April 1993, Volume 43, Issue 4

Case Reports


Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

Fifty clinically diagnosed cases of criminal abortion were studied. Selection criteria included history, evidence of interference, fever, vaginal tears and bleed­ing, lower abdominal pain, tenderness and signs of infection. Aerobic and anaerobic cultures of high vaginal swabs and cul-de-sac aspirates were done on the appropriate media and gram staining performed. The aerobic organisms were identified after 24 hours and the anaerobic ones after 48 hours of growth. Antibiogram was carried out by disc diffusion method. There were 20 acknowledged cases of criminal abortions in the series, majority being performed by local untrained midwives. The major pathogens isolated were E. coli and bacteroides species. The culture of cul-de-sac aspirates had a growth of multiple types of bacteria. A total of 36 organisms isolated yielded 29 aerobes and 7 anaerobes. The gram negative bacteria were highly sensitive to tobramycin and cefotaxime whereas gen­tamycin, cefaclor and tobramycin were most effective against the gram positive cocci. The anaerobes had a 10 percent sensitivity to metronidazole followed by din­damycin and chloramphenicol. Criminal abortions usually associated with sepsis are further complicated with delayed medical attention for purposes of secrecy. E. coli has been found to be the predominant aetiological agent responsible for peritonitis. Peritoneal isolates and pathogens from the vagina usually correlate but occasionally the vaginal commensals as streptococcus viridans, staph. epider­midis and strep. non-haemolyticus can cause peritonitis readily. A combination of antibiotics effective against aerobes and anaerobes is highly recommended in these cases to provide a complete protection and to prevent extra-uterine spread.
UNRUPTURED REMOVAL OF GIANT HYDATID CYST OF ABDOMEN. Shah, M.K. JYak. Instit. Med. Sci., 1991;2:122-123.
Eight cases of giant hydatid cysts removed intact and unruptured from the abdomen are presented. There were 6 males and 2 females with ages between 30-60 years. The duration of the abdominal mass was from 5-20 years. The presenting symptoms were dull aching pain and fullness of the abdomen. A detailed history was noted and the clinical examination revealed a fluid thrill in 4 patients and a mass in the abdomen measuring 15-20 cmx3O-55 cm in all the cases. Laboratory investigations showed a raised ESR, 70-103 mm first hour and a positive casonis test in all cases. The rest of the tests were in the normal range. An ultrasound scan revealed 2 hydatid cysts of the liver One of the spleen and one attached to the mesentery of the small intestine. In 4 cases the anatomical relation was uncertain. The abdominal cavity was opened by a right upper paramedian incision for the liver cysts and left one for the splenic cyst. A right mid-paramedian incision was selected for the remaining 4 cases. All the cysts were removed in to to after identifying the important structures around. Splenectomy had to be resorted to the splenic cyst as it was too large. Removing an unruptured hydatid cyst is the safest procedure for the treatment of this condition as it prevents spilling of the scolyces and later recurrence. It is technically a difficult surgery because all the vital structures in and around the peritoneal cavity have to be saved from injury. Meticulous dissection avoids these hazards. Decompression and marsupialization are other recommended techniques but they all have their risks. Medical treatment with mebendazole has not been very successful and the large doses for prolonged periods are not well tolerated by the patients.
TRICHOBIZOAR Aurangzeb, Mohammed, G., Shah, SH. and Rahman, AJ. Ayub. Med. Coil., 1991;4:54-55.
Two cases of intestinal obstruction due to hair ball tumours (trichobizoar) are presented. The first case was a 24 year old pregnant woman admitted with agonizing abdominal pain since 3 days; not relieved by posture or food. Vomiting and obsolute constipation were also present since 3 days. She had been irritable and at­tempted suicide earlier. Physical examination revealed anaemia, a grossly distended, tense and rigid abdomen with absent bowel sounds. Laboratory tests gave insig­nificant results and the abdominal x-ray showed signs of obstruction. Laparotomy was performed. One litre of dirty fluid was drained and a 400 gm trichobizoar was removed. The second case was of a 27 year old woman with complaints of epigastric pain, intermitent vomiting, palpitation, mild fever and a painful mass in the epigastrium and left hypochondrium since 2 years. Physical examination showed anaemia and a big hard mobile mass in the left hypochondrium and epigastriurn extending to the right hypochondrium. The haemoglobin was 10.4g% and blood urea 64 mg/dl. On laparotomy the stomach was distended and a mass of hair was removed from within. Trichophabia or hair eating is a rare eating disorder usually afflicting females. it is classed as a behaviour disorder and related to zinc and iron deficiency. Psycho­therapy, behaviour therapy and iron with trace elements should be given to these cases.
A study was conducted to determine the reasons for non-compliance of heroin addicts for follow-up after discharge from hospital following detotfication. The records of 50 attenders and 50 non- attenders were studied and characteristics compared. There were all males with the non-attenders being of a higher age (mean 32.8 years against 28.5 years of attenders), with a longer duration of drug abuse (5.67 years against 3.25 years of attenders). There were also more unmarried, illiterate and unemployed individuals with more discharges against medical advice. The difference in attitudes of the two groups is related to the insecurity and financial difficulties due to unemployment, deficiency in social and family support and premature cessation of medica­tion. These findings suggest an improvement plan for the post-treatment phase for the addicts. Social support, sympathetic family environment, assistance in employ­ment and financial help should be the prime considera­tions for rehabilitating these patients.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: