Journal of Case Reports in Practice
Volume:1 Issue: 1, Apr 2013

A pearl is precious even be sole!Over time, the importance of reporting case reports is gaining prominence. It is critical to emphasize that most clinical trials are made on the basis of data obtained from individual cases. Due to lower level of evidence attributable to case studies and less prestigious academic rank for case reports, many exotic and unique cases get being sacrificed and just lodged in individual minds. However, case studies are important tools in medical education and clinical care [1]. This is true especially for rare cases where case-control or randomized controlled trials are absent.Case reports are bricks of science building. No building is separate from its structural units. We believe that these structural moieties of medicine are pearls. We are providing a scientific platform to publish and archive these precious pearls!Each case could be a big teacher not only for the authors but also for any practicing doctors, residents or students [2]. Many students and residents who are beginners start with writing case reports. Some studies showed that junior practitioners are less likely to publish their single cases; however, tendency toward reporting cases is more frequent in specialized disciplines [3].Intelligent physicians and academics are constantly looking and searching their environment to find new facts. Despite a huge body of our knowledge, this is rather nothing in respect to “big holes” within it. “Scientific thinking” and “academic writing” is prerequisite for an academic practice. Many products of medical schools (as “mass production machines”!) are practitioners who are rather “good followers” however only small number of “physicians” or “Hakims” (in Persian and Arab language) think differently, try to find new ways, write more and do something and are blinking stars of the science sky. They work on “cutting edges”. Mimicking and pacing on the paced path of pioneers is not actually an academic fashion per se.Unfortunately most of universities in underdeveloped countries train students to adhere to medical text books [4]. On the other hand residents from developed countries prefer to use Internet and short case review books instead of traditional textbooks [5]. All above is accepted for undergraduate students and residents. Responsibility and duties of academic staff, however, is much heavier than the trainees. All academic staffs should have some role in creation of new products. Report of rare or single case is not the whole work but deep studying and challenging a case could be considered a minimum research and academic work.It seems that critical thinking and academic writing is a kind of creation. Creation is masterpiece of the Lord! Now human being could be vicar of Lord! And we appreciate this new job!Journal of Case Reports in Practice (JCRP) is going to be an instantly updating open- access journal, publishing high-quality, peer reviewed not only case reports but also case series, clinical images, clinical audios, clinical videos and most importantly unique scientific ideas and counter-current opinions. We publish articles from all areas of clinical, radiological and pathological disciplines.In recent years, many scientific journals and media emerged. Most of them are sponsored by giants. We started and are pacing on a long path with our strong motivation, hard work and powerful academic and technical friends.Our international team consists of skilled and scientific multinational scientists with distinguished academic background who has been selected from the best investigators from several universities. Most of our honorial editorial members have been qualified members of other international journals for years and perform their duties as professional authors, reviewers or editorial team.In recent years, many classic paper journals do not accept case reports for publication mostly due to limited page-space in the print version of the journals. This gap of publishing opportunities for authors was the major reason to start new journal specific for case reports.In journal editorial office, after receiving a manuscript, at the outset it will be screened by editor-in-chief for its relevancy and being within the scope of the journal. Then several steps of reviewing and corrections get done preparing it for final proof reading and English editing. Any galley proof will be submitted to the corresponding author for final approval by all authors. Now it is the time that a manuscript will be shown on the journal website. Corresponding authors are most responsible for any duplicate publication or any legal conflicts of published article.We guarantee a “fast track” service with regular updating and publications to encourage young and pioneer investigators to choose JCRP for their cases to report. Except for exceptional cases, we are going to make decision on manuscripts within 29 days. We welcome your nice support and joining us!

Macrophage Activation Syndrome (MAS) is an aggressive and potentially life threatening disease which can occur in rheumatologic diseases, more in systemic juvenile idiopathic arthritis and less in adult onset Still’s disease. We presented here a 22-yr-old female who was admitted with high fever for 3 weeks before admission. According to physical and laboratory results and after ruling out infections and malignancies, she was diagnosed with adult onset Still disease.Despite treatment initiation and improvement, she became dramatically ill one week later and jaundice was created. In physical and laboratory data, high fever, pancytopenia and impaired liver function tests and increased serum ferritin levels were found. Bone marrow aspiration and biopsy showed active hemophagocytosis. She was diagnosed with Macrophage Activation Syndrome associated with adult onset Still’s disease and managed with high-dose corticosteroids and cyclosporine. After this treatment she completely recovered.

In osteopetrosis subtrochanteric area is especially vulnerable to get fractured as it is an area of concentrated stress. We describe two cases of autosomal dominant osteopetrosis with subtrochanteric fractures. In one case upper tibial pin track infection prompted us towards a conservative management with a successful outcome in a time span of 25 weeks.The second case was directly treated by dynamic hip screw fixation though with great difficulty but was complicated by poor callus formation and loosening of implant. Re intervention was done with change of implant and bone grafting with subsequent fracture union. Both the cases experienced a second subtrochanteric fracture in their opposite hips after an average time period of 6 years and were managed operatively.Our experience with these two cases makes us to believe that there can be no clear cut protocol for the management of subtrochanteric fractures in osteopetrosis. Conservative management can still be considered when operative treatment is not an option. On the other hand, operative treatment is associated with considerable difficulty and complications. We thus have to weigh our options accordingly.

The rabies virus entered the body, the virus moves towards the brain along the nerves. Manifestations of rabies appear after 10 to 50 days from entrance of virus to the body. The first symptoms of the disease in humans include: pain at the bite site, a general feeling of illness, depression, headache, nausea, and vomiting.As the virus begins to proliferation and multiply in the spinal cord or brain, neurological symptoms would appear, including Anxiety, confusion, excessive saliva production, hallucinations, high level of excitement, insomnia, restlessness, paralysis of lower legs, voice box spasms and problems swallowing due to painful throat.Pseudorabies where the person after an animal bite behaves as if he is afflicted with rabies, is well introduced in literature and it is one of differential diagnoses of rabies. A 27 year-old, single male with hypochondriasis, a overvalued idea that he had contracted rabies. The patient failed to respond to multiple somatic therapies and twice made a serious suicide attempt. The patient believed in that he is rabid and attack to persons for biting them and bitted himself.The psychodynamics of the present case is various. Our patient had a painful experience, which was traumatizing to his ego, and this precipitated the conversion symptoms and finally the diagnosis was hypochondriasis plus conversion disorder.

Aggregation of some sign and symptoms from different organ system are important issues in medicine. Scleritis, vitiligo, poliosis, dermatitis and multiple sclerosis-like neurologic feature are features from a single pathophysiology. We describe for the first time a 23-years-old male with history of whitish hair discoloration and hypopigmented skin lesions, severe burning sensation all over the body and painful red eye. We proposed a new syndrome which has not been reported yet that merits further attention in clinical practice.

Angiomyxolipoma is considered as a variant of lipoma admixed with myxoid stroma and blood vessels. It was first described in 1996 by Mai and since then, 16 cases have been reported in literature, mostly in subcutaneous tissue. Case report: We report the case of a 50-year-old male who presented with a painless swelling of the right thigh. The ultrasonography revealed a vascularized inhomogeneous, slightly hyperechoic well defined mass measuring a maximum of 8 cm across. The patient underwent a large excision. The diagnosis was retained on histological and immunohistochemical findings. Angiomyxolipoma is an extremely rare benign tumor. This entity has to be differentiated from other benign and malignant lesions, the latter being much more common.

Rheumatoid arthritis (RA) is a multi-system disease characterized by chronic non-specific synovitis associated with rheumatoid factor (RF) or anti-CCP positivity in most proportion of cases. Major target organs in RA are however diarthrodial joints with resultant destruction and ankylosis. RA has pleuroparenchymal involvement with varied manifestations, which includes organizing pneumonia, interstitial fibrosis, airway disorders such as bronchiectasis and bronchiolitis and pulmonary vasculitis and also rheumatoid nodules. [1]On the other hand, Wegener's granulomatosis or recently renamed as Granulomatosis with polyangitis (GPA)is potentially life threatening condition with estimated incidence of 8.5 in a million in general population (Norfolk, primer p.417). Peter McBride (1854–1946) first described the condition in 1897, Heinz Karl Ernst Klinger (1907) added information on it, but the classic picture was presented by Friedrich Wegener (1907–1990). It is a necrotizing granulomatous vasculitis belonging to a major category of ANCA-associated vasculitides which involves sinuses and lung in classic forms. Pulmonary manifestations of Wegener’s granulomatosis could be as lung nodules, which can be cavitate in most instances, acinar shadows which may represent alveolar hemorrhage, mediastinal lymphadenopathy and pleural effusion [1]. Detecting antibodies most specific for these conditions revolutionized the issue of diagnosis and had a good impact on determining prognosis. Impact of ANCA (antineutrophil cytoplasmic antibodies) on whole body of vasculitides was so great so that in a general category suggested by some authors, vasculitides are divided into two major categories of ANCA Associated and Non-ANCA associated vasculitis. It is believed that ANCA may have pathogenic role in pathophysiology of ANCA associated vasculitis. Anti-neutrophil cytoplasmic antibodies (ANCAs) are a group of autoantibodies, against antigens in the cytoplasm of neutrophil granulocytes and monocytes. They are seen in a number of autoimmune disorders, but are highly associated with ANCA-associated vasculitides. ANCAs were basically described by Davies et al. in 1982 in some kind of necrotizing glomerulonephritis.Clinical manifestation of GPA is also similar to RA in a plenty of cases presenting with symmetric polyarthritis. GPA and RA are among the major differential diagnosis in case of multiple pulmonary nodules (MPN). Diagnosis of both RA and GPA is clinical in most instances based on pattern of clinical manifestation, pathological investigation and other laboratory investigations may confirm the diagnosis. Classification criteria of GPA which proposed in 1990 is based mainly on clinical aspects of Painful or painless oral ulcers or purulent or bloody nasal discharge, Abnormal chest radiograph such as nodules, fixed infiltrates, or cavities, Microscopic hematuria or red cell casts, and of course granulomatous inflammation on biopsy specimen. Based on the anatomic ELK classification [2] (E for ear, nose and throat, L for lung and K for kidney) of Wegener's granulomatosis, some patients have the L type with lung involvement only with sparing of the kidney and the upper respiratory tract. A patient is said to be classified as Wegener’s granulomatosis if at least two of these four criteria are present. The presence of any two or more criteria yields a sensitivity of 88.2% and a specificity of 92.0%. On the other hand new classification criteria for RA are mainly based on clinical aspects. (ACR/ EULAR 2010). In practice, patients frequently are diagnosed with RA with clinical picture of symmetric chronic polyarthritis with RF positivity in whom later features of a vasculitis ensues. Although RA per se can manifest as a necrotizing vasculitis but this feature is late in the course of disease and usually evolve in the context of full-picture RA. Most clinicians are familiar with classic differential diagnosis of MPN notably lymphoma, bronchiolitis obliterans organizing pneumonia, RA, GPA, sarcoidosis, fungal infiltrates and lung metastasis.Although tissue diagnosis is cornerstone for diagnosis, ANCA has a pivotal role in differentiating GPA from other diagnosis. The combination of C-ANCA and PR3-ANCA has a high positive predictive value for ANCA-associated vasculitis, particularly Wegener’s granulomatosis. Practically decisions are made individually by collecting clinical and laboratory investigations and biopsy of nodules are preserved for occasional patients. Renal involvement as glomerular hematuria is a discriminative index differentiating clinically GPA from RA. But it is evident in only 60-70% of patients with GPA at presentation. In limited GPA by definition clinical involvement of kidneys are absent. But limited GPA in lung, eye, and kidney has been reported. Based our long term clinical observations, we believe that in pre-ANCA era, it is likely that many cases of GPA were misdiagnosed as RA due to lack of access to ANCA and new modern techniques of investigations. So a global attention and reconsideration is justified regarding classic data on MPN and RA. In our routine practice if a patient with clinical feature of RA show MPN in his or her chest radiograph the likelihood that he or she have had GPA is considered to be very high especially when the patient shows c-ANCA activity. [3]We believe that in similar clinical setting, based on former radiographic and clinical data when modern rheumatology have not been developed the most pertinent diagnoses were RA. Also based on our longitudinal observations, we think the incidence of MPN in RA is very low, considering relative higher frequency of RA in respect to GPA, we have hardly seen any case of MPN secondary to RA during more than 10 years of practice. On the other hand, we had frequent cases of MPN with final diagnosis of GPA. We recall that there are reports of Wegener's granulomatosis that develop in an established case of rheumatoid arthritis although this association is very rare.In the reported cases the majorities were women and RA preceded GPA in all cases except one. [1, 4-7] In most of them there is not enough information of initial evaluation of cases about vasculitis especially GPA and may be some of them were the first GPA. We think when a patient who suspected to have RA presented by MPN we have to evaluate him for vasculitis at least by ANCA, so that positive c-ANCA is actually discriminative for GPA but this important tool was absent in pre-ANCA era. So most cases may be labeled enormously as nodular RA involving lungs[1]. Poorer prognosis of so-called pulmonary nodular RA may be attributable to this missing fact.

Many drugs can cause psychiatric symptoms. Psychiatric symptoms may ensue after treatment, following underlying illness, or unrecognized mental disorder. Dosage escalation, drug overdoses or even withdrawal of some drugs may also cause symptoms such as anxiety, psychosis, delirium, agitation or depression. In this article we briefly report a baclofen-induced psychological problem. This case demonstrates the importance of monitoring neuropsychiatric adverse drug reactions after starting baclofen use in patients with a current or past history of mental disorder. In rare cases, baclofen induced mania is reported [1,2]. In another series baclofen withdrawal led to manic manifestation [3].Mania may occur during treatment, particularly in patients susceptible to bipolar spectrum. Drugs such as levodopa, corticosteroids and anabolic-androgenic steroids may exacerbate mania. Tricyclic antidepressants and monoamine oxidase inhibitors can induce mania in patients with pre-existing bipolar disorders. Management involves discontinuation or dose reduction of the culprit drug when possible, otherwise antipsychotic drugs or lithium may be needed [4, 5].A 47 year old man presented with psychiatric symptoms and mood disorder following ingestion of eight pills of baclofen. He was admitted with insomnia, delirium, visual and auditory hallucination, persecutory delusion, spontaneous tearing, and a strong suicidal ideation. Also opposite sided symptoms like anxiety, verbal and physical aggression and uncontrollable burst of hyper -motility was observed. This was his fourth admission due to psychiatric problems. Later, he showed apathy, hesitation in speaking and is reluctant to being questioned. He has been absolutely symptom free between these episodes. Previous episode was two years ago.The patient is a known case of bipolar disorder, this time considered as mania phase. He was also a heavy smoker for 600pack/year along with 20 years history of opium dependency and four year history of oral drug intake. He was also on medical drugs at the moment with poor medical adherence. His past medical psychiatric therapy includes trihexyphenidyl 2mg daily, lorazepam 1m/Hs, sodium valporate 400mg daily, risperidone 2mg every night. Within the last two months, his therapy has been irregular, and since the last 20 days, he only took lorazepam and lrihexyphenidyl.He has no history of any other organic problem except for hypercholesterolemia. His medication at the time of admission was halopridol 10mg IM, bipridene 5mg IM, oral methadone 14cc daily, cholodiazpoxide 10mg three times daily, sodium valproate 200mg twice daily. His imaging including brain computerized tomography, EEG, and all his laboratory tests was normal. Due to disease flare up, seven sessions of Electroconvulsive Therapy (ECT) performed. Psychotic and mood symptoms recovered completely after ECT therapy.Considering patient’s history and medical assessment, a drug-induced mood disorder after using baclofen is proposed. It seems that psychosis and mood disorder secondary to drug effects are and more severe and potentially refractory to treatment.

This figure illustrates the left knee fluid aspiration of a 68-year-old patient with long standing rheumatoid arthritis (RA) who was also diagnosed with osteoarthritis at the age of 51. His physical examination revealed advanced genu varus deformity of knees with massive joint effusion, but try with a usual 22-gauge needle for aspiration gained no fluid. Second attempt with a Pleural needle biopsy was successful, and more than 60 cc of synovial fluid, full of floating particles typical of «rice bodies», was aspirated. His laboratory investigations showed persistently elevated ESR, positive CRP, negative rheumatoid factor (RF) and low titer of anti-CCP (anti-cyclic citrullinated peptide antibody; ACPA). Histopathologic examination demonstrated non-specific acute on chronic inflammation typical of inflammatory arthritis with fibrin exudates and no granuloma. The most important differential diagnoses of these findings are RA and tuberculosis.