Balloon displacement during caesarean section with pernicious placenta previa: A case report

BACKGROUND For the past few years,preventive interventional therapy has been widely used domestically and overseas,bringing great benefits to pregnant women at high-risk for complications,such as pernicious placenta previa(PPP)and placenta accreta.Nevertheless,there are still few reports on surgical complications related to interventional therapy,and its safety should be a concern.CASE SUMMARY We report a 36-year-old pregnant woman with PPP who underwent balloon implantation in the lower segment of the abdominal aorta before caesarean section.However,the balloon shifted during the operation,which damaged the arterial vessels after filling,resulting in severe postpartum haemorrhage in the patient.Fortunately,after emergency interventional stent implantation,the pa-tient was successfully relieved of the massive haemorrhage crisis.CONCLUSION It seems that massive postoperative bleeding has been largely avoided in preventive interventional therapy in high-risk pregnant women with placenta-related diseases,but surgical complications related to intervention therapy can also cause adverse consequences.It is equally important for clinical doctors to learn how to promptly identify and effectively treat these rare complications.

Pernicious anemia: New insights from a gastroenterological point of view

Pernicious anemia （PA） is a macrocytic anemia that is caused by vitamin B12 deficiency, as a result of intrinsic factor deficiency. PA is associated with atrophic body gastritis （ABG）, whose diagnosis is based on histological confirmation of gastric body atrophy. Serological markers that suggest oxyntic mucosa damage are increased fasting gastrin and decreased pepsinogen I. Without performing Schilling＇s test, intrinsic factor deficiency may not be proven, and intrinsic factor and parietal cell antibodies are use- ful surrogate markers of PA, with 73% sensitivity and 100% specificity. PA is mainly considered a disease of the elderly, but younger patients represent about 15% of patients. PA patients may seek medical advice due to symptoms related to anemia, such as weak-ness and asthenia. Less commonly, the disease is suspected to be caused by dyspepsia. PA is frequently associated with autoimmune thyroid disease （40%） and other autoimmune disorders, such as diabetes mellitus （10%）, as part of the autoimmune polyen-docrine syndrome. PA is the end-stage of ABG. Long- standing Helicobacter pylori infection probably plays a role in many patients with PA, in whom the active infectious process has been gradually replaced by an autoimmune disease that terminates in a burned-out infection and the irreversible destruction of the gastric body mucosa. Human leucocyte antigen-DR genotypes suggest a role for genetic susceptibility in PA. PA patients should be managed by cobalamin replacement treatment and monitoring for onset of iron deficiency. Moreover, they should be advised about possible gastrointestinal long-term consequences, such as gastric cancer and carcinoids.

Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section

Objective:This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.Methods:We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019.All patients underwent abdominal aortic balloon occlusion before their cesarean section.Seventyeight patients received bilateral uterine artery embolization,and among them,placenta accreta was found at the opening of the cervix in 13 patients.Due to suturing difficulty after the removal of the placenta,gauze packing was used to temporarily compress the hemorrhage.As soon as the uterus was sutured,emergent bilateral uterine artery embolization was performed.Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured,therefor,bilateral uterine artery embolization was performed urgently.Results:Of the 623 patients,545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section.No hysterectomies were performed.In the 78 patients,the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation;the volume of blood transfused was 360-1,750 ml(average:960 ml).The fetal fluoroscopy time was 3–8 s(average:5 s).The dose of radiation exposure was(4.2±2.9) m Gy.Fetal appearance,pulse,grimace,activity,and respiration(Apgar) score were normal.No serious complications were observed during or after the operation in the follow-up visits.Conclusion:For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion,bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation,and lowers the risk of hysterectomy.

Treatment of solitary gastric carcinoid tumor by endoscopic polypectomy in a patient with pernicious anemia

Type I gastric cardnoid tumors result from hypergastrinemia in 1%-7% of patients with pernicious anemia. We diagnosed pernicious anemia in a 48-year-old female patient with complaint of fatigue for three months. She had no gastrointestinal symptoms. Endoscopic examination ot the upper gastrointestinal tract revealed atrophic gastritis and a polypoid lesion in the corpus of 3-4 mm in size. Endoscopic polypectomy was performed. Histopathological examination of the specimen revealed positive chromogranin A and synaptophysin stainings compatible with the diagnosis of a carcinoid tumor. Serum gastrin level was increased, urinary 5-hydroxyindoleacetic acid was within the normal range. There was no other symptom, sign, or laboratory finding of a carcinoid syndrome in the patient. No metastasis was found with indium-ill octreotide scan, computed tomographies of abdomen and thorax. Type I gastric carcinoid tumors are only rarely solitary and patients with tumors 〈 1 cm in size may benefit from endoscopic polypectomy.

Clinical Analysis on the Effectiveness of Conservative Compression Suture Technique to Conserve Fertility on Pernicious Placenta Previa

Objective: To evaluate the effectiveness of conservative compression surgical suture techniques used for the management of pernicious placenta previa to conserve fertility in the subsequent pregnancies. Study Design: This was a non-comparative retrospective study of 188 patients diagnosed with pernicious placenta previa who underwent cesarean section in The First Hospital of Jilin University, China, from 1 January 2013 to 1 January 2018. Successful group was defined as those in which the intraoperative bleeding was managed by either modified CHO or by B-lynch suture technique and those who had further intervention including hysterectomy were designated as failure group. Results: Out of 217 patients, 188 met inclusion criteria and 29 patients were excluded. In 188 cases, 183 (97.34%) cases successes and 5 (2.65%) cases had hysterectomy. Among included group, 118 patients (62.76%) had undergone emergency cesarean section and 70 patients (37.23%) underwent elective cesarean section. The emergency group had significantly lesser gestation period of gestation at the time of cesarean section (P = 0.021) and lower neonatal weight (P = 0.001) than that of elective group. The estimated blood loss during surgery was 500 - 3200 ml (mean: 925 ml). Additionally, the amount of bleeding was found to be significantly more in patient with intraoperative complication (P = 0.007) and in patient with implanted placenta (P 0.001). Conclusion: The conservative compression suture technique including modified CHO and B-lynch suture technique during the cesarean delivery is a feasible, safe and effective alternative conservative surgical technique for the management of bleeding in case of pernicious placenta previa. Besides good surgical outcome and proper neonatal result this technique also reduces the rate of hysterectomy, thus conserving the fertility.

Pernicious anemia: What are the actual diagnosis criteria?

A gastric intrinsic factor output under 200 U/h after pentagastrin stimulation (N > 2000 U/h) is specific for pernicious anemia. The other findings are either variable or non specific. Serum intrinsic factor antibodies, considered as specific in general practice, are present only in half of the patients with pernicious anemia. In their absence, since the disappearance of the Schilling tests, the gastric tubage currently used for the study of gastric acid secretion, is obligatory for the simultaneous study of intrinsic factor output. This study is important to eliminate another disease much more frequent than pernicious anemia, the protein bound to cobalamin malabsorption was observed in achlorhydric simple atrophic gastritis in the presence of intrinsic factor secretion.

Pernicious Anemia Associated Autoimmune Diseases in a Sub Saharian African Internal Medicine Service

Introduction: Pernicious anemia is an autoimmune disease. It is characterized by the presence of an autoimmune atrophic gastritis and various autoantibodies that lead to a vitamin B12 deficiency responsible for a macrocytic anemia. It is frequently associated with other specific or non-organ- specific autoimmune diseases. We report six patients with pernicious anemia associated with other autoimmune diseases. Patients and Results: There were six patients (4 females/2 males), mean age of 39.67 years. In all cases it was found macrocytic anemia. The average Hb was 6.08 g/dl and the average MGV: 110.67 fl. Bone marrow aspiration was performed in all patients. Megaloblastosis compatible with a lack of vitamin B12 or folic acid was constant. Determination of serum vitamin B12 was low in all cases while folic acid levels were within standards. Immuno- logically it was found in all patients, a positivity of anti-intrinsic factor antibody and/or anti- parietal cells antibody at rates up to 67 times over normal ranges. Pernicious anemia was associated with autoimmune thyroid dysfunction in 4 patients. It was two cases of Hashimoto thyroiditis at hypothyroidic phase (high TSHus, thyréoperoxydase anti-antibody positive (over 10 N) in both cases and Graves’ disease in the two other cases. Pernicious anemia was associated with a syndrome of primary antiphospholipid antibody in a case. Furthermore pernicious anemia was found in a patient autoimmune type 1 diabetes with strongly positive anti -GAD antibodies and rheumatoid arthritis by retaining it in the diagnosis of multiple autoimmune syndrome. Conclusion: These cases illustrate the existence of the association of pernicious anemia with other autoimmune diseases in our context. This should encourage practitioners to seek hided autoimmune diseases when they consider the diagnosis of pernicious anemia.

Treatment of a patient with severe cerebral malaria during the COVID-19 pandemic in China:A case report

BACKGROUND On June 30,2021,China received certification from the World Health Organization for malaria elimination.However,this certification does not signify the absence of malaria within China.Due to the increasing frequency of international exchanges and collaborations,the threat of imported malaria persists in China.Consequently,the prevention and control of imported malaria have become a primary focus for our country to maintain its malaria elimination status.CASE SUMMARY Herein,we present a case report of a 53-year-old Chinese man who worked in Africa for nearly two years.He was diagnosed with malaria in the Democratic Republic of the Congo between November 19 and November 23,2022.After receiving effective treatment with oral antimalarial drugs,his condition improved,allowing him to return to China.He was later admitted to our hospital on January 12,2023,during the coronavirus disease 2019 pandemic in Huangshi,China.Through a thorough evaluation of the patient's symptoms,clinical signs,imaging and laboratory test results,and epidemiological data,he was rapidly diagnosed with severe cerebral malaria.The patient underwent successful treatment through a series of intensive care unit interventions.CONCLUSION The successful treatment of this imported case of severe cerebral malaria provides a valuable reference for managing patients with similar malaria infections and has significant clinical implications.

BIERMER’s Disease: About 4 Cases Diagnosed at Regional University Hospital of Ouahigouya (Chur/Ohg) and Literature Review

Megaloblastic pernicious anemia is an autoimmune disorder, considered rare in African context. The objective of this study was to report four clinical cases collected at the CHUR/OHG, and to review the literature. The study population consisted of two men and two women. The clinical manifestations were mainly neurological and hematological. The neurological signs were mainly paresthesia. One patient presented memory problems. On the biological level, macrocytic anemia and vitamin B12 deficiency were reported in two cases prior to treatment while the other two without serological assay of vitamin B12 were put on trial treatment. Anti-intrinsic factor antibodies were positive in three patients. The Schilling test was not used. Upper gastrointestinal endoscopy revealed atrophic fundic gastritis in all four patients who received treatment through intramuscular injection of hydroxocobalamin (vitamin B12). The evolution was favorable after one month of treatment in all cases. The literature review is dominated by clinical case reports, the largest cohorts of which are from the Maghreb.

Subclinical Hypothyroidism, Its Manifestations and Management a Case Report

Introduction: Thyroid states can be associated with psychiatric manifestations, be it hypothyroid, hyperthyroid or even euthyroid. The effect of depression is significant in subclinical hypothyroidism. Sometimes, its signs and symptoms are indistinguishable from Major Depressive Disorder. Our immunological system and early embryologic origins also play a role in the coexistence of other comorbidities like Pernicious Anemia. Case: A 35-year-old Hispanic female presented with significant low mood, somnolence, weight gain, increased hunger, cold intolerance and epigastric pain. It is important to note the variety of clinical manifestations of our hypothyroidism patient to understand its associations and help us with a better approach to treatment. Discussion: Standard approaches to treatment of Subclinical Hypothyroidism will depend mostly on laboratory findings such as TSH levels and free T4. Individualized therapy chosen for our patient was based on his mood symptoms, laboratory findings and coexistence of Pernicious Anemia. The use of daily 0.025 mg of levothyroxine, 10 mg of escitalopram oxalate and weekly injections of cyanocobalamin were treatments of choice. Conclusion: During follow up of our patient, we can conclude that Levothyroxine and Escitalopram Oxalate were able to improve hypothyroidism symptoms, reduce thyroglobulin and peroxidase antibodies and improve mood symptoms including cognitive functions. In addition to this, weekly cyanocobalamin injections were integrated into the management. As parietal cell antibodies decreased, gastrointestinal symptoms also disappeared. By addressing the concerns of our patient, we improved quality of care, and this is reflected in the patient’s wellbeing in physical and psychological.

Lack of specific association between gastric autoimmunity hallmarks and clinical presentations of atrophic body gastritis

AIM： To investigate the possible relationships between gastric autoimmune phenomena and clinical presentations of this disorder, in consecutive atrophic body gastritis patients. METHODS： A total of 140 atrophic body gastritis patients, diagnosed as consecutive outpatients presenting with macrocytic or iron deficiency anemia, or longstanding dyspepsia underwent gastroscopy with antral and body biopsies, assay of intrinsic factor, parietal cells and Helicobacter pylori （ H pylon） antibodies. Gastritis was assessed according to Sydney System. RESULTS： Parietal cell antibodies were equally distributed in all clinical presentations, whereas the positivity of intrinsic factor antibodies （49/140, 35%） was significantly higher in pernicious anemia patients （49.2%） than in iron deficiency （21.1%） and dyspeptic patients （27.8%）. No specific pattern of autoantibodies was related to the clinical presentations of atrophic body gastritis. A positive correlation was obtained between the body atrophy score and the intrinsic factor antibody levels （r=0.2216, P=0.0085）. Associated autoimmune diseases were present in 25/140 （17.9%） patients, but the prevalence of autoimmune diseases was comparable, irrespective of the clinical presentations. CONCLUSION： The so-called hallmarks of gastric autoimmunity, particularly in intrinsic factor antibody cannot be usefully employed in defining an autoimmune pattern in the clinical presentations of ABG.

Life threatening vitamin B_(12) deficiency:will timely screening make a difference?

INTRODUCTION While Vit.B12 deficiency is common,with aprevalence of about 15% in the elderly,andrecommendations for treatment available,detectionof deficiency at the pre-clinical stage by appropriatescreening does not always take place.Our report isan example of life threatening Vit.B12 deficiencydiagnosed at age 56,with the onset of Vit.B12depletion likely to have begun in the

Biermer Disease: Initial Presentation and Follow-Up of 66 Patients in Internal Medicine Department in Senegal

Pernicious anemia in black people, is little known. Through this study we assess its diagnostic and evolutive aspects, and compare vitamin therapy B12 intramuscular and oral. Sixty six Biermer disease patients followed (January 2000-June 2014) at Internal Medicine Department of Aristide Le Dantec University Teaching Hospital (Senegal) are included. They were 26 men and 46 women (gender ratio: 0.65), who had a mean age of 47.84 years ± 15.25 years. Patients consulted for anemia (65 cases), acquired melanodermia (36 cases), gastrointestinal symptoms (30 cases), peripheral neuropathy (27 cases), venous thrombosis (2 cases), acute depression (1 case). Macrocytosis was observed in 52 cases. The mean hemoglobin in the vitamin B12 intramuscular group (52 patients) or oral group (14 patients) was the inclusion: 6.55 g/dl ± 3.12 g/dl vs 6.52 g/dl ± 2.18 g/dl (p = 0.04);and at day 8 treatment: 8.69 g/dl ± 2.49 g/dl vs 8.85 g/dl ± 1.9 g/dl (p = 0.43). Neurological and vascular presentations are unusual in contrast to macrocytic anemia. Oral administration of vitamin B12, simple and effective should be recommended in country with limited resources.

Successful type-oriented endoscopic resection for gastric carcinoid tumors: A case report

The standard treatment in Japan for gastric carcinoid has been gastrectomy with lymphadenectomy. This report describes the possibility of endoscopic treatment as an appropriate option for gastric carcinoid fulfilling certain conditions. A 46 year old woman underwent endoscopic mucosal resection for two 3 mm gastric carcinoids. The patient had hypergastrinemia with pernicious anemia and type A chronic atrophic gastritis, suggesting that the tumors were type Ⅰ in Rindi's classification. Both tumors were located in the mucosal layer with no cellular polymorphism and were chromogranin A positive. Neither tumor recurrence in the stomach nor distant metastases have been documented during the 5 years of follow-up. Although many type Ⅰ gastric carcinoids may be clinically indolent, reports on successful endoscopic treatment for this carcinoid have been scanty in the literature in Japan, presumably because of the hitherto surgical treatment stance for the disease. This report discusses how the size, number, depth and histological grading of the type Ⅰ gastric carcinoid could allow the correct identification of a benign or malignant propensity of anindividual tumor and how endoscopic resection could be a treatment of choice when these factors render it feasible. This stance could also obviate unnecessary surgical resection for more benign tumors.

Biermer Disease in an Unusual Neurological Presentation without Anemia: A Case Report

Background: Biermer disease is a megaloblastic disease caused by vitamin B12 deficiency. It is a rare clinical entity especially in subsahara Africa. Case presentation: We report the case of a 45 years old female patient who consulted for a one month history of generalised muscle cramps, weakness and numbness of all four limbs. Physical examination was relevant for a poor gait, poor coordination of both upper and lower limbs, a positive Romberg sign, normal muscle tone in all four limbs, reduced pallesthesia and deep tendon reflexes, abolished plantar reflexes. Paraclinical investigations revealed macrocytosis without anemia, a low cyanocobalamin (vitamin B12) level with a normal folic acid level, an atrophic corporeofundic mucosa which upon pathological analysis revealed a chronic atrophic gastritis with no Helicobacter pylori infection. Anti-intrinsic factor antibodies were positive while anti parietal cells antibodies were negative. The diagnosis of Biermer disease was considered and the patient did well on vitamin B12 supplementation. Conclusion: Though a rare disease, Biermer disease should be considered in a patient who consults for polyneuropathy even in the absence of anemia.

Seronegative Myasthenia Gravis and a Biermer’s Anemia:A Rare Association

We report a rare association of seronegative myasthenia gravis and a Biermer’s anemia (or pernicious anemia). A Senegalese patient of 31 years has been followed for a vitamin B12 deficiency anemia, 12 months before his hospitalization in our department. She has been admitted for an intense and invalidating fatigability in spite of the correction of anemia, associated to a right ptosis. This clinical picture has electively been improved to the prostigmine test. The electromyography had revealed a compatible decrement with a diagnosis of myasthenia. The positivity of the antibodies anti gastric parietal cells and the twice negativity of the antibody against acetylcholine receptor (AChR) and muscle-specific kinase (MuSK) had permitted to deduct a diagnosis of seronegative myasthenia and Biermer’s anemia. The evolution was favorable under substitutive B12 vitamin therapy associated to corticotherapy and azathioprine. We insist on the research and the early treatment of a myasthenia, in a context of Biermer’s anemia, before suggestive clinical signs in spite of the negativity of the anti-Rach antibodies and anti-Musk.