INDUS
CASE FILES
LEAKING
ABDOMINAL ANEURYSMECTOMY WITH TRIPLE VESSEL CORONARY ARTERY
DISEASE
  A
68 years old bind, hypertensive and chronic heavy smoker
male patient with known triple vessel coronary artery disease
was admitted to Indus Hospital with severe left flank pain
of five days duration on May 2, 1994. The patient was taking
Monotrate 40 mg. BID and Diltiazem 60 mg. TID. B.P. on admission
was 180/100 mm. Hg. in both arms and pulse rate was 68 per
minute.
Earlier, he was admitted with similar, but milder complaints
for three weeks at a premier Institute of Medical Sciences
in New Delhi and, finally, was turned down for surgery of
the expanding aneurysm of the abdominal aorta due to high
cardiac risk. Surgical revascularization of coronaries was
abandoned due to risk of rupture or dissection of the Aneurysm.
Resection of leaking aneurysms
of abdominal aorta (10.5 cms. in diameter) and right common
iliac artery and replacement with a synthetic bilateral aortofemoral
bypass graft was undertaken as an urgent procedure under general
anesthesia at Indus Hospital. His hospital course was excellent
with the exception of anterolateral myocardial ischemia in
the immediate post-operative period which responded to medical
therapy. Patient survived to live more than three years after
which he died of some abdominal malignancy according to his
family.
MIRACULOUS RECOVERY AFTER
EPIDEMIC DROPSY
A
68 years old house wife was admitted to Indus Hospital on
April 17, 2000 with 30 days history of generalized swelling
of the entire body with progressive shortness of breath
, restriction of activity, insomnia , nausea and decreasing
urinary output despite treatment by a medical specialist
at Pathankot who diagnosed her as a case of hypothyroidism.
She had history of coronary artery disease with old myocardial
infarction in 1985 and cholecystectomy for calculus disease
in 1997.
Poisoning from consumption
of Argemone Mexicana contaminated mustard oil was suspected.
She had history of coronary artery disease with old myocardial
infarction in 1985 and cholecystectomy for calculus disease
in 1997. There was no history of congestive heart failure
, liver , kidney or thyroid disease in the past .
Physical examination
on admission revealed normal vital signs , orthopnea and
generalized anasarca with clothes soaking wet due to water
oozing from the entire body without sweating. Heart sounds
were muffled and breath sounds were reduced at the lung
bases , bilaterally. Jugular venous pressure was raised.
Massive ascites and third degree uterine prolapse were noted.
LAB. DATA
:
Pertinent investigations revealed cardiomegaly with
massive bilateral pleural effusions , marked pericardial
effusion and ascites. Kidneys and liver parenchymas were
hyperechoic . EKG showed low voltage and sinus tachycardia.
Hgb. 7.5 g/dL, Hct. 23% , WBC 15,400/cu. mm. , Polymorphs.
78% , Platelets 1,20,000/ cu. mm., Sed rate 22/ hr. , Total
Proteins 7.6 g/dL, Albumin 5.2 g/dL, Fasting Blood Sugar
95 mg/dL. Liver , Kidney, Cardiac and Coagulation Profiles
as well as Serum Electrolytes and Urinalysis were normal.
Stools were positive for occult blood. Thyroid function
tests showed normal TSH , near normal T3 ( 2.29
pg/mL ) and reduced Free T4 levels (0.66 ng/dL
). Anti 38 kDa, Mycobacterium and Anti Nuclear Antibody
were negative. Peritoneal and Pleural fluid analysis showed
transudative characteristics with negative cytology, bacterial
smears and cultures . Polymorphs 70%, Lymphocytes 30%. Pericardial
Fluid : Proteins 3.1 g/dL , Cholesterol 50 mg/dL , Polymorphs
13%, Lymphocytes 87% , Gram Stain and Routine Culture Negative
, AFB Smear Negative .
PROVISIONAL DIAGNOSES :
1. Epidemic
Dropsy, Rule Out Tubercular Pericarditis
2.
Subclinical Hypothyroidism
3.
Coronary Artery Disease with Old Myocardial
Infarction
4. Status
Post-operative Cholecystectomy |
HOSPITAL
COURSE :
Patient was started on oxygen by face mask and a lifeline
with D5W. She was continuously monitored in the Critical
Care Unit. Soon after admission, there was no urine output
for 2 hours after which dopamine infusion was started for
hypotension (BP 80/60). She was hypovolemic despite being
water logged. Patient responded to dopamine infusion which
was gradually tapered off over the next five days. Human
albumin, parenteral amino acids , furosemide and mannitol
were carefully administered. Patient was digitalized and
started on thyroxin (0.1 mg./day) and anti-tubercular regimen
with prednisone @ 0.75 mg./Kg body weight. Supportive therapy
was continued. 300 C.Cs of clear yellowish fluid was removed
with pericardiocentesis and several liters of straw colored
fluid was removed from the peritoneal and pleural cavities
by repeated paracentesis and thoracentesis to help the patient
breathe better . Pleural effusions were seen to re-accumulate
quite fast, requiring insertion of bilateral chest tubes
in stages for continuous drainage and chemical pleurodysis.
Packed RBCs were transfused twice in order to improve the
oxygen carrying capacity. Intensive diuresis was continued
with spironolactone and furosemide administered twice a
day along with supportive and symptomatic treatment. Steroids
were changed to alternate day therapy. Patient was discharged
home on the 38th Hospital day for out-patient follow-up
with residual ascites and pericardial effusion, both of
which cleared completely over the next four months. Patient
remains asymptomatic one year after the hospital discharge.
SURGERY
FOR ADVANCED LUNG CANCER
A 70 years old , chronic heavy
smoker man with history of alcohol abuse was admitted to Indus
Hospital on June 23, 1998 , with five years history of progressive
pain in the left scapular reason . Pain was almost continuous
and unbearable for six months despite medical treatment for
many years from a local civil hospital. He also complained
of anorexia and epigastric abdominal pain for six days prior
to admission . Rest of the history was non-contributory.
On physical examination,
his vital signs were normal . The patient was afebrile, acyanotic
, non-icteric without edema or lymphadenopathy. Clinical examinations
of heart , extremities and neck was unremarkable. Breath sounds
were diminished in the left scapular area , otherwise , lungs
were clear to auscultation. There was epigastric tenderness
without abdominal organomegaly, ascites or palpable masses
.
LAB. DATA
Hgb. 12.6 gm/ dL , Hct. 38% ,
R.B.Cs 4.7 m/cu.mm. , WBC 14600 /cu.mm , Polys 82% , Lymph.
16% , Mono. 1% , Eosin. 1% , Platelets 2,20,000/cu.mm., Sed
Rate 40 mm/hr. , Urinalysis normal , Stools normal , VDRL
non-reactive , Serum Chemistry Profile and Electrolytes were
normal , PBS normocytic normochromic , Sputum for AFB Smears
negative , Mantaux Skin Test negative , Electrocardiogram
and Pulmonary Function Tests were normal, X-rays Chest showed
a large patchy radiodensity in the superior segment region
of left lower lobe with normal heart size and mediastinal
shadows and no free fluid, X-rays of cervical spine showed
narrowing of C5-C6 and C6-C7 disc spaces, Ultrasonography
of Abdomen was normal , Double Contrast Upper G.I. Barium
X-rays with Small Bowel Follow-through Studies showed Pylorospasm
with Gastric Dilatation .
Esophagogastroduodenoscopy
showed superficial ulcerations in the Prepyloric region along
the lesser curvature and in the pyloric channel . Examination
of esophagus and duodenum was unremarkable.
Flexible
Bronchoscopy showed an endobronchial neoplasm at the superior
segmental bronchial orifice of the left lower lobe which proved
to be poorly differentiated squamous cell carcinoma by biopsy.
Nuclear Bone Scan , CT Scans of head and liver showed no metastatic
disease.
DIAGNOSES :
1. Squamous Cell Carcinoma,
Left Lower Lobe With Invasion of Chest Wall .
2.
Peptic Ulcer Disease.
HOSPITAL COURSE
After
one week triple antibiotic and five weeks H2 blocker
and antacid treatment for peptic ulcer disease , the patient
was readmitted for left standard posterolateral thoracotomy
under general endotracheal anesthesia . A large , bulky tumor
mass in the superior segment of lower lobe was found to invade
the lingular segment of the upper lobe as well as the structures
in the seventh and eighth intercostal spaces posteriorly.
Intercostal lymph nodes were also involved. Left lower lobectomy
with wedge resection of lingula and wide exicision of chest
wall , including the seventh , eighth and ninth ribs , was
performed without prosthetic reconstruction of the chest wall.
The patient made a slow, but an uneventful recovery and was
discharged home on the 21st Hospital day in good condition
.
FOLLOW-UP
Patient was readmitted to Indus
Hospital nine months after the Hospital discharge with pulmonary
tuberculosis involving the upper lobe of the right lung. He
was given antitubercular treatment for nine months with complete
resolution of the disease . He has been followed at yearly
intervals for three years . The patient has gained weight
, remained free of metastatic disease , but continues to smoke
and abuse alcohol despite instructions to the contrary.
MALIGNANT BRONCHIAL
CARCINOID REQUIRING PNEUMONECTOMY
A 34 years
old woman with known pregnancy induced systemic arterial
hypertension for 2 years was seen at Indus Hospital on July
04 , 2001 with 10 months history of 12 kg weight loss ,
diarrhoea , dyspepsia and occasional vomiting without hemetemesis
, melena or hematochesia . Blood pressure was controlled
with 50 mg. Atenelol O.D. She had no other symptoms except
scanty menstrual periods .
Examinations showed no abnormal
physical findings . BP was 130/80 mm. Hg. , Pulse 84 per
minute , Weight 56 kg , Respiration 16 per minute . Temperature
was normal .
Lab Data : Hgb. 12.6 gm % , Hct. 38% , RBC's 4.7 million
/ cu. mm , WBC 7200/cu. mm. , Sed. Rate 6 mm. , DLC : normal
. Urinalysis : 2-3 pus cells / H.P.F. , otherwise normal
. Blood Group : O , Rh +ve . Blood Chemistry Profile , Serum
Electrolytes and Coagulation Profile were normal . Thyroid
Function Tests showed marked hypothyroidism with Free T3
= 1.88 pg./ mL. , Free T4 = 0.49 ng./dL. , TSH = 68.73 uIU
/ mL. VDRL was non-reactive . HIV Screening Test and Mantaux
Skin Test were negative . Stool examination for Ova , Cysts
and Occult Blood was negative.
12 lead EKG
was normal . Chest X-rays showed right hilar enlargement
. CT Scan of Thorax confirmed the presence of a 3.8 cm.
soft tissue mass adjacent to the right main bronchus without
significant post -contrast enhancement and normal pulmonary
parenchymal fields , subcarinal and left hilar areas .
Flexible fiber-optic bronchoscopy showed
a polypoid mass projecting from the right middle lobe bronchial
orifice with intact mucosal lining. Bronchial washings were
negative for malignant cells . However , bronchial biopsies
showed brochial carcinoid tumor .
Although ,
patient's symptoms of diarrhoea could be explained on the
basis of carcinoid syndrome , double contrast upper G.I.
and small bowel follow-through Barium x-rays were done which
were suspicious for features of inflammatory bowel disease
with floculation of barium and thickened mucosa in the small
bowel . Esophagus , stomach and duodenum were normal .
  Patient
was treated for hypothyroidism with 75 microgram thyroxine
daily and metastatic work- up including CT Scans of brain
, abdomen and nuclear bone scan were performed which were
all negative for metastatic disease . Treatment for inflammatory
bowel disease was withheld pending removal of bronchial
carcinoid tumor to see weather carcinoid syndrome was the
underlying cause of her diarrhoea .
HOSPITAL COURSE:
A standard postero-lateral right thoracotomy under general
anesthesia was performed on July 21 , 2001 . Although ,
the right upper lobar bronchus was free of tumor involvement
, its venous drainage was involved by the malignant carcinoid
, necessitating right pneumonectomy for complete removal
of the tumor . Patient tolerated the procedure well and
made an uneventful recovery .
FINAL HISTOPATHOLOGICAL DIAGNOSIS :
Central Carcinoid tumor ( lung) with capsular invasion and
surrounding lung parenchyma free from invasion . Reactive
hyperplasia of mediastinal lymph nodes .
She , however, continued to have symptoms
of diarrhoea on and off after removal of the tumor . In
view of the high incidence of small bowel tuberculosis in
India , the patient was , empirically , started on anti-tubercular
treatment with excellent symptomatic response . She continues
to do well and remains asymptomatic.
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