Several foreign bodies throughout the torso following a shotgun injury

A 50 year old man with a history of posterior bullet shot with a shotgun was presented to the hospital 18 hours after the accident complaining of abdominal and gluteal pain. He had stable vital signs, no respiratory distress, and no active bleeding. Physical examination revealed abdominal tenderness and generalized abdominal guarding.After a primary survey, a complete abdominopelvic ultrasonography and whole body computed tomography (CT) scan were performed (Figure 1) and revealing several bullet fragments (confirmed with Hounsfield scale) in paraspinal and abdominal wall, mesenteric fossa, pererectal and prenephric area, intestinal surroundings and illiac fossa (Figure 2 and 3).One of the bullet fragments was observed in left inferior renal calyx (Figure 4). Moreover another fragment was touching aortic arch (Figure 5).Afterwards, the patient underwent explorative laparatomy. About two liters of blood clot was observed in pelvic fossa. Also evidences of spleen injury and pancreas head and rectum hematoma with no active bleeding was observed. All four quadrants were packed, drainage was applied for pancreas. Since there was no fragment in aortic intima, no intervention was needed.After post-operative antibiotic therapy and other follow-ups such as urologic assessments, the patient was discharged. After two weeks, the patient was again referred to the hospital with pain in the site of drainage tubes. In laboratory tests amylase levels was 162 (U/L) and lipase levels was 83 (U/L). Plural effusion and atelectasis were observed in left lung CT scan (Figure 6) which did not need invasive intervention. Accumulation of spleen subcapsular fluid was observed in abdominopelvic CT scan. Loculated fluid collection was observed in pancreaticosplenic and paracolic areas (Figure 7) which led to diagnosis of pancreas drainage infection. The patient was treated with wide spectrum antibiotics and the symptoms were resolved. Also, there was the possibility for lead poisoning with lead bullet fragments, therefore serum levels of lead were examined after two months. The results showed a high level of lead concentration in serum (29 µg/dL). The patient was treated with antioxidant and vitamin C and asked to refer to the hospital every 2 months to check the lead level and have it under control. Administrating chelating agents such as dimercaptosuccinic acid and calcium disodium EDTA should be considered if the serum lead level is increased in the follow-up. Moreover, with the possibility for secondary adverse effects due to retained fragments, such as fistula formation, visceral adhesion, recurrent infection, et Cetra, the patient was advised to do frequent imaging checkups. According to similar cases and new studies, the presence of the lead in the bullet fragments won’t be causing any contraindications for magnetic resonance imaging but may cause some artifacts thus the alternative imaging tests such as CT or X-ray graphy are suggested. There’s also no evidence for the pellets movements and visceral organs injury after MRI in shotgun injury cases

Findings of the Peripheral Blood Smear in Patient Suspected with Sepsis Admitted in Emergency Department

مقدمه: شناخت بهترین شیوه های تشخیص پاراکلینیک نقش مهمی در تشخیص افتراقی مبتلایان به سپسیس و بهبود پیش آگهی نهایی بیماران ایفا می نماید. لذا این مطالعه به منظور بررسی یافته های لام خون محیطی در بیماران مشکوک به سپسیس و ارتباط آن با تشخیص نهایی انجام شد. روش کار: در این مطالعه مشاهده ای که به صورت مقطعی انجام گردید، تعداد 348 بیمار مشکوک به سپسیس بستری در اورژانس بیمارستان شهدای تجریش در سال 1396 مورد ارزیابی قرار گرفتند و یافته های لام خون محیطی در آنها تعیین شده و ارتباط آن با تشخیص نهایی در بیماران بستری ارزیابی گردید. یافته ها: میانگین سنی بیماران مورد بررسی 3/62 سال با انحراف معیار 7/17 سال بود. همچنین 2/53 درصد از بیماران مورد بررسی مذکر و 8/46 درصد مونث بودند. شایعترین تشخیص های نهایی شامل پنومونی (29 درصد) و عفونت ادراری (1/18 درصد) بودند. در مورد یافته های لام خون محیطی ارتباط آماری معناداری با تشخیص نهایی بیماران در مورد یافته های ترومبوسیتوپنی (000/0 = p)، ترومبوسیتوز (032/0 = p)، مورفولوژی غیرطبیعی (049/0 = p) وجود داشت. نتیجه گیری: در مجموع چنین استنباط می شود که تعداد پلاکتها و مورفولوژی غیرطبیعی می توانند کارآیی تشخیصی خوبی در مورد بیماران مشکوک به سپسیس داشته باشند.Introduction: Determination of good diagnostic tools is an issue of importance specially to differentiate between sepsis etiologies and improvement of prognosis. Hence our purpose was to determine the finding of the peripheral blood smear (PBS) in patients with suspected of sepsis and its association with the final diagnosis in the year 1396. Methods: In this cross-sectional comparative survey, 348 consecutive patients with suspected of sepsis admitted in emergency department of Shohaday-e-Tajrish Hospital were enrolled and the association of finding of the peripheral blood smear in patients with the final diagnosis in the year 1396 were determined. Results: The results in this study demonstrated that pneumonia and urinary tract infection were seen in 29% and 18.1%. Thrombocytopenia (p=0.000), thrombocytosis (p=0.032), and abnormal morphology (p=0.049) were related to final diagnosis. Conclusion: Totally, according to the obtained results it may be concluded that platelet count and PBS morphology are important related factors for sepsis

Paraneoplastic acute eosinophilic pneumonia due to carotid angiosarcoma: A rare case

Key Clinical Message This case report emphasizes that we should analyze a patient's signs and symptoms as a whole rather than relying exclusively on a common pattern to diagnose the condition and indicates that thorough histological investigation and sample collection are needed to accurately diagnose this malignancy. Abstract Angiosarcoma is a rare, fatal, and poorly understood malignant tumor of vascular endothelial cells which is a challenging disease to diagnose in the clinical settings and requires early diagnosis to achieve a favorable prognosis. Paraneoplastic syndromes associated with angiosarcoma can include hypercoagulability, thrombocytopenia, anemia, fever, weight loss, and night sweats. In some cases, the paraneoplastic syndrome can be the first sign of the underlying malignancy. Here, we present a 47‐year‐old individual with angiosarcoma over the right scapula accompanied by hemoptysis and other pulmonary complaints whom at first was thought to be metastatic polmunary involvement. However, the patient's dramatic response to corticosteroids, in addition to further imaging and paraclinical studies, led us to an acute eosinophilic pneumonia (AEP) diagnosis which is an eosinophilic infiltrations of alveolar spaces. The patient received chemotherapy for angiosarcoma and radiation, since the brachial nerve network was disrupted, leaving the tumor unresectable. After 3 years of continuous follow‐up, the patient is now completely cured

Waldenström's macroglobulinemia with necrotic extremities: A case with challenging diagnosis

Key Clinical Message Waldenström's macroglobulinemia may begin with constitutional symptoms that are common in primary care settings and it is crucial for physicians to be aware of the potential complications of hyperviscosity syndrome and to employ the appropriate diagnostic methods in order to achieve better outcomes. Abstract Waldenström's macroglobulinemia (WM) refers to a type of lymphoplasmacytic lymphoma distinguished by the hyperproliferation of plasma cells, lymphocytes, and plasmacytoid lymphocytes. The disease is primarily diagnosed by increased monoclonal immunoglobulin M (IgM) levels and lymphoplasmacytic cell infiltration into the bone marrow. Individuals exhibit a high risk for hyperviscosity syndrome (HVS) as immunoglobulin levels increase. In addition to constitutional symptoms (fever, night sweats, and unintentional weight loss), clinical findings such as cytopenia, hepatosplenomegaly, and lymphadenopathy, this condition may cause hyperviscosity‐related organ failures. Here we discuss a patient with WM who presented with neurological complaints and blurry vision and developed necrosis at distal portions of his body during the 6‐month course of the disease