Arteriovenous malformations (AVMs) are defined as aberrant linkages between arteries and veins in the absence of a capillary network. This case report will discuss the incidental finding of an AVM likely originating from the diaphragm. A 65-year-old female presents for an umbilical hernia repair. Her past medical history is significant for HTN, type 2 diabetes mellitus, gastroesophageal reflux disease, and class 1 obesity. She has a past surgical history of hysteroscopy in 2020 and laparoscopy in 1996. She has no history of tobacco use, alcohol use, or recreational drug use. She is allergic to contrast. A computed tomography (CT) scan was ordered and incidentally showed a soft tissue mass in the left upper quadrant adjacent to the stomach and diaphragm, possibly a gastrointestinal stromal tumor (GIST) or splenule, in addition to diastasis of the abdominal wall. Biopsies of the esophagus, stomach, and duodenum from the esophagogastroduodenoscopy (EGD) were all benign. A nuclear medicine scan of the liver and spleen found an estimated 2.3 cm soft tissue nodule located between the fundus of the stomach and the left hemidiaphragm that does not demonstrate sulfa colloid uptake and is therefore not consistent with a splenule. This is the only incidence cited of an AVM originating from the diaphragm. We suspect that the origin of this AVM is the inferior phrenic artery. The decision for management for this case was to get a CT scan of the abdomen and chest to trace the path of the AVM and manage with surveillance.
Purpureocillium lilacinum is a filamentous fungus commonly found in soil that has been recognized as an opportunistic pathogen. Cutaneous infections with Purpureocillium lilacinum are relatively rare, and they usually occur in individuals with some predisposing factors such as minor trauma or pre-existing skin conditions. Infections in immunocompetent individuals are unexpected due to the fungus’s typically low pathogenicity and the robust immune response of healthy individuals. In immunocompetent hosts, the skin serves as an effective barrier against many fungal infections. While cases of cutaneous infections in immunocompetent hosts have been documented, they are considered rare outliers. Presented is the case of a 93-year-old male who presented to the emergency department with a 10-day history of progressive, painful left upper extremity erythema and swelling. The patient had aggressive progression of hemorrhagic bullae requiring surgical debridement. While the patient’s presentation was originally thought to be consistent with necrotizing fasciitis, only cutaneous necrosis was encountered, and the patient was ultimately diagnosed with a superficial P. lilacinum infection. The failure of treatment leading to death in the described case could be attributed to a combination of factors including intrinsic resistance of the fungus, delayed diagnosis, underlying health conditions, antifungal susceptibility variations, fungal persistence, and immunosuppressive factors.
Thumb carpometacarpal (CMC) arthritis is one of the most common and debilitating pathologies evaluated by the hand surgeon, affecting up to 35% of individuals over 55 years of age. Though multifactorial in etiology, dorsal and radial subluxation of the thumb CMC due to incompetency of the volar beak ligament is thought to be among the most important factors contribution to the arthritis. Multiple operative interventions have been proposed to best address this pathology. In the United States, trapeziectomy with ligament reconstruction and tendon interposition (LRTI) as described by Burton and Pellegrini remains the most widely used technique. As an isolated trauma, dislocation of the thumb CMC joint is a rare injury, only comprising approximately 1% of injuries evaluated by hand surgeons. Typically, thumb CMC dislocations occur due to axial load with the thumb in a flexed position. They are most commonly dorsal dislocations, and are thought to occur due to failure of the dorsoradial ligament. To date, no cases of CMC dislocation after LRTI have yet been described in the literature. Here we present a patient with volar thumb CMC dislocation as a rare complication after LRTI. After percutaneous pinning and immobilization followed by hand therapy, the patient has had a successful return to work with improved pain, restored function, and no further instability.
The success rate of vascularized free flap transplantation in head and neck oncologic surgery is high, ranging from 94% to 98.8%; however, flap necrosis sometimes occurs after surgery. When vessel-related complications occur, flap necrosis proceeds rapidly. Thus, flap monitoring after surgery is especially important. We recently treated two patients with flap-related complications. A vesicle appeared on the surface of the flap and enlarged within a short time; the flap’s color changed to purple, and a reoperation was eventually performed. While there are approaches to monitor flaps, this is the first report suggesting the assessment of vesicle formation for flap monitoring, since the vesicles occur several hours before changes in the flap color.
Isolated congenital aplasia of carpal bones in the absence of an associated congenital syndrome is exceedingly rare. Since the first documented case report of congenital carpal bone absence in 1911, only 12 additional case reports have been published. Here we present a case report of an otherwise healthy 43-year-old male with unilateral congenital absence of the lunate, which has only been previously reported once in the literature.
