All email texts exchanged during the preparation stage were analyzed, and frequently appearing words (quality element) and word counts (quantity element) were compared between Drill 1, which was organized without a manual, and Drill 2, organized with a manual. RESULTS: Word frequency analysis revealed that the key components of the manual (visualization of necessary work, preparation of documents in a certain format, and clarification of aims of the drill) contributed to the effectiveness of the preparation process for Drill 2. Furthermore, work volume during the preparation for Drill 2 was decreased by 41.9% from that during the preparation for Drill 1. CONCLUSION: Preparation of a high-quality manual is crucial so that emergency physicians can plan and execute a disaster medical response drill. Email text analysis can serve as an objective method assessing the quality of manuals.
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Ectopic varices include all varices except esophageal or gastric varices and comprise large portosystemic venous collaterals that occur anywhere in the abdomen. Ectopic varices are relatively rare; however, approximately 5% are related to gastrointestinal bleeding. Ectopic varices usually occur in the rectum, duodenum, or colon, and portal hypertension is the most common cause. Hemodynamic profiles of ectopic varices remain unknown, and extensive bleeding from these structures occurs because diagnosis and treatment are difficult. Here we report a case of obscure gastrointestinal bleeding (GIB) due to ectopic varices in the small intestine that flowed into the inferior epigastric vein. Our observations suggest that when obscure GIB is detected in patients with either cirrhosis or post-surgical history including incisional hernia, it is essential to acquire multilanar reconstruction images and volume-rendered 3-dimensional reconstruction of computed tomography scans to investigate the complex venous supply and optimize decisions for therapy.