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GLOBAL MEDICAL DIGEST ISSUE 1. AUGUST 2013. www.globalhospitalsindia.com Hyderabad | Chennai | Bengaluru | Mumbai

IN THIS ISSUE 1 Chondrosarcoma of Humerus (Bone Cancer) Wide Excision and Humerus Megaprosthesis

Chondrosarcoma of Humerus (Bone Cancer) Wide Excision and Humerus Megaprosthesis A 36 years old female patient came from East Godavari was admitted with a secondary chondrosarcoma of the left proximal humerus (left side) patient complained of swelling around left shoulder and difficulty in using left shoulder since 3 years.

2 Acute Cerebellitis with Brainstem compression and Hydrocephalus

3 Fracture Acetabulum with Symphysis pubis disruption

4 Unusual Presentation of Cysticercosis (Taeniasis)

Before surgery

Patient operated with wide excision and proximal humerus megaprosthesis on 9/5/13. Drain removal and dressing done on 4th POD. Wound healthy. Patient stable at the time of discharge. Surgical Procedure: Wide Excision Proximal Humerus+Proximal Humerus Megaprosthesis (SUSHRUT). The patient underwent a successful surgery and we could prevent her hand from being amputated. Now the patient is comfortable in moving the hand and leading a normal life.

5 Translumbar Ivc Permcath Insertion After surgery

Dr. Srinivas CH MS (Ortho), Fellowship in Orthopaedic Oncology Consultant Orthopaedic Oncologist

Dr. Madhav Yendru MS (Ortho), M.Ch. (Ortho) UK Sr Consultant Spine & Musculo-skeletal Oncology

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Acute Cerebellitis with Brainstem compression and Hydrocephalus

Fracture Acetabulum with Symphysis pubis disruption

A 25 years married female came to us with complaints of slurring of speech, dysarthria, difficulty in walking for the last 4 days. She had severe headache with vomiting for 2 days. Plain MRI of the brain done outside showed mild hydrocephalus. Initially a possibility of chronic meningitis was considered; later MRI brain with contrast was done which didn’t show any meningeal enhancement. However cerebellum was bulky and it was completely obliterating the 4th ventricle and there was increase in hydrocephalus.So, EVD was placed for hydrocephalus and CSF was analyzed. CSF analysis was within normal limits.

Fractures of the acetabulum occur primarily in young adults as a result of high-velocity trauma. These fractures are often associated with other life-threatening injuries.

So, a diagnosis of acute cerebellitis with brainstem compression and hydrocephalus was made.She underwent external ventricular drainage procedure and was also treated with IV methyl prednisolone over next 5 days. Patient had a significant improvement in headache and was discharged. After 2 weeks patient almost recovered totally except for mild slurring of speech.

Displacement of the fracture fragments leads to articular incongruity of the hip joint that results in abnormal pressure distribution on the articular cartilage surface. This can lead to rapid breakdown of the cartilage surface, resulting in disabling arthritis of the hip joint. Anatomic reduction and stable fixation of the fracture, such that the femoral head is concentrically reduced under an adequate portion of the weight bearing dome of the acetabulum, is the treatment goal in these difficult fractures. Disruptions of the symphysis pubis are typically described as resulting from an anterior or posterior force impacting the pelvis. Treatment options for symphyseal disruptions consist of external fixation or more mechanically sound open reduction with internal fixation, when the pubic diastasis measures greater than 1.5 cm. Open reduction and internal fixation is preferred for unstable symphyseal injuries. A male patient of age 33 years came with pain swelling around pelvis and spine and scrotal swelling and inability to walk. After sustaining injury to pelvis due to fall from a height resulting in Comminuted Anterior Column fracture of Left Acetabulum with Disruption of Symphysis pubis. Principal diagnosis: Acetabulum fracture right, right inf. pubic rami fracture pubic diasthesis, L1 wedge compression fracture, sacral fracture. Other diagnosis: anterior abdominal wall haematoma. Initially he was stabilized in ICU and later taken up for surgery.

This condition is very rare and is fatal in 50% of cases. Early recognition and surgical treatment has altered the final outcome in this patient. Even though ADEM is a common entity, presenting with hydrocephalus is very rare, very few case reports have been reported to have survived after treatment.

Dr. Naveen Kumar Venigalla MD (NIMS), DNB, DM Neuro (NIMS) Consultant - Neurologist

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Patient operated for fracture acetabulum right and pubic diasthesis using the Ilioinguinal approach, a 3.5-mm reconstruction plate is molded along the iliac fossa, across the iliopectineal eminence to the pubic tubercle and the body of the pubis. A separate 3.5-mm reconstruction plate is used to fix the disrupted symphysis pubis after reduction and bone grafting.

Before surgery

After surgery

Post-operatively, collection noted in drain and soakage of dressings seen. CT abdomen done and found normal. Wound dressings done regularly and S/R done on 12th POD, the wound healed in 12 days. Foley’s catheter maintained for 2 weeks. Mobilization in bed continued for 6 weeks. After which, Partial weight bearing mobilization with walker started. He now has full range of movement in the hip and mobilizing well with a single elbow crutch.

Issue 1. August 2013. www.globalhospitalsindia.com


Surgical procedure: orif pelvis left anterior column + pubic symphyhsis + bone grafting done

Dr. Chandra Bhushan MS (Ortho), (ODTS London) HOD & Chief Orthopedic Surgeon

Dr. Arvind Gandra MS (Ortho) Consultant Orthopedic Surgeon

Unusual Presentation of Cysticercosis (Taeniasis) A 40 year old woman presented to the Obstetrics & Gynaecology out patients with a history of vaginal discomfort during menstruation. She initially observed a thread like structure in the sanitary napkin admixed with blood.. However there was no positive history of dysmenorrhoea, menorrhagia, and symptoms related to tuberculosis. Physical examination was unremarkable. An initial impression of possible mucus threads admixed with blood was entertained by the gynaecologist and the patient was reassured and sent home. However she reported back to the out patients with persisting symptoms and at this juncture, the patient also produced a thread like structure in a box mixed with menstrual blood and she was referred to the medical department for further management. At the medical department, a repeat physical examination proved unremarkable and the haematological examination revealed a Hb of 8 gms%, a TLC of 8200 cells/ mm3, a differential count revealed an eosinophilia of 10% and a platelet count of 2.5 lakhs. Histopathological examination of the thread like structure showed a worm which was identified as Taenia solium. A modified Z.N. stain revealed a small worm with hooklets and the diagnosis of cysticercosis/ taeniasis was entertained. The patient was administered on Albendazole at a dose of 15mg/Kg for 28 days. The patient unfortunately was lost to further follow up.

This is being reported as a rare site of cysticercosis in the body. The other unusual sites are the cardiac and skeletal muscles and the eye. We believe this to be one of its first kinds to be reported in the south of India in the last five years. More work could have been done to ascertain other body sites infected in this patient. The same could notbe done as she was lost to follow up and never reported back to the out patients department. The natural course of the disease in this patient was baffling and could not be conclusively ascertained. However it is theorized that the worm could have been implanted in the uterus from the circulation and shed along with the menstrual flow over a period of time. This also agrees with the concept that the time period between infection and manifestation of symptoms in cysticercosis could be several months to years. Dr. Krishna Prabhakar MD (Internal Medicine)

Dr. Ranganathan Iyer MD, FRCPath( UK), DNB, DPB, MAMS

Dr. Mahendra J Parage MD (Path)

Dr. Pranathi Reddy MD, FRCOG

Translumbar Inferior Vena Cava Catheter Insertion A novel route for HEMODIALYSIS when all other options fail 65 year old diabetic gent, on HD for 8 years, with multiple bilateral jugular, subclavian permcaths and acute femoral catheters and multiple abdominal surgeries in the past, AVFistula surgery not possible due to poor vein caliber. Presently with a poorly functioning left subclavian permcath, on the verge of getting defunct, and a large clot in the SVC around the catheter tip. How do we dialyze him further?

Cut sections of the worm

Cysticercosis/ taeniasis is a common infestation caused by the Pork tape worm Taenia solium. The intermediate stage of this parasite is infectious to human beings with a preference for the CNS causing neurocysticercosis, in addition to afflicting other organs such as muscles, the eyes and the uterus and causing similar lesions. Whilst our patient confessed to partaking a non vegetarian diet, she denied having eaten pork at any point in time. This may not exclude cysticercosis in this patient as it is known to contaminate drinking water and even salads. . In addition to the aforementioned routes of infection, one could also be auto infected. Manifestations depend on the location and the number of cysticerci and the host immune response.

Issue 1. August 2013. www.globalhospitalsindia.com

Patient is placed in prone position & draped

Translumbar catheter kit

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Uppermost point of right iliac crest is palpated

Point of entry is confirmed under fluoroscopy, with artery forceps as marker

Needle is slowly withdrawn with continuous aspiration with syringe

Confirmation of IVC puncture is done with contrast injection After

We present the procedure of translumbar IVC HD catheter procedure performed first time in South India.

Guide wire is inserted and canula removed

Checked with fluoroscopy

Infiltration of local anaesthetic

Tunnel created with tunneler and catheter brought through

Insertion of introducer needle (canula with stylet)

Confirmation of position with fluoroscopy

INDICATION FOR TRANSLUMBAR IVC PERMCATH: No other viable long term vascular access possible, ‘last resort’. Clot in SVC, thrombosed major neck veins. Peritoneal dialysis ruled out. Dr. Sridhar G MD, DM Consultant - Nephrologist

Needle is pushed further under fluoroscopic vision up to midline (do not cross midline) in postero-anterior direction towards L2-L3 in a 45° angle

Editorial Desk Dr. K.V. Kamesh, MD (Internal Medicine), Chief - Critical Care & Internal Medicine Email: medicaldigest@globalhospitalsindia.com 4

Dr. Ashwinikumar Aiyangar MD, DNB Consultant - Nephrologist Dr. J Ramashankar MD, DM Consultant - Nephrologist

Catheter inserted after dilatation of tract and through peel-off sheath. This is the final position - tip in right atrium

Dr. Sandeep Reddy MD, DM Consultant - Nephrologist

Issue 1. August 2013. www.globalhospitalsindia.com

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