Abstract

Spontaneous rupture of a hepatocellular carcinoma is a rare and lethal complication in the emergency department. A caudate lobe hepatoma rupture is even rarer. It can be treated with vascular embolization, surgical intervention or supportive care. A 70-year-old woman with underlying hepatocellular carcinoma presented to our emergency department with severe abdominal pain encompassing the entire region for half a day. Abdominal computer tomography scans with and without contrast medium revealed a large hematoma confined to the lesser sac of the abdomen. It was initially diagnosed as a ruptured aneurysm. A ruptured caudate lobe hepatoma with acute hemorrhage into the lesser sac was diagnosed after reviewing and discussing the imaging findings with the radiologist. The patient was treated with supportive care without vascular embolization or surgical intervention because there was no imaging evidence of active contrast extravasation and the vital signs were within the normal range. After reviewing the literature, our case appears to be the second only case treated with supportive care and discharged without complications.

Keywords: hepatoma, hepatocellular carcinoma, caudate, rupture, peritonitis

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method for long-term ventilation of critically ill patients in many intensive care units (ICUs). However, serious complications related to PDT have been reported, including several cases of intraoperative loss of airway with fatal consequences. (1) Generally, this is the result of the required delicate position of the endotracheal tube (ETT) during PDT, with a partially deflated cuff located at the level of the vocal cords. This position of the ETT may lead to accidental extubation and loss of airway during the procedure, especially in difficult patients with a short, bull neck. On the other hand, too deep a position of the tip of the ETT can lead to accidental punction of Murphy's eye, with impalement of the ETT. (2) Unfortunately, the operator performing the PDT evaluates the correct position of the tip of the ETT on the basis of questionable, indicative, indirect parameters and clinical signs such as: capnography, the curve on the ventilator monitor and respiratory movements of the thoracic wall.

Abstract

Parathyroid gland carcinoma is uncommon disease, accounting less than 1% among the cases of primary hyperparathyroidism. There has been reported variations in prevalence between the nations, with higher occurence in Japan and Italy, according to their referral centers. Parathyroid cancer occurs mostly in patients above 30 years, but no sex differences have been noticed. Clinical signs correspond to symptoms of hypercalcaemia, which is usually severe, due to high production of parathyroid hormone in mostly functional tumors. Palpable mass in the neck and osteoporosis are present in about 50% of the cases.
We report a case of 24-year old female victim of traffic accident, suffering severe traumatic injuries- intracerebral and brainstem bleeding and contusions, together with femoral fracture, in which intensive care management simptoms suspicious to parathyroid carcinoma have been observed. Further imaging, laboratory findings, and clinical signs confirmed diagnosis. Surgery, with „en bloc" excision of the node together with adherent tissue has been performed. Definite histopathology finding approved parathyroid carcinoma. Clinical signs and laboratory findings normalized in the next period, and patient was discharged from our intensive care.
This case indicates that close monitoring of clinical signs, biochemical findings together with imaging modalities available, help not to miss such rare diseases, which might be masked by primary trauma.

Key words: polytrauma, parathyroid gland, carcinoma, treatment

Abstract

Delayed presentation of a traumatic diaphragmatic hernia is an infrequent condition with a high mortality and morbidity rate. This case describes a 26-year-old man presenting with a 2-day history of cramping abdominal pain, dyspnea, nausea, and vomiting. The patient reported a penetrating thoracic injury one year prior to the development of clinical signs. Computed tomography revealed the presence of empyema or parapneumonic effusion of the left hemithorax. Based on the clinical history and physical findings, a diaphragmatic hernia was considered and an emergency laparotomy with segmental resection of strangulated jejunum and reduction of remaining bowel was performed. A 1.5 cm tendinous defect was identified and repaired. The patient recovered and was discharged uneventfully.
Conclusion: the early recognition of a delayed diaphragmatic hernia contributed to the uneventful recovery of this critically ill patient.

Key words: traumatic diaphragmatic hernia, penetrating thoracic injury, helical computed tomography, emergent laparotomy, tendon defect

Abstract

Introduction. Cyanosis and dyspnoea with interatrial shunting of blood occurring without change in body position are termed platypnea-orthodeoxia-like syndrome.
Case presentation. We describe a female newborn with sepsis, who developed cyanosis. Two weeks after the initial appearance of cyanosis she presented with a right-sided diaphragmatic hernia, which was not seen on the initial X-rays. The hernia was surgically repaired. Her postoperative course was uneventful.
Conclusions. In our case, interatrial shunting of blood was presumably caused by disturbed intrathoracic pressures. Positive pressure ventilation and sepsis may also contribute to the development of such a syndrome.

Key words: cyanosis, right-to-left shunt, infant, sepsis, congenital diaphragmatic hernia