Introduction
SARS CoV19 infection can predispose to many autoimmune and neurological conditions, thymomatous myasthenia gravis being one of them. The rarity of these case poses therapeutic dilemmas about their further management.
Presentation of case
A 61 year old gentleman who had covid19 infection 2 months back, presented with new onset myasthenia gravis and an anterior mediastinal mass. He was diagnosed as a case of anti acetyl choline receptor antibody positive thymomatous myasthenia gravis. The patient was posted for video assisted thoracoscopic excision of thymoma. The procedure was uneventful and patient was discharged with improvement in myasthenic symptoms. Histopathological examination confirmed the diagnosis of WHO Type A Spindle cell thymoma.
Discussion
SARS CoV19 infection is associated with an array of autoimmune disorders due to various proposed phenomenon including molecular mimicry and loss of immune tolerance. Post infectious thymomatous myasthenia gravis is extremely uncommon, and can be managed with open, minimally invasive or robotic approach.
Conclusion
This is the first documented case of post covid19 infection thymomatous myasthenia gravis to the best of our knowledge, managed with minimally invasive thoracoscopic surgery. Further research is required for documentation of the natural history of the disease and therapeutic outcomes.
Patients with thromboembolic disorders are commonly on anticoagulants; hence, they are susceptible to bleeding episodes such as ecchymosis, gingival, subconjunctival bleeding, and rarely can have intramural hematoma of small bowel causing patient to present with intestinal obstruction. It is a rare cause of mechanical bowel obstruction requiring a nonsurgical management.Our patient was a 55-year-old male, a known case of thromboembolism on warfarin medication, presented with abdominal pain and vomiting. Patient's laboratory reports reflected anemia and deranged coagulation profile with prothrombin time and international normalized ratio, both being elevated. Intramural hematoma of jejunum was diagnosed by abdominal contrast-enhanced computed tomography. Conservative management was done, warfarin was stopped and vitamin K was administered. Patient received fresh frozen plasma and packed cell blood.It is important to suspect warfarin toxicity in patients on the medication who come with such presentation to avoid surgical management, which could be catastrophic due to excessive bleeding. It is important for regular monitoring of coagulation profile of such patients and to reduce prescribing other medications that can interact with warfarin. It is worth noting that novel oral anticoagulants, such as dabigatran and rivaroxaban, are associated with fewer side effects and do not require close laboratory monitoring.
Background
Paratesticular fibrous pseudotumour is a rare benign growth with unclear pathogenesis and clinical management. It has been linked to Serum IgG4-related disease. This mass can notoriously masquerade around as a malignancy; however, a conservative (testis sparing) approach is sufficient as surgical management.
Case presentation
We present the case of a 35-year-old gentleman who presented with a slow growing paratesticular mass, raising the suspicion of a malignancy. However, normal tumour markers and benign appearance on imaging modalities compelled us to give trial of local excision with intra-operative frozen section analysis. After confirmation of benign pathology of the mass, the incision was closed. Final histopathology confirmed the diagnosis of benign paratesticular fibrous pseudotumour, and serum IgG levels were noted to be elevated.
Conclusion
Thus, using tumour markers, radiological imaging and intraoperative frozen section, a potential radical resection can be avoided, testis sparing surgery, employed.
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