Several cases of acute necrotizing encephalopathy (ANE) with influenza A (H1N1) have been reported to date. The prognosis of ANE associated with H1N1 is variable; some cases resulted in severe neurologic complication, whereas other cases were fatal. Reports mostly focused on the diagnosis of ANE with H1N1 infection, rather than functional recovery. We report a case of ANE with H1N1 infection in a 4-year-old Korean girl who rapidly developed fever, seizure, and altered mentality, as well as had neurologic sequelae of ataxia, intentional tremor, strabismus, and dysarthria. Brain magnetic resonance imaging showed lesions in the bilateral thalami, pons, and left basal ganglia. To our knowledge, this is the first report of ANE caused by H1N1 infection and its long-term functional recovery in Korea.

The optimal method of fixation for primary total hip replacements (THR), particularly fixation with or without the use of cement is still controversial. In a systematic review and metaanalysis of all randomized controlled trials comparing cemented versus uncemented THRS available in the published literature, we found that there is no significant difference between cemented and uncemented THRs in terms of implant survival as measured by the revision rate. Better short-term clinical outcome, particularly an improved pain score can be obtained with cemented fixation. However, the results are unclear for the long-term clinical and functional outcome between the two groups. No difference was evident in the mortality and the post operative complication rate. On the other hand, the radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis. We concluded in our review that cemented THR is similar if not superior to uncemented THR, and provides better short term clinical outcomes. Further research, improved methodology and longer follow up are necessary to better define specific subgroups of patients in whom the relative benefits of cemented and uncemented implant fixation can be clearly demonstrated.

Post-pancreaticoduodenectomy hemorrhage is a life threatening complication reported to occur in 2-7% of patients. Historically, treatment required an exploratory laparotomy. Introduction of endovascular embolization has broadened the available treatment options. The most common location for a post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage exist and are hard to localize, thus they are often treated with open surgery. Here we report two cases of CTA proven hemorrhage from the dorsal pancreatic arcade and transverse pancreatic artery, which were successfully located with conventional angiography and treated with endovascular arterial coil embolization. Both patients were status post-pancreaticoduodenectomy (Whipple procedure) and presented with a sentinel bleed and a drop in hematocrit levels.

Intramural esophageal hematoma is part of a spectrum of esophageal injuries. Vomiting and straining, endoscopic procedures and bleeding disorders are the most common predisposing factors. However, it can also be an unusual complication of anticoagulation and/or thrombolysis therapy. The most common symptoms are retrosternal chest pain, dysphagia and hematemesis. Computed tomography is the modality of choice and treatment is medically conservative with the cessation of Warfarin and thrombolysis use. When anticoagulation and/or thrombolysis therapy is necessary, periodic reassessment for symptoms of intramural esophageal hematoma may be helpful for early identification and management. We described one case of intramural esophageal hematoma possibly resulting from anticoagulation and/or thrombolysis therapy in the setting of pulmonary embolism.

Biliary tract complications are the most common complications after liver transplantation. These complications are encountered more commonly as a result of increased number of liver transplantations and the prolonged survival of transplant patients. Biliary complications remain a major source of morbidity in liver transplant patients, with an incidence of 5%-32%. Post liver transplantation biliary complications include strictures (anastomotic and non-anastomotic), leaks, stones, sphincter of Oddi dysfunction, and recurrence of primary biliary disease such as primary sclerosing cholangitis and primary biliary cirrhosis. The risk of occurrence of a specific biliary complication is related to the type of biliary reconstruction performed at the time of liver transplantation. In this article we seek to review the major biliary complications and their relation to the type of biliary reconstruction performed at the time of liver tranplantation.

Subcutaneous emphysema occurs when air is forced beneath the tissue, leading to swelling, crepitus on palpation and has the potential to spread along the fascial planes. This report describes the youngest case of subcutaneous emphysema related to dental treatment that has been documented to date. In addition to the patient's age, the case is of interest because periorbital subcutaneous emphysema is a rarest complication of stainless steel crown procedure.

Percutaneous transseptal mitral commissurotomy (PTMC) is the treatment of choice in rheumatic mitral stenosis. The reuse of sterilised PTMC balloon catheters is widely practised to bring down the procedure cost and have proven safety and efficacy. The reused balloons may deform and are prone to rupture causing fatal complications like embolism either of the torn balloon material or air. We report a first case of Accura balloon rupture during PTMC to the best of our knowledge. Fortunately, there was no complication in our patient. Thus, during the balloon preparation it should be examined for any deformity or tear and air should be removed completely to prevent fatal outcome. The repeated use of the hardware should be limited and an informed consent regarding the possible complications of the reused hardware should be taken.

Intracranial haemorrhage is a known complication after fibrinolytic therapy and occurs usually in the first 24 h. We report a 35-year-old woman who presented with severe central chest pain and she was diagnosed as anterior ST elevation myocardial infarction. She was given fibrinolytic therapy with Tenecteplase. She responded well to the treatment with a decrease in the intensity of chest pain and resolution of the ST segment elevation. She was taken for coronary angiogram the next day, which revealed an occlusion of the left anterior descending (LAD) artery, and stenting of LAD was carried out. Four days later, she developed severe headache, confusion, slurring of speech and right haemiparesis. CT brain revealed intracerebral haemorrhage and she was referred to an neurosurgeon who advised for conservative management. Her condition gradually improved with physiotherapy and was discharged home with no marked functional impairment.

Cerebral venous sinus thrombosis  is a rare but serious cause of headache. In this report, we present a young man with poorly controlled Crohn's disease who presented with a 2-week history of headache and fluctuating left-sided sensory and motor symptoms. CT demonstrated changes consistent with either a subarachnoid haemorrhage or venous sinus thrombosis. The ensuing magnetic resonance venogram confirmed superior sagittal venous sinus thrombosis and an infarct of his right superior frontal lobe. The patient was started on low-molecular weight heparin and steroids. He required multi-disciplinary input from the stroke physicians, neurologists, gastroenterologists, dieticians and physiotherapists. He made a full neurological recovery and is now on long-term azathioprine. The purpose of this report is to highlight the consideration of venous sinus thrombosis in the diagnosis of headache and as a rare extraintestinal complication of Crohn's disease.

BACKGROUND:

Perforation is a serious life-threatening complication of lymphomas involving the gastrointestinal (GI) tract. Although some perforations occur as the initial presentation of GI lymphoma, others occur after initiation of chemotherapy. To define the location and timing of perforation, a single-center study was carried out of all patients with GI lymphoma.

PATIENTS AND METHODS:

Between 1975 and 2012, 1062 patients were identified with biopsy-proven GI involvement with lymphoma. A retrospective chart review was undertaken to identify patients with gut perforation and to determine their clinicopathologic features.

RESULTS:

Nine percent (92 of 1062) of patients developed a perforation, of which 55% (51 of 92) occurred after chemotherapy. The median day of perforation after initiation of chemotherapy was 46 days (mean, 83 days; range, 2-298) and 44% of perforations occurred within the first 4 weeks of treatment. Diffuse large B-cell lymphoma (DLBCL) was the most common lymphoma associated with perforation (59%, 55 of 92). Compared with indolent B-cell lymphomas, the risk of perforation was higher with aggressive B-cell lymphomas (hazard ratio, HR = 6.31, P < 0.0001) or T-cell/other types (HR = 12.40, P < 0.0001). The small intestine was the most common site of perforation (59%).

CONCLUSION:

Perforation remains a significant complication of GI lymphomas and is more frequently associated with aggressive than indolent lymphomas. Supported in part by University of Iowa/Mayo Clinic SPORE CA97274 and the Predolin Foundation.