BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,es...BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,esophageal perforation,medi-cally induced factors,etc.Its common symptoms are chest pain,tightness in the chest,and respiratory distress.Most mediastinal emphysema patients have mild symptoms,but severe mediastinal emphysema can cause respiratory and circulatory failure,resulting in serious consequences.CASE SUMMARY A 75-year-old man,living alone,presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol.Due to the remoteness of his residence and lack of neighbors,the patient was found by his nephew and brought to the hospital the next morning after the disease onset.Computed tomography(CT)showed free gas in the abdominal cavity,mediastinal emph-ysema,and subcutaneous pneumothorax.Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated.Therefore,we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia.An operative incision of the muscle layer of the patient's abdominal wall was made,and a large amount of subperitoneal gas was revealed.And a continued incision of the peritoneum revealed the presence of a perforation of approx-imately 0.5 cm in the gastric antrum,which we repaired after pathological examination.Postoperatively,the patient received high-flow oxygen and cough exercises.Chest CT was performed on the first and sixth postoperative days,and the mediastinal and subcutaneous gas was gradually reduced.CONCLUSION After gastric perforation,a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm,and upper gastrointestinal angiography can clarify the site of perforation.In patients with mediastinal emphysema,open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure.In addition,thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.展开更多
BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloi...BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloid heavy and light chain(AHL)is relatively uncommon and its biopsy diagnosis is usually limited to cases that show strong equivalent staining for a single immunoglobulin(Ig)heavy chain and a single light chain,further supported by mass spectrometry(MS)and serum studies for monoclonal protein.But polyclonal light chain staining can pose a challenge.CASE SUMMARY Herein we present a challenging case of renal AHL with polyclonal and polytypic Ig gamma(IgG)staining pattern by immunofluorescence.The patient is a 62-yearold Caucasian male who presented to an outside institution with a serum creatinine of up to 8.1 mg/dL and nephrotic range proteinuria.Despite the finding of a polyclonal and polytypic staining pattern on immunofluorescence,ultrastructural study of the renal biopsy demonstrated the presence of fibrils with a mean diameter of 10 nm.Congo red was positive while DNAJB9 was negative.MS suggested a diagnosis of amyloid AHL type with IgG and lambda,but kappa light chains were also present supporting the immunofluorescence staining results.Serum immunofixation studies demonstrated IgG lambda monoclonal spike.The patient was started on chemotherapy.The chronic renal injury however was quite advanced and he ended up needing dialysis shortly after.CONCLUSION Tissue diagnosis of AHL amyloid can be tricky.Thorough confirmation using other available diagnostic techniques is recommended in such cases.展开更多
BACKGROUND A foreign body in the digestive tract is a common disease in the clinic.However,it is rare for a foreign body to migrate into the liver.Most patients are diagnosed before or after perforation of the digesti...BACKGROUND A foreign body in the digestive tract is a common disease in the clinic.However,it is rare for a foreign body to migrate into the liver.Most patients are diagnosed before or after perforation of the digestive tract.Laparoscopic removal of intrahepatic foreign bodies is an effective treatment method.CASE SUMMARY A 55-year-old male patient was admitted to the hospital due to fever for 3 d,in addition to pain and discomfort in the right side of his waist.After admission,abdominal computed tomography showed a foreign body in the liver,and gastroscopy did not indicate obvious erosion or ulcers.The patient then underwent laparoscopic surgery.During the operation,an abscess was seen near the gastric antrum and between the caudate lobes of the liver.It was approximately 30 mm×31 mm×23 mm in size.The abscess was cut open,and a fish bone was found inside.The fish bone had penetrated the liver and was successfully removed.It was confirmed that the fish bone migrated from the stomach to the liver.CONCLUSION Although intrahepatic foreign bodies are rare,they should be diagnosed and treated as early as possible to avoid serious complications such as intrahepatic abscess,which may lead to liver resection and even life-threatening events.展开更多
文摘BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,esophageal perforation,medi-cally induced factors,etc.Its common symptoms are chest pain,tightness in the chest,and respiratory distress.Most mediastinal emphysema patients have mild symptoms,but severe mediastinal emphysema can cause respiratory and circulatory failure,resulting in serious consequences.CASE SUMMARY A 75-year-old man,living alone,presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol.Due to the remoteness of his residence and lack of neighbors,the patient was found by his nephew and brought to the hospital the next morning after the disease onset.Computed tomography(CT)showed free gas in the abdominal cavity,mediastinal emph-ysema,and subcutaneous pneumothorax.Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated.Therefore,we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia.An operative incision of the muscle layer of the patient's abdominal wall was made,and a large amount of subperitoneal gas was revealed.And a continued incision of the peritoneum revealed the presence of a perforation of approx-imately 0.5 cm in the gastric antrum,which we repaired after pathological examination.Postoperatively,the patient received high-flow oxygen and cough exercises.Chest CT was performed on the first and sixth postoperative days,and the mediastinal and subcutaneous gas was gradually reduced.CONCLUSION After gastric perforation,a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm,and upper gastrointestinal angiography can clarify the site of perforation.In patients with mediastinal emphysema,open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure.In addition,thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.
文摘BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloid heavy and light chain(AHL)is relatively uncommon and its biopsy diagnosis is usually limited to cases that show strong equivalent staining for a single immunoglobulin(Ig)heavy chain and a single light chain,further supported by mass spectrometry(MS)and serum studies for monoclonal protein.But polyclonal light chain staining can pose a challenge.CASE SUMMARY Herein we present a challenging case of renal AHL with polyclonal and polytypic Ig gamma(IgG)staining pattern by immunofluorescence.The patient is a 62-yearold Caucasian male who presented to an outside institution with a serum creatinine of up to 8.1 mg/dL and nephrotic range proteinuria.Despite the finding of a polyclonal and polytypic staining pattern on immunofluorescence,ultrastructural study of the renal biopsy demonstrated the presence of fibrils with a mean diameter of 10 nm.Congo red was positive while DNAJB9 was negative.MS suggested a diagnosis of amyloid AHL type with IgG and lambda,but kappa light chains were also present supporting the immunofluorescence staining results.Serum immunofixation studies demonstrated IgG lambda monoclonal spike.The patient was started on chemotherapy.The chronic renal injury however was quite advanced and he ended up needing dialysis shortly after.CONCLUSION Tissue diagnosis of AHL amyloid can be tricky.Thorough confirmation using other available diagnostic techniques is recommended in such cases.
基金Supported by Zhejiang Province Administration Foundation of Traditional Chinese Medicine,No.2020ZB305。
文摘BACKGROUND A foreign body in the digestive tract is a common disease in the clinic.However,it is rare for a foreign body to migrate into the liver.Most patients are diagnosed before or after perforation of the digestive tract.Laparoscopic removal of intrahepatic foreign bodies is an effective treatment method.CASE SUMMARY A 55-year-old male patient was admitted to the hospital due to fever for 3 d,in addition to pain and discomfort in the right side of his waist.After admission,abdominal computed tomography showed a foreign body in the liver,and gastroscopy did not indicate obvious erosion or ulcers.The patient then underwent laparoscopic surgery.During the operation,an abscess was seen near the gastric antrum and between the caudate lobes of the liver.It was approximately 30 mm×31 mm×23 mm in size.The abscess was cut open,and a fish bone was found inside.The fish bone had penetrated the liver and was successfully removed.It was confirmed that the fish bone migrated from the stomach to the liver.CONCLUSION Although intrahepatic foreign bodies are rare,they should be diagnosed and treated as early as possible to avoid serious complications such as intrahepatic abscess,which may lead to liver resection and even life-threatening events.
