IntroductionNecrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality.Case presentationTwo case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days.ConclusionsNecrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.
IntroductionRussell’s viper (Daboia russelii) is one of the most common medically important snakes reported in Sri Lanka. Its envenomation leads to significant mortality and morbidity with local, hematological, neurological and renal complications. Here we report the case of a patient who presented with bilateral blindness secondary to a bilateral posterior circulation ischemic stroke instead of the usual neurological manifestations of Russell’s viper envenomation. There were no reported cases of cortical blindness following a Russell’s viper bite. Only a few reported cases of ischemic strokes following a Russell’s viper bite were found in the literature.Case presentationA 54-year-old Sri Lankan woman developed bilateral blindness due to a posterior circulation infarct following Russell’s viper envenomation.ConclusionIschemic stroke following a Russell’s viper bite is very rare and cortical blindness is not reported as the clinical presentation. Also, we emphasize the importance of considering the possibility of ischemic stroke in patients who develop unusual neurological manifestations following Russell’s viper envenomation.
BackgroundElectrical injury may result in arrhythmias, however atrial fibrillation following low voltage electrocution is not a common occurrence.Case presentationA 70-year-old South-Asian woman with no prior history of cardiovascular disease presented following an accidental low voltage electrocution with loss of consciousness. On initial assessment she was found to be in atrial fibrillation with a moderate to rapid ventricular rate. Troponin I and 2D echo were normal. Transient rise in markers of muscle damage were noted. The arrhythmia resolved spontaneously without active intervention.ConclusionLoss of consciousness and the path of electrical conduction involving the heart may herald cardiac involvement following electrocution. Low voltage electrocution may cause cardiac insult. Conservative management may suffice in management of atrial fibrillation without cardiovascular compromise.
IntroductionPyomyositis, though classically considered a tropical disease, has a variable geographic prevalence. Among the predisposing risk factors, immunodeficiency plays an important role. Pyomyositis has a tendency to mimic more commonly considered diseases, and a lack of familiarity with it is a cause of delayed diagnosis.Case presentationA 53-year-old South Asian man with newly diagnosed type 2 diabetes mellitus was referred to our medical unit in an advanced stage of the disease, which was complicated by sepsis and acute kidney injury. Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient’s complicated state. Antibiotic therapy was initiated, and clinical stabilization was achieved with supportive measures. Following the patient’s recovery from sepsis, his persistent leukopenia and anemia was suggestive of an underlying immunodeficiency, and a subsequent bone marrow biopsy revealed acute myeloid leukemia, M2 variant. Multi-disciplinary care was initiated by the medical, surgical and oncological teams.ConclusionAwareness of tropical pyomyositis is lacking. Common predisposing behaviors and conditions should always be sought and investigated. Immunosuppressive state is an important predisposing factor in the pathogenesis of pyomyositis. Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed. Identifying one cause should not halt the search for others, as pyomyositis may herald underlying sinister diseases.
BackgroundPosterior reversible encephalopathy syndrome is a presentation which is diagnosed clinico-radiologically. The primary aetiological processes leading to posterior reversible encephalopathy syndrome are many, which include autoimmune conditions. Polyarteritis nodosa as an aetiological factor for posterior reversible encephalopathy syndrome is rare. We present a case of polyarteritis nodosa complicated by posterior reversible encephalopathy syndrome.Case presentationA 26-year-old South-Asian female presented with left sided focal seizures with secondary generalization and visual disturbance for 2 days duration. She had a prior history of arthralgia and weight loss with no medically explainable cause for young onset hypertension. Examination revealed a right claw hand with a palpable vasculitic type of rash involving both the palmar surfaces. Symptoms responded to management with anti-hypertensives and anti-epileptics. Whole blood count, iron studies, erythrocyte sedimentation rate and C-reactive protein values portrayed an ongoing chronic inflammatory process. Serological studies such as Anti-nuclear antibody, Anti -double stranded deoxyribonucleic acid, Anti-neutrophil cytoplasmic antibody and Anti-cyclic citrulinated peptide were negative. Magnetic resonance imaging revealed high signal intensity on T2 in both occipital lobes. Skin biopsy of the palm revealed moderate vessel vasculitis. Renal imaging revealed structurally abnormal kidneys with micro aneurysms in the right renal vasculature. Repeat magnetic resonance imaging of the brain two months later showed marked improvement. A diagnosis of polyarteritis nodosa with posterior reversible encephalopathy syndrome was made.ConclusionsPosterior reversible encephalopathy syndrome should not be missed. Investigations for an aetio-pathological cause should be considered including the rarer associations like polyarteritis nodosa.
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