Saulat H. Fatimi

PULMONARY HYDATIDOSIS: CLINICAL PROFILE AND FOLLOW UP FROM AN ENDEMIC REGION

Objectives:  The aim of this case series was to study the clinical presentation, treatment and outcome of pulmonary hydatid cyst disease at a tertiary care centre.

Ganglioneuroblastoma of the posterior mediastinum: a case report

IntroductionGanglioneuroblastoma is a rare peripheral neuroblastic tumor that is derived from developing neuronal cells of the sympathetic nervous system, and is found mostly, but not exclusively, in babies and young children.Case presentationTo the best of our knowledge, there have been no previously reported cases of ganglioneuroblastoma of the mediastinum from Pakistan. We present a case of ganglioneuroblastoma in an eight-year-old Pakistani Sindhi boy incidentally found to have a large posterior mediastinal mass that on biopsy initially looked like ganglioneuroma. He underwent successful excision of the mediastinal mass and remained stable post-operatively. Final pathology findings showed a ganglioneuroblastoma. He has remained free of symptoms on long-term follow-up.ConclusionsThe rarity of this tumor along with its almost exclusive occurrence in the pediatric population necessitates a thorough investigation of patients presenting with a symptomatic mass.

Tuberculous endocarditis: valvular and right atrial involvement

Valvular endocarditis due to Mycobacterium tuberculosis is a rare clinical entity. It is usually manifest in the context of disseminated tuberculosis in immunocompromised patients. This report describes a unique case of a 30-year-old immunocompetent man with an incidental finding of tuberculous valvular endocarditis. The patient had a large mass on the anterior mitral leaflet and severe mitral regurgitation. He underwent mitral valve replacement and Mycobacterium tuberculosis was cultured from the valve vegetation and the right atrial masses. Post-operative recovery has been uneventful without relapse for 24 months.

Major thoracic vessels and cardiac trauma: case series from a center in a developing country

BACKGROUND Seventy-five percent of all trauma-related deaths are related to thoracic trauma. Very few penetrating cardiac trauma patients arrive to the hospital alive. Due to its high prevalence, an understanding of the pathogenesis, manifestations and management of cardiac trauma by the medical personnel is becoming increasingly important. METHODS We retrospectively reviewed the files of 169 patients with a preoperative diagnosis of vascular injury who underwent management at the Aga Khan University Hospital from 2001 to 2006. Of these patients, 13 had cardiovascular and cardiac injuries. RESULTS 23% (n=3) had cardiac injuries; 2 had right ventricle injuries and 1 had injury to both ventricles. Great vessel injuries included: pulmonary artery (n=2), inferior vena cava (n=1), left carotid artery (n=1), left subclavian artery (n=2), and right subclavian artery (n=3). 53.8% of the patients suffered from postoperative complications. The overall mortality of patients with major thoracic vessel and cardiac trauma was found to be 15.4%. CONCLUSION We believe that, in the past, the inevitable delay in diagnosis led to unsuccessful thoracotomies, late transfers to the operating room and physiological deterioration of the patient. As the incidence of trauma is increasing worldwide, it is essential for surgeons to be prepared to handle cardiovascular and cardiac trauma injuries immediately, as delay can adversely affect the outcome in terms of both morbidity and mortality. All patients presenting with trauma to the chest should be assessed with a high index of suspicion for major cardiovascular injuries. Early diagnosis, prompt transfer to the operating room and speedy and perfect surgery influence a favorable outcome.

Atypical Pulmonary Giant Hydatid Cyst as Bilaterally Symmetrical Solitary Cysts

A pulmonary giant hydatid cyst, a special clinical entity, is rare. Our case involves a young patient who presented with a bilaterally symmetrical solitary cyst in each lung, a feature consistent with congenital lung cysts. The radiological and immunological findings were equivocal. A diagnosis of giant hydatid cyst was made intraoperatively and both cysts were removed conservatively. A follow-up showed complete recovery.

Body mass index—predictor of outcome after coronary artery bypass grafting

Objective: Increased body mass index has been associated with increased postoperative morbidity. We studied the effect of body mass index in our population, using a modified scale suggested by the World Health Organization. Methods: From January 2006 to December 2008, 1019 patients undergoing first-time isolated elective coronary artery bypass grafting were selected from our cardiac surgery database. Data were analyzed by univariate and multivariate analyses. Results: Of the 1019 elective coronary artery bypass patients, 168 (15.8%) had a normal body mass index (18.5–22.9 kg·m−2) and 894 (84.2%) had a high body mass index (≥23.0 kg·m−2). There were 921 (86.7%) patients with 3-vessel disease, and 1012 (95.3%) had internal mammary artery grafts. The 30-day mortality was 0.8%. Multivariate analysis revealed age, hospital stay, perfusion time, and renal failure were significantly associated with hospital complications. High body mass index was not significantly associated with morbidity or mortality. The model had an adequate fit at p = 0.708 by the Hosmer and Lemeshow test. Conclusion: Increased body mass index alone is not a predictor of increased mortality and morbidity. In fact, these outcomes were associated with advanced age, hospital stay, perfusion time, and renal failure.

Imaging and Intervention of Paraneoplastic Effect of a Right Atrial Myxoma on Factor VII Activity Levels

We present the case of a 64-year-old Pakistani man with right atrial myxoma, recently diagnosed with acquired severe factor VII (FVII) deficiency. The patient presented with a history of chronic hiccups and weight loss. Initial evaluation revealed an isolated prolonged prothrombin time, severely reduced FVII activity level, and a giant right atrial myxoma protruding into the right ventricle on computed tomographic thorax and echocardiography. After surgical resection, the patient maintained normal prothrombin time with increased FVII activity level in the immediate 24 hours postoperatively, and a dramatically high level of FVII activity at the 2-month follow-up. We believe that the paraneoplastic effect of myxoma on the FVII activity levels is previously unreported. In addition, we believe that hiccups as a presenting symptom for a myxoma with an atypical origin from the lateral wall of the right atrium has not been reported.

Late Concomitant Pseudoaneurysm and Arteriovenous Fistula of the Subclavian Artery: A Developing Country Perspective

Concomitant subclavian artery pseudoaneurysm and arteriovenous (AV) fistula has been rarely reported. We report a case of late concomitant pseudoaneurysm and AV fistula of the subclavian artery caused by a gunshot wound. Open surgical approach with an infraclavicular approach was used; subclavian artery was repaired with a Gortex interposition graft and subclavian vein was ligated. The postoperative course was uneventful. In developing countries, where the endovascular expertise is unavailable or if the lesion is large, open surgical approach provides similar results as an endovascular approach.

Giant synovial cell sarcoma of the thorax in a 46-year-old man: a case report

BackgroundAlthough synovial cell sarcoma is a common tumor of the extremities, its occurrence in the thorax has been less frequently documented.Case presentationA 46-year-old Pakistani man presented with a 2 month history of progressively increasing cough and left lower chest pain. Initial evaluation was done using a chest x-ray; the patient was found to have a large mass involving the lower portion of the left chest. A computed tomography scan was performed next which showed a large mass involving the left chest wall with invasion into the pericardium and left hemidiaphragm. En bloc surgical resection of the tumor was undertaken. Final pathology showed synovial cell sarcoma of the thorax. At one-year follow-up, the patient has shown no recurrence of the disease.ConclusionWe have described a rare case of a large synovial cell sarcoma of the thorax. Surgical resection appears an appropriate modus operandi for managing giant synovial cell sarcomas of the thorax. However, there is a need to clearly define post-operative strategies for cases with extensive involvement of surrounding structures.

Hernia of morgagni presenting as constipation in a 65-year-old male

Hernia of Morgagni is congenital defects in the diaphragm. They are mostly asymptomatic and present with vague symptoms when they do so. A high index of suspicion is required for timely diagnose of this condition. Here we present the case of a 65-year-old male patient presented to our institute with constipation for the past six months. Chest radiology raised the suspicion of a hernia which was further confirmed by contrast studies. Laparotomy was done and the hernia sac identified, colon and greater omentum reduced and defect repaired. He was discharged in stable condition and was doing well on follow-up.