General Medicine
Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/32547
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Browsing General Medicine by Author "Martinez, Maria Francesca Ysabelle"
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Item A Rare Case of Paraumbilical Hernia Containing and Obstructing the Stomach(2024-03-21) Martinez, Maria Francesca Ysabelle; Prado, Cynthia; Cao, Ngan; Ngo, Wayne; Salinas, Miguel; Maheshwari, MukulBackground: Abdominal hernias occur when peritoneal lined organs protrude through the abdominal wall. They are common with an estimated prevalence of 25% in adults. Patients may be asymptomatic but surgical intervention may be advised if patients are at risk for complications such as incarceration and strangulation. Initial diagnosis of abdominal hernias is made clinically but may be assisted with imaging. Computed tomography (CT) is the current modality of choice. In this case report, we specifically focus on midline abdominal hernias. These include epigastric, paraumbilical, umbilical, and hypogastric hernias. The most frequent abdominal hernia is the paraumbilical/umbilical hernia which account for 13.9% of all hernias. These occur due to weakness or defect in the linea alba and/or abdominal rectus muscles. Patient presentation varies but many have a visible bulge that may or may not be tender to palpation. Typical contents of paraumbilical/umbilical hernias include peritoneal fat, omentum, small bowel, and large bowel. We present a unique case of stomach herniation into a pre-existing ventral abdominal hernia that has been described only a few times in the last century. Identification with CT allowed for appropriate anatomical resolution to assess for bowel obstruction and strangulation of hernia contents. Case Presentation: A 72-year-old female presented to the emergency department with abdominal pain, nausea, and emesis. Prior computed tomography (CT) studies completed one month before presentation showed a large, ventral abdominal paraumbilical hernia without obstruction or strangulation. However, one month later she presented with worsening symptoms of abdominal pain, nausea, and emesis. Repeat abdominal and pelvis CT showed interval herniation of the distal stomach and proximal bowel into the patient’s known paraumbilical hernia. This resulted in gastric outlet obstruction. Immediate management included intravenous fluids, nasogastric tube placement and surgical correction. Operative report revealed a large ventral abdominal hernia with viable stomach, proximal duodenum (D1), cecum, ascending and transverse colon, and multiple loops of small bowel without evidence of strangulation. The patient successfully recovered after surgery. Conclusion: A rare complication in paraumbilical/umbilical hernias is gastric herniation into an existing hernia. Patients may present with red flag symptoms such as abdominal pain, nausea, and emesis. Quick identification of these symptoms and rapid visualization with CT will help identify the extent of herniation and other complications such as bowel obstruction, strangulation, and incarceration. A major risk factor for gastric herniation is weakened abdominal muscles and increased laxity of stomach ligaments found in populations such as multiparous women of middle to late ages. Healthcare professionals should be aware of patients who fit this demographic to educate them on the risk of herniation and recommend them for prophylactic surgical treatment.Item Tapinarof-Induced Folliculitis Outside of Treated Psoriasis Plaques: A Case Report(2024-03-21) Martinez, Maria Francesca Ysabelle; Scheufele, Christian; Weis, StephenBackground: Tapinarof 1% cream is a novel non-steroidal topical medication recently FDA-approved for plaque psoriasis. Plaque psoriasis is a chronic inflammatory skin disorder that manifests as erythematous plaques with micaceous scale on the body, often associated with pruritus. Appearance and symptoms of the plaques can greatly impact patients’ quality of life. Tapinarof’s non-steroidal mechanism allow for longer treatment periods without topical corticosteroid side effects e.g. skin atrophy, hypopigmentation, telangiectasia, and striae. Adverse events identified during pivotal trials may not be completely defined before widespread clinical use. This case reports a new presentation of folliculitis with tapinarof use. Case Presentation: A 25-year-old female with trisomy-21 presented for a rash on her left lower leg. The eruption began one year earlier. The eruption was not associated with pruritus, joint pain or nail changes. A clinical diagnosis of plaque psoriasis was made. Due to unsuccessful response with topical steroids and topical vitamin D analogues, alternative treatment was started with topical tapinarof. After approximately two months of treatment, the patient presented with a new concern of an itchy rash. On exam she had follicular papules around the original plaque. In addition, she had follicular papules and pustules following a linear distribution ascending the affected leg. These papules were distant from the original eruption. There were similar scattered papules on the unaffected leg. A clinical diagnosis of folliculitis was made. Bacterial and fungal cultures were negative. A biopsy demonstrated folliculitis and special stains did not show organisms. Conclusion: Tapinarof cream is a novel non-steroidal treatment option for plaque psoriasis. Tapinarof is considered by many to have a better safety profile when compared to topical steroids. Adverse events reported in tapinarof clinical trials included folliculitis at or near the site of psoriatic /plaque. This case is unique as the folliculitis occurred not just at the site of application, but also occurred distant to the site. The distribution has not been previously reported. Our case provides histological confirmation of folliculitis as a side effect. This unusual distribution of folliculitis may be due to external factors such as transfer of the medication by bed sheets or clothing. An alternative theory may be scratching of the plaque then subsequent spread to the areas where folliculitis is now evident. Further experience with tapinarof will more completely define tapinarof associated folliculitis. In the meantime, clinicians treating patients with tapinarof who develop folliculitis need to consider this possibility in their differential diagnosis.