We describe an innovative interventional technique for the repair of a postoperative enterocutaneous fistula (ECF). In the reported case, surgical repair of the ECF was contraindicated, while endoscopic closure was unsuccessful. Correction of this high-outflow fistula was achieved using an Amplatzer septal occluder, which was deployed under simultaneous fluoroscopic and endoscopic guidance. The use of an Amplatzer septal occluder should be taken into consideration when there is a need to treat high-outflow ECF in patients who cannot undergo surgery.
A 56-year-old man presented with a painless lump in the left breast that had been growing for approximately 2 years. The patient also had bloody nipple discharge for the last 2 years. There were no other relevant features in the history, which included diabetes mellitus.Physical examination revealed a 3 cm soft mobile lump in the left breast and a palpable left axillary lymph node. Conventional low-dose mammography was performed initially, which demonstrated a well-circumscribed mass of intermediate density, posterior to the nipple. There were no calcifications (Fig. 1). In order to determine the solid or cystic nature of the lesion, an ultrasound study was performed. Using a 7.5 MHz probe, it showed a 27 mm × 22 mm lesion, predominately cystic, but an irregular soft tissue mass (13 mm × 12 mm) projected from the wall into the lumen (Fig. 2). Color and power Doppler revealed minimal vascularity in the mass. The axillary lymph node was of a reactive type and presented intensive vascularity of the hilus.On aspiration, bloody fluid was obtained and cytologic examination showed cellular atypia. Excisional surgery Figure 1. Low-dose mammography. Mediolateral oblique and craniocaudal views show a wellcircumscribed mass of intermediate density posterior to the nipple.
IntroductionThe mortality of listerial rhombo-encephalitis exceeds 26% and may involve otherwise healthy patients. A case is presented of a man with fatal listerial infection of the central nervous system that was monitored in an intensive care unit.Case presentationA 42-year-old, previously healthy man was admitted with fever of 39°C, blurred vision, confusion and headache. He had right-sided central facial paresis, bilateral absent gag reflex and bilateral cerebellar ataxia. After a few hours, he became septic and developed bilateral vocal cord paralysis and airway obstruction. He was intubated and put on mechanical ventilation. Computed tomography brain scans revealed multiple frontal hypodense areas and slight hydrocephalus. Cerebrospinal fluid findings included pleocytosis of 4200 cells/μL (77% neutrophils), protein of 114 mg/dL and normal glucose levels. Listerial infection was suspected; therefore ampicillin was added to his initial therapeutic regimen, already including ceftriaxone and gentamicin. All cultures were negative, and no immunologic abnormality could be documented, but the patient's clinical condition deteriorated rapidly. Continuous neuromonitoring by means of transcranial Doppler and optic nerve sonography along with follow-up computed tomography brain scans confirmed the severity of the brain damage; hence, dexamethasone and mannitol were also administered. The patient was clinically documented as 'brain dead' 7 days after his admission to the intensive care unit; thereafter, blood- and post-mortem brain tissue cultures grew Listeria monocytogenes.ConclusionThis case report illustrates the importance of neuromonitoring in patients with severe brain damage. We also show that, despite prompt antibiotic treatment and dexamethasone administration, listerial infection of the central nervous system can be lethal.
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