Delayed presentation of blunt duodenal injuries in children. Case report and review of literature

Background. Duodenal injuries are rare in children and classically present following a fall over the handle bar. Retroperitoneal location of the duodenum may lead to delay in diagnosis, and missed injuries are associated with increased morbidity and mortality. Case report. A 5-year-old child was admitted to the National Trauma Center, in Tirana (Albania), 28 hours after a Motor Vehicle Crash (MVC), complaining of mild abdominal pain. He was febrile (39°C) and had a white blood cells count of 18,000 mm3. On physical exam he had mild tenderness. Plain abdominal X-rays and Focused Abdominal Sonography for Trauma (FAST) were negative for free air or free fluid. The CT scan of the abdomen demonstrated free air and fluid in the retroperitoneal space. At laparatomy, a perforation of the second portion of the duodenum was found. A single layer suture repair of the duodenum with wide drainage was performed. The patient was discharged from the hospital tolerating oral feeding 8 days later. Conclusion. Duodenal injuries in children are rare. Most duodenal hematomas are managed non-operatively. This is a case of MCV with delayed presentation that was treated surgically for perforation successfully.

Seizure and Profound Hypokalemia: Unusual Presentation of Primary Hyperparathyroidism

A 68-year-old man was admitted because of tonic–clonic convulsion. He had been receiving 200 mg itraconazole for 10 days. He had hypokalaemia (2.2 mEq/l), hypercalcaemia (Cacorr 11.0 mg/dl) and elevated serum parathyroid hormone (PTH, 95 pg/ml). Ultrasound examination of the neck revealed a low echoic tumour. Cessation of itraconazole and fluid supplementation eradicated clinical symptoms and profound hypokalaemia, but serum potassium remained low normal (3.4 mEq/l) and the mild hypercalcaemia and elevated PTH were unchanged. To conclude, a small amount of itraconazole (200 mg) precipitated profound hypokalaemia and seizure in a patient with mild hyperparathyroidism and low normal serum potassium.

Lymphadenopathy after Initiating HAART in an HIV-positive Patient with Kaposi's Sarcoma: a Case of Multicentric Castleman's Disease

We present the case of a 33-year-old lady who was diagnosed with disseminated Kaposi’s sarcoma and HIV infection. The patient improved on highly active antiretroviral therapy (HAART), however, nine days into treatment, she became febrile and dyspnoeic and developed tender cervical and axillary lymphadenopathy. Despite treatment for suspected sepsis and immune reconstitution, she died in intensive care. Lymph node biopsies revealed coexistent Castleman’s disease and Kaposi’s sarcoma. Initiation of HAART can be rarely associated with unmasking and rapid progression of Castleman’s disease, a phenomenon called immune reconstitution. Urgent investigation and treatment with agents such as steroids and cytotoxic drugs can be life-saving.

A Case of Mesenteric Pseudocyst Causing a Massive Abdominal Swelling

We present the case of a 55-year-old man, with a self-limited febrile condition associated to polyserositis with inconclusive investigation. Bilateral pleural and pericardial effusions resolved. The peritoneal fluid loculated and was compatible with an exudate. The patient remained clinically asymptomatic. Two years later, examination revealed a palpable and painless abdominal mass, which imaging study suggested a cystic lesion. Surgical resection was performed and the histological examination revealed a mesenteric pseudocyst. Mesenteric pseudocysts are rare intra-abdominal cystic masses, mostly benign, without causing specific symptoms. Although imaging tests are useful for their differential diagnosis, the histology is mandatory.