15^th International Conference on Clinical & Medical Case Reports April 16-17, 2020 Amsterdam, Netherlands

Biography:

Maria Corbetta is a Research Fellow at Hunter New England Health District in Newcastle, Australia. With a career of over 10 years in surgical roles, Maria has been working for the Australian Health workforce since 2015, where she has been pursuing a career in General Surgery. She is a passionate surgical trainee, with interest in advanced laparoscopic surgery and surgical oncology.

Abstract:

Background

Small bowel obstruction is a common cause of surgical admission, a minority (0.08%) of which is caused by Foramen of Winslow hernia (FOWH). This entity can be particularly difficult to diagnose, and have been associated with high mortality rates in former years.  With the development of accessible computer tomography (CT) earlier diagnosis can be achieved, resulting in better outcomes. The conjunction of FOWH and Mackle’s diverticulum has been reported in the literature, however as a rarity. In this case report, a 76-year-old gentleman presented to our emergency department with features of small bowel obstruction (SBO) and found to have a Meckel’s diverticulum herniating through FOW as a cause of his SBO.

Case Report

A 76 yrs. patient presented to the emergency department with a one-day history of obstructive symptoms associated with central abdominal pain. His medical background consisted of ischaemic heart disease (previous Coronary Artery Bypass Graft surgery), dyslipidemia, melanoma excision, open hernia repair and open appendectomy. An Abdominal CT was performed, and it showed a FOWH. He was then taken to theatre for a laparoscopic reduction of small bowel obstruction. Intraoperatively, a Meckel’s diverticulum herniated through the Epiploic foramen causing the SBO was identified. Decision was made to perform a diverticulectomy; in a tangential fashion. This was performed using a 60mm laparoscopic GIA stapler. The patient had an uneventful postoperative recovery, being discharged from hospital D4 post procedure. The histopathology was reviewed and it confirmed normal histology without ectopic tissues.

Biography

Maria Corbetta is a Research Fellow at Hunter New England Health District in Newcastle, Australia. With a career of over 10 years in surgical roles, Maria has been working for the Australian Health workforce since 2015, where she has been pursuing a career in General Surgery. She is a passionate surgical trainee, with interest in advanced laparoscopic surgery and surgical oncology.

Biography:

Dr. Moleño is a currently undergoing her residency training in General Surgery at Rizal Medical Center in Manila, Philippines.

Abstract:

Many cases of acute abdominal pain lead to emergency hospital admissions, a large proportion of which have impending or already perforated hollow viscus, rendering an acute abdomen secondary to a ruptured viscus one of the most common surgical emergencies.  The two most common pinpointed initiating factors of a ruptured viscus are Helicobacter pylori infection and chronic non-steroidal anti-inflammatory drug or steroid abuse. 

This case report details the occurrence of double gastric perforation in a middle-aged man who was a known heavy smoker and alcoholic beverage drinker, with no elicited history of NSAID abuse, and with questionable history of illicit drug use.  Multiple peptic perforations are a relatively rare entity, much more double gastric perforations, outside the context of a traumatic event.  The challenge posed by this case is the lack of literature that would confirm if the predisposing factors that contribute to the development of multiple peptic perforations are the same as those that initiate perforations specifically located within the borders of the stomach.  A validation study would prove to be helpful in the management and further work-up of a double gastric perforation as well as in assessing if current therapeutic guidelines of peptic perforations are applicable precisely to multiple gastric perforations.

The rare nature of this case can provide an impetus in the study of non-traumatic double gastric perforations, especially since the strongest predisposing factors identified in multiple peptic perforations – H. pylori infection and chronic NSAID use – were both absent in this patient.

Biography:

Sujata Sai is a resident in surgery at Manipal Hospital, Bangalore. She is passionate about saving and changing lives. She also enjoys blogging about her experiences as a surgical resident. She has consistently done excellently academically, and has excelled in multiple extra curricular activities as well – She has given the Trinity College of Music Piano exams, is a part of several volunteer organisations for social service and participates in several sports as well.

Abstract:

Biography:

Dr. Saumya M. Shah is currently an internal medicine resident at the Mayo Clinic in Rochester, MN. She completed her medical school at the Mayo Clinic School of Medicine and is interested in a career in academic medicine.

Abstract:

Introduction: Wernicke-Korsakoff (WK) syndrome is known to be one of the most serious neurologic consequences of thiamine deficiency secondary to malnutrition and most commonly, excess alcohol use. The presenting symptoms of WK syndrome often include ophthalmoplegia, ataxia, and confusion. However, various studies have indicated that less than 10% of patients present with the triad of symptoms. Most often, mental status change is the most common presenting symptom.1,2 Moreover, patients with alcohol use disorder often present to the hospital with other medical complications of their alcohol consumption, including pancreatitis or alcoholic hepatitis, so the underlying neurologic syndrome related to thiamine deficiency can be missed.

Case Description: A 51-year-old Bangladeshi man presented to the emergency department (ED) with complaints of nausea, vomiting, diarrhea, and substernal chest pain after consuming “two beers and a bad taco”. He provided incongruent information to different providers, including his country of origin, where he resided, and the events preceding arrival to the ED. Previous outside records indicated visits to multiple different hospitals in different cities across the country. Physical exam was significant for severe cachexia, scleral icterus, horizontal-gaze nystagmus, periumbilical tenderness, and thick hyperkeratotic plaques affecting the palms, soles, and extending up the calves.  On laboratory workup, white blood cell count was 17.5/mm3, AST 97 U/L, ALT 35 U/L, lipase 4706 U/L, and blood alcohol level <10 mg/dL. He was admitted and treated for acute pancreatitis with fluid resuscitation. Given the presence of the hyperkeratotic lesions, a nutritional work-up was performed and was significant for severe malnutrition with low zinc levels (0.32, N 0.66-1.10 mcg/ml), vitamin A (8, N 15-60 mcg/dl), and 25-hydroxy vitamin D (8.4, N 20-50 ng/ml). Nutritional supplementation including intravenous thiamine, zinc, vitamin A, and D was initiated, and psychiatry was consulted to assess cognitive ability in the setting of no known prior psychiatric diagnosis. He displayed deficits in autobiographical memory and spatiotemporal narratives as well as circumstantial and illogical thought association. His Montreal Cognitive Assessment score was 15/27 and mental state was notable for confabulation and an abulic affect to situations. Findings on MRI of the brain of global brain parenchymal volume loss out of proportion to that expected for the patient's chronological age, and his clinical findings were all felt to be consistent with Wernicke-Korsakoff syndrome. The patient chose to leave the hospital before the treating physician recommended discharge and was lost to follow up.

Discussion: This case demonstrates the sequelae of chronic alcoholism leading to thiamine deficiency and the development of Wernicke-Korsakoff syndrome with confabulations and memory loss. Recurrent “subclinical” signs of Wernicke-Korsakoff syndrome may often be missed by clinicians in patients with inconsistent healthcare utilization and varying providers during each ED visit.  If thiamine deficiency is recognized early, there may be reversibility of the neurologic features, but in this case, there was no recognized irreversibility, as is typically seen with Wernicke-Korsakoff syndrome. While often non-specific, it is crucial for the clinician to carefully observe and assess patients that may have signs of Wernicke’s encephalopathy so treatment can be initiated prior to development of permanent neurologic damage.

Biography:

Dr. Montagnon attended Mayo Clinic Alix School of Medicine where she graduated in 2019. She is currently an internal medicine preliminary year resident and will begin dermatology residency at Mayo Clinic in July 2020.

Abstract:

A 56-year-old male presented to clinic with a 3-month history of increasing dyspnea, 1-month history of skin lesions, and 2-week history of arthralgias and decreased muscle endurance. Physical exam revealed inspiratory crackles to the midlungs bilaterally, intact muscle strength but fatigability, stiffness of the hands, raised rash on his torso, dry scaly plaques on the fingers, and tender, papular lesions on the palms. He was Jo-1 negative, but melanoma differentiation-associated gene 5 (MDA5) antibody positive. CK and aldolase were normal, but MRI of lower extremity muscles showed patchy muscular edema/inflammation. CT chest showed patchy bilateral groundglass and reticular opacities suggestive of organizing pneumonia. Skin biopsy was consistent with dermatomyositis. The patient was diagnosed with MDA5-positive dermatomyositis with interstitial lung disease (ILD) and initiated on prednisone 40 mg daily within 2 weeks of presentation; higher doses were precluded due to side effects. His arthralgias and rash improved, however dyspnea continued to worsen over the next 2 weeks. Mycophenolate mofetil was added within a month of presentation. Unfortunately, his respiratory status rapidly deteriorated over the next 2 weeks, requiring intensive care unit admission and did not significantly improve despite pulse IV methylprednisolone, cyclophosphamide, plasmapheresis, and ECMO support. Due to minimal clinical improvement, he is currently being considered for lung transplantation while rituximab is being added. ILD accompanying MDA5 dermatomyositis is often rapidly progressive and associated with a poor prognosis. Early recognition with aggressive upfront treatment with immunosuppression is critical for management, but deterioration may still occur.

Biography:

Jonathan Moriarty is currently a junior doctor at the Furness General Hospital in the UK currently working in the Acute Medicine Department. He graduated from the University of the West Indies Mona, Jamaica with an M.B.B.S degree at the age of 23 before migrating to the UK.

Abstract:

Hypereosinophilia is associated with both haematological and neurological conditions. This case seeks to highlight the differentials for two seemingly related conditions which were, in fact, independent of each other.

An 81 year old asthmatic female with chronic lower back pain, presented to the Emergency Department with a left foot drop which started 3 days earlier. She had an incidental finding of an eosinophilia of 19.9 x 10 ⁹/L (normal 0.05-0.5 x 10⁹/L). Significant examination findings included a power of 1/5 in all muscle groups of the left foot as well as an absent left ankle reflex. Differentials for the co-occurrence of the eosinophilia and the foot drop included Eosinophilic Granulomatosis with Polyangiitis (EGPA). However, nerve conduction studies were not in keeping with a mononeuritis multiplex but were more suggestive of an L5/S1 radiculopathy. A MRI of the lumbosacral spine confirmed nerve root impingement and left lateral disc protrusion in the regions of L4-L5 and L5-S1 respectively. We sought to rule out haematological causes and the bone marrow biopsy, cytogenetic studies, flow cytometry and molecular studies were also negative.

‘Idiopathic Hypereosinophilic Syndrome’ was the most likely diagnosis, since all other potential causes were excluded. She was commenced on oral corticosteroids and after 9 days of treatment the eosinophilia resolved and the foot drop improved with physiotherapy. . Initially, it appeared a straightforward diagnosis of EGPA but once we scratched beneath the surface it became clear that the foot drop was a ‘red herring’.

Biography:

Dr Natassja Moriarty completed her MBBS degree with Honours in 2015 at the University of the West Indies, Jamaica. She is currently an FY2 in Cardiology at the Furness General Hospital. She has published a case repost in a reputed journal and is currently working towards entering the IMT training programme in the UK.

Abstract:

This case report seeks to highlight an interesting case of a ruptured papillary muscle mimicking a mitral valve vegetation post myocardial infarction (MI).

We present a 59-year-old male with no comorbidities with a 1-week history of intermittent left-sided chest pain and exertional dyspnoea who was diagnosed and managed initially as a late presentation of Acute Coronary Syndrome (ACS). Significantly he had a new onset pansystolic murmur, ischaemic changes in the inferior leads on ECG, raised troponins and a predominantly right sided pulmonary oedema on chest X-ray. Echocardiogram demonstrated severe mitral valve regurgitation and mitral valve vegetation. Inpatient coronary angiogram demonstrated 100% stenosis to the right coronary artery.

He received a 6 weeks course of antibiotics for culture negative endocarditis, with a plan in place for mitral valve replacement surgery.

Interestingly, he was found to have a papillary muscle anatomy variant during surgery. It was rupture of this small papillary muscle head due to the right coronary infarct that created the severe mitral regurgitation with the piece of the papillary muscle head moving in and out of the ventricle thus mimicking vegetation.

This is a rarely documented occurrence in the literature and thus another example of an atypical presentation of a commonly highlighted post MI complication.

Biography:

Milica Glusac was born in Niksic Montenegro in the year of 1981. Completed University School of Medicine in Podgorica  at the age of 25  and specialization study  of gynecology and obstetrician  at University in Belgrade at the age 33. Nowadays works in general Hospital in Niksic.

Abstract:

Pseudomyxoma peritonei  is a rare clinical entity with estimated incidence  of one to two per  million per year. It is characterized by diffuse intraabdominal gelatinous collections with mucinous implants on peritoneal surfaces and the omentum. PMP predominantly originates in the appendix in men, and synchronous ovarian and appendiceal   disease in women.

We presented a rare case of PMP caused by primary mucinous adenocarcinoma of the appendix who spread to the right ovary in the 48-years female.

She complained to   abdominal distension, abdominal pain in lower right quadrant and appearance umbilical hernia about two months duration. Expression levels of the tumor markers CA 125, CEA and   CA 19-9 were elevated but HE 4 was in normal range.

She underwent gynecologic  ultrasound, computed tomography scan and MRI  which   showed   multiseptated  cystic mass  in her  right lower quadrant  and a large amount of ascites in all abdominal recess uses.

The presumed preoperative diagnosis was Ca ovarii with dissemination lesions into liver, splenic and peritonea.  She underwent to exploratory laparoscopy.

 Approximately 5000 ml of gelatinous fluid was aspirated from the pelvis and abdomen. The right adnexectomy  and biopsio peritonei  was done .

Surgical specimens were submitted for immunohistochemical examinations to distinguish the origin of the tumor and finally it showed low grade mucinous adenocarcinoma  appendix.

In conclusion diagnosis of the adenocarcinoma appendix   is difficult due to its lack of specific symptoms and signs. Adenocarcinoma appendix is an extremely rare disease in clinical practice. Until 2002, less than 250 cases had been reported in literature.

Biography:

Milica Glusac was born in Niksic Montenegro in the year of 1981. Completed University School of Medicine in Podgorica  at the age of 25  and specialization study  of gynecology and obstetrician  at University in Belgrade at the age 33. Nowadays works in general Hospital in Niksic.

Abstract:

Torsion of a subserosal myoma is a rare surgical emergency that is infrequently diagnosed preoperatively.

The first reported  case of  the  acute abdomen causing by torsion of uterine subserosal myoma was  in 1952  Tordera and others. Since than till today  it was described in literature  less than 50 cases  of torsion myoma in non pregnant women.

I present a rare case torsion of  subserosal myoma in the fundus uteri  for the  720 degrees  and torsion uteri in the isthmus level for the 180 degrees  in a postmenopausal  woman. A 61- year old woman admitted in  department of gynecology  General Hospital Niksic in February 2017  with  suddenly onset   severe abdominal pain  with  a few hours duration.  She also complained  to nausea and cold sweating . After clinical and ultrasound examination preoperative diagnosis was : Abdomen acutum. Myoma uteri subserosum torquatum. Virgo intacta. Postmenopausis. She underwent laparatomy and was found to have  complete necrotic subserosal myoma  sized about 10 cm   in the fundus  uteri with torsion  about 720 degrees  and  necrotic small uterus  with torsion at the level of the isthmus  for 180 degrees. Total hysterectomy with  adnexectomy lat.sin.was done. Postoperative recovery was regular  and she went home the day fourth after operation. In conclusion  torsion of myoma uteri is an extremely rare condition .Most cases were diagnosed intraoperatively.My  case is  case with a preoperative diagnosis based only on clinical and ultrasound examinations.

Biography:

Dr Mohamed Shirazy is specialised in both ICU and Emergency Medicine. After graduation from the Faculty of Medicine, Alexandria University, Egypt in 2008, he did his ICU training for 5 years during which he got a master degree in Critical Care Medicine. Afterwards he got the European Diploma in Intensive Care Medicine and the Membership of the Royal College of Emergency Medicine. Dr Shirazy worked in Egypt, Bahrain and is currently an associate specialist in Emergency Medicine in the University Hospitals of Morcambe Bay NHS Foundation Trust, UK.

Abstract:

A 72-year-old housewife presented with ischemic cerebrovascular stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) followed by mechanical thrombectomy under general anesthesia were attempted. The patient developed stridor and tongue swelling, in addition to hypotension and bradycardia, 60 min after completion of the rt-PA infusion. The airway was intubated, and intramuscular adrenaline, together with intravenous hydrocortisone and diphenhy- dramine, were administered. On the second day, the tongue edema subsided, and the cuff leak test was negative. However, extubation was not attempted due to the development of brain edema. A tracheostomy was later performed, and the patient was weaned off mechanical ventilation.

Biography:

Dr Mohamed Shirazy is specialised in both ICU and Emergency Medicine. After graduation from the Faculty of Medicine, Alexandria University, Egypt in 2008, he did his ICU training for 5 years during which he got a master degree in Critical Care Medicine. Afterwards he got the European Diploma in Intensive Care Medicine and the Membership of the Royal College of Emergency Medicine. Dr Shirazy worked in Egypt, Bahrain and is currently an associate specialist in Emergency Medicine in the University Hospitals of Morcambe Bay NHS Foundation Trust, UK.

Abstract:

Background:

Anaphylaxis is a life-threatening condition, which is diagnosed clinically and confirmed by raised serial serum tryptase levels.

Case Presentation

A 75-year-old female, who was known to be allergic to penicillin was mistakenly prescribed meropenem, resulting in anaphylactic shock. She was mechanically ventilated and received intramuscular adrenalin in addition to intravenous hydrocortisone and chlorpheniramine, and nebulised salbutamol. Within two days, the anaphylactic shock had resolved, she was weaned off mechanical ventilation, and discharged to the ward. Procalcitonin (PCT) and serum tryptase levels sent within the first hour of the anaphylaxis. However, the initial and serial serum tryptase levels came significantly high, confirming the diagnosis of anaphylaxis, initial PCT level came significantly high as well. Daily follow up of the PCT levels went back to normal.

Conclusion:

PCT can be an alternative diagnostic biomarker of anaphylaxis

Biography:

Abstract:

CASE STUDY

This case study focuses on a 66-year-old patient, allergic to penicillin, with endometrial actinomycosis, with no history of intrauterine contraceptive (IUD) administration, with symptomatology in the form of postmenopausal uterine bleeding and lower pelvic pain. Endometrial actinomycosis is an infection that occurs rarely, accompanied by non-specific symptomatology. The diagnosis is based on histological examination of affected tissue sample. The treatment is conducted with antibiotic therapy, administering high doses of intravenous antibiotics and, in certain cases, surgical treatment, as was the case in our patient.

INTRODUCTION

Actinomycosis is a rare, chronic infectious disease caused by anaerobic, gram positive, filamentous microorganisms of the genus Actinomyces. The most commonly isolated species is Actynomices israeli (1). It is found as part of the normal flora of the human mouth, gastrointestinal and urogenital tracts. Healthy mucosa is a barrier against its spread in the body (2). The destruction of the mucosal barrier caused by traumas during endoscopic examinations, operations, or chronic inflammatory diseases is a predisposing factor for the development of actinomycosis. The disease occurs in several forms, the most common being cervicofacial, abdominal, and thoracic, while pelvic, generalized as well as localized on the CNS, are less common. (3, 4, 5, 6, 7,8) The uterus is relatively resistant to infections and endometrial infection is very rare. Genital infection is usually endogenous, possibly developed by direct spread through the abdomen, by ascending or inoculation, associated with IUDs, contaminated pessary, uterine prolapse, and criminal abortions (13) and it is difficult to make the diagnosis preoperatively. Endometrial Actynomucosis causes atypical symptoms such as abdominal pains, internal bleeding in genital organs, so it is difficult to determine the right diagnosis.The diagnosis of actinomycosis is most commonly made by isolating actinomycosis from a bioptate sample (9,10). In actinomycosis therapy, penicillin G is an option, in high doses and long-term use. Patients allergic to penicillin have been treated by tetracycline, clindamycin, erythromycin and cephalosporins (10, 11, 12). Surgical procedures are sometimes required. (9,10)

Biography:

Abstract:

Introduction:

All PRP systems are different, so they consequently produce different results. The technique used for the isolation and concentration of platelets directly affects the availability and functionality of the growth factors. Effective cellular therapy requires a framework for cell migration, the progenitor cells, which can be transformed into bone- or soft-tissue. The plasma gel can also serve as signalling proteins for the modulation of the repair and regeneration.

I-Stem PRP system in combination with plasma gel, called Plasmafill, provides a complex mix of cells, proteins and plasma gel frameworks, which helps to optimize the conditions for healing and regeneration.

The concentration of the growth factors in any PRP preparation is directly proportional to the amount of platelets contained in PRP. The most important growth factors identified in the highly concentrated PRP are:

• Platelet Derived Growth Factor – growth factor (PDGF): is chemoattractive for the stem cells endothelial cells

• Transforming Growth Factor Beta (TGF-β): promotion of cell mitosis and differentiation of connective tissue and bones
• Vascular Endothelial Growth Factor (VEGF)- Vascular Endothelial Growth Factor is a group of proteins that act as signalling molecules in angiogenesis: stimulates the angiogenesis and is chemoattractive for osteoblasts

Materials And Methods:

Preparation of plasma gel

An 8.7 mL venous blood sample was drawn under aseptic conditions. The blood was aspirated with a 21 G needle into a 10 mL syringe preloaded with 1.3 mL of anticoagulant citrate dextrose (ACD) solution (in rats: 2 mL venous blood sample mixed with 0.3 mL of ACD). Each blood sample was centrifuged for 15 minutes at 3000 RPM, 72 g, at 4℃, resulting in the following three layers: an inferior layer composed of red cells, an intermediate layer composed of white cells, and a superior layer made up of plasma. The 6 mL plasma layer was centrifuged for another 5 minutes at 1000 g in order to obtain a two-part plasma sample: the upper part consisting of 5.5 mL of platelet-poor plasma (PPP) and the lower part consisting of 0.5 mL of platelet-rich plasma (PRP) The PPP was then gently aspirated with a pipette and placed in a sterile injection bottle, being careful not to mix the PPP with PRP.

The injection bottle was attached to a dental syringe and heated at 100℃ for 12 minutes in a heating machine . The injectable plasma gel was then ready for use. An injection needle was attached to the dental syringe, and the plasma gel was injected into the target site.

Taking a whole blood sample and centrifuging at 3000 RPM for 15 min. (B) The blood was separated into three layers. (C) The platelet-poor serum layer was collected and pipette into sterilized injection bottles. (D) The injection bottle was attached to a dental syringe and heated at 100℃ for 12 minutes. The collected serum finally turned to plasma gel. (E) The plasma gel was a semi-solid and easily injectable material that was stable at the injection site. (F) The plasma gel was maintained over 1 year in the sterilized injection bottle, but exposed to room air, the plasma gel disappeared within 1 month. (G) Electron microscope findings of plasma gel: the plasma gel showed the typical shape of protein structures on an electron microscope

Result:

The plasma gel was a semi-solid and easily injectable material which was stable at the injection site The plasma gel was maintained well at the same consistency for over 1 year in a sealed injection bottle; however, when exposed to room air (opened bottle), the plasma gel disappeared within one month). Under an electron microscope, plasma gel was seen to consist of many same-sized round particles, which represented a consistent and homogenous protein feature

The Plasma Bio-Filler is injected to volumize, face, lips for a totally natural face-lift.
Plasma Gel has the same color and consistency as autologous fat, but when injected, the softness is much better than autologous fat and it allows being more precise and refined.

The advantage with other synthetic fillers is that this bio-active material works under the skin reactivating the natural dermal regeneration processes; with the bio-filters, there is no risk of allergic reactions, so it 100% safe.

Biography:

Abstract:

Introduction: Solitary fibrous tumors are tumors of mesenchymal origin that occur in the extremities and occasionally in pleura, meninges, and so on, but are extremely rare in the adrenal gland. Their biological behavior is variable but mostly benign.

Case presentation: A 13-year-old Oromo girl presented with a progressively increasing right upper abdominal mass of 3 years’ duration. She had dull dragging pain and an occasional low-grade fever. On examination she had 20 × 20 cm mass with well-defined medial and inferior border. Both ultrasound and computed tomography scan showed a highly vascularized mass arising from her right adrenal gland but she had neither the constitutional symptoms of a functional adrenal tumor nor an abnormal biochemical test. Surgical resection showed a vascularized mass with attachments to the right lobe of the liver with a weight of 1900 g. It was found to be a giant solitary fibrous tumor of her right adrenal gland with infrequent mitosis. She stayed for 5 days after surgery and was discharged. She showed remarkable recovery at follow-up at 3 months.

Conclusion: Although very rare, solitary fibrous tumor of the adrenal gland should be considered in differential diagnosis of adrenal masses.

Biography:

Abstract:

Case report

A 30-year-old woman presented with 2-week history of generalized abdominal pain, nausea, vomiting and 1-week history of high-grade fever and chills. Examination findings and initial investigations were unremarkable. CT abdomen was requested and grossly normal.

The patient had travelled to Pakistan and Dubai 4 weeks prior to these symptoms. On further clarification, she had attended to a wedding and had salads and had 1 -week history of diarrhea in Pakistan for which she had taken Metronidazole and diarrhea had settled. Apart from that, her trip was unremarkable, no animal exposure, no flu symptoms or no high-risk behaviors. At this point, Enteric fever was highly suspected and further investigations including blood culture, stool MCS, parasitology and malaria film were sent. Blood culture later incubated Salmonella Paratyphi A. She was given IV Ceftriaxone after discussion with local microbiologist and subsequently discharged.

Discussion

Enteric fever is an invasive bacterial infection acquired through consumption of contaminated food or water.

Organisms responsible for enteric fever are Salmonella enterica serotypes Typhi (S. typhi) and Paratyphi A, B, and C.

It should be suspected in a febrile patient with gastrointestinal symptoms who has been to endemic area.

Classic manifestations include relative bradycardia and rose spots.

Culturing organisms continues to be the mainstay of clinical diagnostic testing.

MDR strains are prevalent worldwide and antibiotics choice should be discussed with microbiologist.