Telila Mesfin,1 Kenbon Seyoum,2 Mesfin Tsegaye,1 Eshetu Mesfin,3 Geda Tilahun,1 Gela Atlie1
1School of Medicine, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 2Department of Midwifery, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 3Department of Public Health, ICAP, Finfine, Oromia, Ethiopia
Correspondence: Telila Mesfin, Tel +251931504321, Email [email protected]
Introduction: Phocomelia is an uncommon congenital condition in which the hand or foot are normal or almost normal but the proximal section of the limb – the humerus or femur, radius or tibia, ulna or fibula –_is missing or noticeably hypoplastic. It refers to how the patient’s limbs resemble marine creatures’ flippers and its prevalence is 0.62 in 100,000 births. Case: We present a 15-min-old male neonate born to a para-four mother who did not remember her LNMP but claimed to be amenorrheic for the past nine months. The mode of delivery was by cesarean section to extract alive neonate weighing 2.01 kg with APGAR scores of 5 and 6 at first and fifth minutes, respectively. The neonate did not cry and was resuscitated for five minutes. He was then transferred to neonatal intensive care unit for further management and investigations. His vital signs were pulse rate 160 beats per minute, respiratory rate 70 breaths per minute, temperature 33.4 degrees centigrade and saturation was 60% off oxygen. On HEENT anterior fontanelle measures 2 cm by 2 cm and has micrognathia and short neck. On the respiratory system, there were intercostal and subcostal retractions, labored breathing and grunting. On the musculoskeletal system there is bilateral upper extremity shortening, the right lower limb was normal in position and structure, the left leg rotated inward (bent in medially) at the knee joint and foot was normal in structure. Conclusion: Phocomelia is a rare congenital anomaly in which the hand or foot are directly attached to the trunk. Ultrasonography should be done as early as possible to identify fetal anomalies in order to plan subsequent management. Keywords: phocomelia, upper limb, ultrasonography, neonate
Introduction
Phocomelia is an uncommon congenital condition in which the hand or foot are normal or almost normal but the proximal section of the limb – the humerus or femur, radius or tibia, ulna or fibula – is missing or noticeably hypoplastic ( Figure 1 ). The hand or foot is directly linked to the trunk in true phocomelia, which is distinguished by the complete absence of the limb’s intermediate segments ( Figure 2 ). The term “phocomelia” was derived from Greek words, and it refers to how the patient’s limbs resemble marine creatures’ flippers. 1 It was first coined by Geoffroy Saint-Hilaire. 2 Its prevalence is 0.62 in 100,000 births. 3 It is also associated with Robert syndrome which is characterized by tetraphocomelia (symmetrical limb reduction) with craniofacial anomalies, growth retardation, mental retardation, cardiac and renal abnormalities. 4
Figure 1 A male neonate with complete upper limb phocomelia and internally rotated left lower limb. Figure 2 X-ray showing hands directly attached to the trunk and hypoplastic scapulae. Case Presentation
We present a 15-min-old male neonate born to a para-four mother who did not remember her LNMP but claimed to be amenorrheic for the past nine months. His mother had antenatal care at the nearby health center twice and was uneventful. However, she had no early obstetric ultrasound. Otherwise, she has no history of chronic medical illnesses like diabetes mellitus and hypertension. During her current pregnancy, she had no fever, headache or blurring of vision. She had never used any drug other than ferrous sulfate throughout this pregnancy. Her prior children are all healthy and alive. On her arrival at our hospital, she had vaginal bleeding of two hours duration. Subsequently, she was admitted with a diagnosis of third-trimester pregnancy plus multigravida plus antepartum hemorrhage secondary to abruptio placentae plus severe oligohydramnios plus breech presentation. On pelvic examination, she had active vaginal bleeding. Obstetric ultrasound was done on arrival. Accordingly, the gestational age was 34 weeks, the placenta was fundal with a retroplacental clot, and amniotic fluid was significantly decreased with a single deepest pocket of 1.5 cm. The estimated fetal weight was 2.4 kg and breech presentation. Other investigations of the mother are blood group AB+, VDRL=negative, RBS=120 mg/dL, on CBC, white blood cells=9000, hemoglobin=11 gm/dL, platelet=180,000 and neutrophil=60%. After informed written consent was taken emergency cesarean section was done for already mentioned indications to extract a live neonate weighing 2.01 kg with APGAR scores of 5 and 6 at first and fifth minutes, respectively. The neonate did not cry and was resuscitated for five minutes. He was then transferred to neonatal intensive care unit for further management and investigations. On arrival, the neonate was in respiratory distress. His vital signs were pulse rate 160 beats per minute, respiratory rate 70 breaths per minute, temperature 33.4 degrees centigrade and saturation was 60% off oxygen. On HEENT anterior fontanelle measures 2 cm by 2 cm and has micrognathia and short neck. On the respiratory system, there were intercostal and subcostal retractions, labored breathing and grunting. On precordial examination, s1 and s2 well heard, no murmur or gallop rhythm. On the musculoskeletal system there is bilateral upper extremity shortening, the right lower limb was normal in position and structure, the left leg rotated inward (bent in medially) at the knee joint and foot was normal in structure ( Figure 3 ). On neurologic examination he was lethargic, the tone was normotonic on lower right extremity and the Moro reflex was difficult to assess. Laboratory investigation showed blood group=A+, CRP=reactive, WBC=30,000, neutrophil=54%, lymphocytes=21.1%, HGB=8 gm/dL and platelet=150,000. X-ray imaging was done and it shows extreme shortening of upper extremities. The left lower limb is internally rotated. Echocardiography was normal. With an assessment of late preterm (34–36 weeks by Ballard score) plus low birth weight plus appropriate for gestational age plus phocomelia plus perinatal asphyxia plus early onset neonatal sepsis he was managed with oxygen support, maintenance fluid, and intravenous antibiotics. The neonate died after three days of hospital stay. Figure 3 A limb X-ray showing internal rotation of left lower leg. Discussion
Phocomelia is the absence of a large portion of the upper and/or lower limbs with preservation of the affected limb’s hands and/or feet. 5 Frantz and O’Rahilly defined phocomelia as a type of intercalary failure of formation. Even though their classifications are simple, it has yet to be validated in practice. 6 In phocomelia, the cells stopped growing or died, obstructing the normal growth of limbs, eyes, the brain, or other tissues. 7 The first instance of phocomelia was reported in Germany in 1956 in a child whose mother had taken thalidomide during pregnancy and who was born without arms and only having vestigial flipper-like hands. 8 It can manifest alone as a skeletal deformity or in conjunction with other visceral abnormalities such as cleft palate, hypertelorism, microretrognathia, horseshoe kidney, and polycystic kidney. 3 Our patient had micrognathia, internally rotated left leg and short neck. Otherwise, no other visceral malformations were observed. The differential diagnosis could be sporadic phocomelia, Holt–Oram syndrome, thrombocytopenia-absent radius syndrome (TAR syndrome), Roberts syndrome, and thalidomide-induced phocomelia. 9
The fourth and fifth children of an Italian couple who were first cousins were born with abnormalities including “double cleft of the lip and palate, protrusion of the intermaxillary portion of the upper jaw, and imperfect development of the bones of the four extremities”, according to John B. Roberts’ description of the family in 1919. Over time, these deformities have come to be recognized as the characteristics of Roberts syndrome. 10 This rare autosomal recessive disorder is characterized by tetraphocomelia (symmetrical limb reduction), craniofacial defects, growth retardation, mental impairment, and cardiac and renal abnormalities. 11 SC phocomelia, which was first described in 1969 by Herrmann in a family with surname beginning with S and another with surname beginning with C has a less severe symmetric limb reduction, flexion contractures of several joints, minor facial deformities, growth retardation, and perhaps mental retardation. 12 SC phocomelia is also autosomal recessive in its inheritance. The severity of the two syndromes can be thought of as falling on a scale, with SC phocomelia being on the milder end and RBS on the more severe end. While severely affected Roberts syndrome newborns may be stillborn or pass away in the postnatal period, people with SC phocomelia often live to adulthood. 10
There are a number of risk factors that are believed to be associated with phocomelia. Among the many etiological factors suspected of causing this anomaly, thalidomide is a well-known teratogenic drug. In addition, it has an impact on the neurological, gastrointestinal, cardiovascular, and genitourinary systems. 3 Thalidomide has anti-inflammatory, immunomodulatory, and antagonizing properties. It specifically inhibits angiogenesis in the limb, can cause cell death, and induces the formation of reactive oxygen species in limb tissue. 13 However, for this particular patient his mother did not take any drugs other than the usual medications prescribed during pregnancy. Likewise, none of her previous children had this kind of malformation. Phocomelia can also be brought on by vascular disruption and ischemia, as shown in limb reduction deficits, mutant genes, chromosomal abnormalities linked to trisomy 18, environmental factors, such as teratogens, and a mix of genetic and environmental factors (multifactorial inheritance). 14 Apart from this, substance abuse, such as cocaine or alcohol, gestational diabetes, and X-ray radiation exposure during pregnancy can lead to phocomelia. 15 , 16
Antenatal care should be attended as per WHO protocol so that early in utero identification and possible termination of pregnancies with lethal congenital anomalies can be done. Prenatal diagnosis has been reported as early as 11 weeks of gestation in a high-risk pregnancy with fusion abnormalities of both upper and lower extremities and a large cystic hygroma over the lower back. 17 To determine gestational age, look into possible pregnancy issues, and keep track of complex pregnancies when they happen, imaging ultrasound scans are frequently employed. The World Health Organization (WHO) updated its list of advised interventions for standard prenatal care in 2016 to include one ultrasound scan before 24 weeks of pregnancy. 18 Routine antenatal ultrasound screening, frequently done in both the first and second trimesters, has long been a common procedure in the majority of high-income countries. An imaging ultrasound scan during the first trimester (up to and including 13 weeks and 6 days of gestation) aims to determine the gestational age, the location of the gestational sac, the number of fetuses, and, in the case of multiple pregnancy, the chorionicity and amnionicity. In addition, toward the end of the first trimester, nuchal translucency thickness is frequently measured in settings that allow it. Between 18 and 24 weeks, second-trimester ultrasound scans can be performed to examine the fetal anatomy in greater detail, look for fetal anomalies, count the number of fetuses present, locate the placenta, and determine the gestational age. 19 Therefore, ultrasound imaging should be done as early as possible to detect the fetal anomalies and plan subsequent interventions to avoid unnecessary cesarean delivery. Conclusion
Phocomelia is a rare congenital anomaly in which the hand or foot are directly attached to the trunk. It is less severe form of Roberts syndrome and the patients with this condition can survive up to adulthood. Even though prenatal thalidomide exposure has been extensively linked with phocomelia alcohol intake, cigarette smoking and cocaine abuse have also been reported to cause it. Ultrasonography should be done as early as possible to identify fetal anomalies in order to plan subsequent management. Data Sharing Statement
Data on the case clinical information, informed consent form, and images are available for review from the corresponding author upon request. Consent
Written informed consent was taken from the patient’s parent for publication of his condition and accompanying images. Disclosure

Bilateral Upper Limb Complete Phocomelia: A Case Report

Knowledge of Sexual and Reproductive Health Rights Among University Students: A Cross-Sectional Study in Southeast Ethiopia

Published 30 December 2022Volume 2022:15 Pages 769—772
Telila Mesfin,1 Gosaye Debele,2 Kenbon Seyoum,3 Sisay Dadi,4 Mesfin Tsegaye,1 Degefa Gomora,3 Chala Kene,3 Gudisa Tolosa1
1Department of Medicine, Madda Walabu University Goba General Hospital, Goba, Ethiopia; 2Department of Surgery, Madda Walabu University Goba General Hospital, Goba, Ethiopia; 3Department of Midwifery, Madda Walabu University Goba General Hospital, Goba, Ethiopia; 4Department of Internal Medicine, Madda Walabu University Goba General Hospital, Goba, Ethiopia
Correspondence: Telila Mesfin, Tel +251931504321, Email [email protected]
Introduction: Abscess of the tongue is a very rare disease that potentially compromises the airway. Acute tongue abscess symptoms include swelling or a lump in the deep tissues of the tongue, throbbing local pain, a discomfort that radiates to the ears, fever, difficulty swallowing, deliberate fixation of the tongue due to pain, and eventually, difficulties breathing. Case: This is a 50-year-old male patient who presented with a complaint of severe tongue pain and swelling of three days duration. Associated with this, he had pain while swallowing, difficulty opening his mouth, shortness of breath, and drooling saliva. Likewise, he had a high-grade fever and a global type of headache. On physical examination, there was significant tongue swelling on the left anterolateral area, fluctuant on palpation, and had erythematous border. After informed consent was taken the patient was transferred to the operation room with the diagnosis of tongue abscess. Subsequently, incision and drainage were done under general anesthesia, and about 30mL of thick pus was drained. The pocket was washed with normal saline and 2% hydrogen peroxide. The patient was transferred to the surgical ward with stable vital signs and had been on antibiotics. He was discharged after two days of hospital stay. Conclusion: Abscesses in the tongue are quite uncommon due to its rich vascular supply, lymphatic drainage, and saliva’s immunologic advantage. Thorough diagnosis and successful treatment of tongue abscess prevent potential airway compromise. Antibiotic treatment should cover gram-positive and gram-negative anaerobes. Keywords: tongue abscess, khat chewing, sonography
Introduction
Abscess of the tongue is a very rare disease that potentially compromises the airway. 1 The tongue’s strong keratinized epithelium, the density of its muscle compartments, its rich vasculature, and the bactericidal properties of saliva all serve to prevent infection. 2 However, when host defense mechanisms are impaired, tongue abscesses are more likely to occur. Breached surface barriers, foreign bodies, and immunodeficiency states predispose to tongue infections. 3 Acute tongue abscess symptoms include swelling or a lump in the deep tissues of the tongue, throbbing local pain, a discomfort that radiates to the ears, fever, difficulty swallowing, deliberate fixation of the tongue due to pain, and eventually, difficulties breathing. 4 Therefore, it is crucial to identify tongue infections as soon as possible and treat them as an emergency, especially if dyspnea and dysphagia are present. In particular, if left untreated, abscesses around the root of the tongue could be lethal. 5 These lesions should be opened and drained once diagnosed. 6
Clinical Presentation
This is a 50-year-old male patient who presented with a complaint of severe tongue pain and swelling of three days duration. Associated with this, he had pain while swallowing, difficulty opening his mouth, shortness of breath, and drooling saliva. Likewise, he had a high-grade fever and a global type of headache. Otherwise, he had no trauma to his tongue, no recent dental or oral procedures, no history of cigarette smoking, and no history of chronic medical illness like diabetes mellitus, cardiac disease, and hypertension. Historically, he had severe standing dental pain for the past six months prior to his current complaint. He has been chewing khat since his childhood and had poor oral hygiene. On physical examination, he was acutely sick looking and his vital signs were, blood pressure 115 by 70 mmHg, pulse rate 120 beats per minute, respiratory rate 20, temperature 39 degrees centigrade, and oxygen saturation 92% off oxygen. On HEENT examination there was significant tongue swelling on the left anterolateral area, fluctuant on palpation, and had a erythematous border ( Figure 1 ). There is multiple teeth decay in both maxillary and mandibular areas. There were no pertinent findings on the remaining systems. Figure 1 Swollen tongue on the left anterolateral border found during physical examination. After informed consent was taken the patient was transferred to the operation room with the diagnosis of tongue abscess. Subsequently, incision and drainage were done under general anesthesia, and about 30mL of thick pus was drained. The pocket was washed with normal saline and 2% hydrogen peroxide. The patient was transferred to the surgical ward with stable vital signs and had been on ceftriaxone 1 gm iv twice daily (BID) and metronidazole 500 mg iv three times per day (TID) for two days. He was discharged after two days of hospital stay with improvement and Augmentin 625 mg PO TID for five days. Discussion
Abscesses in the tongue are quite uncommon that occur in immunocompromised patients or healthy persons with pierced tongues. 3 Although the tongue is exposed to numerous possible pathogens, it is comparatively immune to infection. 4 The regular movement of the tongue, which enables the saliva to continuously generate a cleansing effect, as well as its thick layer of keratinized mucosa, which is resistant to microbial penetration; muscle tissue, which makes up the majority of its parenchyma and with its rich circulatory supply; rich lymphatic drainage; and saliva’s immunologic characteristics. 7 , 8
A variety of conditions, including tumors, cysts, infarctions, edema, infections, hemorrhages, metabolic macroglossia in hyperpituitarism or hypothyroidism, developmental macroglossia in lingual thyroid, and ectopic lymphoid tissue are included in the differential diagnosis of tongue abscess. 9 , 10 Most tongue abscesses are unilateral and located in the anterior two-thirds of the tongue. 11 The same is true for this patient which is located in the left anterolateral part of the tongue. A painful swelling that causes the tongue to protrude, dysphagia, odynophagia, and speech impairment are common symptoms of tongue abscesses. 12 , 13 The current patient also experienced severe tongue pain and swelling. Along with this, he experienced pain while swallowing, trouble opening his mouth, shortness of breath, and dribbling of saliva. He also had a high-grade fever and headache. The possible explanation for the abscess may be long-standing poor oral hygiene. This might be due to the fact that the patient was chewing the khat since his childhood. There are two forms of tongue abscess; superficial and deep. The inflammatory process of a superficial abscess is situated right below the mucosal membrane. The back of the tongue is the primary place. It is uncomfortable to touch and is dense and swollen. With such a configuration, a pathological focus can open and spontaneously drain. After that, the patient feels a reduction in pain and a decrease in swelling. Even though the tongue wound might epithelialize fast, an abscess relapse is likely if the lesion is not properly treated. 6 The inflammation of the deep tongue muscle tissue is a characteristic of deep abscesses. The course is more severe, with a 38 to 39 degree centigrade temperature, overall weakness, appetite loss, and headaches. A thorough physical examination reveals a significant increase in swelling of the tongue. This could impair speech and food intake. In severe circumstances, the patient has trouble even drinking liquids or breathing through their mouth. Patients with severe conditions can appear with upper airway blockage that necessitates an emergency tracheostomy. 8 Typically, submandibular lymph nodes expand quickly, becoming painful yet movable. 6
Sonography, CT, and MR imaging are just a few of the imaging methods that can be utilized to assess tongue swellings. 7 , 8 , 10 Although vascular lesions and abscesses are defined and distinguished by ultrasonography, using the transducer in the mouth is challenging. 14 It has been observed that a lingual abscess appears on sonography as a hypoechoic lesion surrounded by a hyperechoic ring. However, sonography is not always practical since if the tongue is swollen and squeezed, the patient may feel discomfort or severe pain. 7 , 8
A correct diagnosis is the first step in the successful treatment of tongue abscesses, which also includes maintaining the airway, performing an incision, and drainage. Next, the proper antibiotic therapy should target Streptococci, Staphylococci, and Gram-negative anaerobes. Since continuous nidus of infection can cause an abscess to return, aspiration alone is frequently insufficient therapy and must be combined with incision and drainage. 6
Conclusion
Abscesses in the tongue are quite uncommon due to its rich circulatory supply; lymphatic drainage; and saliva’s immunologic characteristics. Thorough diagnosis and successful treatment of tongue abscess include maintaining the airway, performing an incision, and drainage. Antibiotic treatment should cover gram-positive and gram-negative anaerobes. Data Sharing Statement
Data on the case clinical information, informed consent form, and images are available for review from the corresponding author upon request. Ethical Approval

Tongue Abscess: A Case Report

Telila Mesfin,1 Yohannes Tekalegn,2 Mudesir Aman,3 Girma Geta,4 Adugna Ketema,4 Fekata Defere,1 Dejene Girma,1 Mesfin Tsegaye,1 Takele Mengistu,1 Kenbon Seyoum4
1Department of Medicine, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 2Department of Public Health, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 3Department of Surgery, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia; 4Department of Midwifery, Madda Walabu University Goba General Hospital, Goba, Oromia, Ethiopia
Correspondence: Kenbon Seyoum, Tel +251915821035, Email [email protected]
Introduction: Foreign body ingestion causes a serious health problems like bleeding, abscess formation, septicemia, perforation, and obstruction of the esophagus, stomach and the intestine. In adults, foreign body ingestion is more common in the elderly, individuals with mental illness or who have an intellectual disability, alcohol poisoning, prison inmates, and drug traffickers. Case Presentation: We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He is a known schizophrenic patient for the past three years and has been on follow up at a nearby hospital. He swallowed metallic nails in an attempt to kill himself. On abdominal examination there was distension, and epigastric tenderness. His plain abdominal x-ray showed multiple radiopaque foreign body in the stomach. Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach. Then, with the impression of gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia. Dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver was found intra operatively. Conclusion: Passage of curved metal through the throat is a rare case. Mentally ill individuals need close follow up and physiological consultation. Keywords: foreign body ingestion, metal, Schizophrenia
Introduction
An ingested foreign body is anything (including food) that comes from outside the body and ingested to the mouth and gastrointestinal tract (GI). 1 Inedible collections or undigested material in the GI tract is known as bezoars. 2 Ingestion of a foreign body is a common occurrence in children between 6 months and 6 years of age, but in adults it can be accidentally swallowed with food. 3 In adults, foreign body ingestion is more common in the elderly, individuals with mental illness or who have an intellectual disability, alcohol poisoning, prison inmates, and drug traffickers. 1 , 4 Foreign bodies stuck in the areas of anatomical narrowing may require endoscopic or surgical intervention, however the majority of foreign bodies that pass the esophagus will exit the GI tract without incidence. 5 , 6
Foreign body ingestion causes a serious health problems like bleeding, abscess formation, septicemia, perforation, and obstruction of the esophagus, stomach and the intestine. 1 , 5 , 7 These complications can be related to clinical manifestations such as nausea, vomiting and severe constipation based on the location and severity of obstruction and perforation. 8 Ingested foreign materials are most of the time associated with medical disorders, anatomic abnormalities, gastric motility disorders. 9
Case Presentation
We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He has significant weight loss. He is a known schizophrenic patient for the past three years and has followed up at a nearby hospital, after which he has been off his medication for the past two months. He swallowed metallic nails in an attempt to kill himself. On presentation his vital signs were, blood pressure 110/70, pulse rate 128, respiratory rate 20, axillary temperature 36.5 and oxygen saturation 92%. On abdominal examination there was distension, epigastric tenderness and no signs of fluid collection. On admission his blood tests were, white blood count 15,000, hemoglobin 14 gm/dl, platelet 138,000 and granulocytes 77%. Serum electrolytes, random blood sugar and organ function tests (liver and renal) were in normal range. On the other hand, his plain abdominal x-ray showed multiple radiopaque foreign body namely nail in the stomach ( Figure 1 ). Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach. Figure 1 Plain abdominal x-ray showing multiple metallic nails in the stomach and first part of the duodenum. Eventually, with the impression of complete gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia ( Figure 2 ). Intraoperative findings were dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver. Subsequently, gastrotomy was made proximal to the foreign body area. Foreign bodies consisting of sixty curved, and straight nails of various sizes, needle and wire were removed with sponge forceps ( Figure 3 ). Gastrotomy incision was repaired with two layers. Abdominal cavity was washed with warm normal saline. The abdominal incision was closed with two layers. The patient was then transferred to surgical ward with stable vital signs and put on antibiotics. Postoperative hematocrit was 36%. The patient was discharged after four days of hospital stay and linked to psychiatric department for further evaluation. Figure 2 Intraoperative procedure showing removal of metallic nails. Figure 3 Showing metallic nails of various sizes and shapes after removal. Discussion
Accidental and intentional ingestion of foreign bodies usually occurs in children, but anyone such as prisoners and drug traffickers can be affected. 6 , 8 , 10 Most foreign bodies pass through the gastrointestinal tract and are passed into the feces within less than a week without surgical intervention. 6 , 8 Foreign body size is predictive of passage through the alimentary tract. 6 For example, blunt objects under 6 cm and smaller than 2.5 cm diameter are likely to easily pass. 11
Few studies have reported the ingestion of sharp and blunt metallic materials by the mentally ill, and prisoner individuals. These individuals present with various gastrointestinal symptoms ranging from mild to severe cramps. 5–7 , 12 Mentally ill, or psychiatric patients frequently exhibit respiratory distress, choking, vomiting, unwillingness to eat, drooling, wheezing, and blood-stained saliva. 12 Similar to this, the current case was also presented with vomiting of ingested matter for the last one month. Factors like hallucination may cause ingestion of foreign materials in the schizophrenic individuals. 8 We present the known schizophrenic patient who presented with abdominal distension after ingestion of curved and straight metal nails of various sizes. The study reported that mentally ill individual ingest foreign bodies caused by hallucination, 8 but in our case the patient ingested the metals in an attempt to kill himself. The intraoperative finding revealed sixty curved and straight nails, needle and wires. The available literature has shown that the maximum number of ingested foreign body is 158. 13
Foreign body impaction can happen at anatomically narrowed areas such as the lower esophageal sphincter, ileocaecal valve, and anus, physiologically angled areas such as the duodenum’s curvature, or pathologically strict places. 10 As indicated in the current situation, curved nail can also pass the lower esophagus. Areas affected by eosinophilic esophagitis, Crohn’s disease, or areas of prior surgical anastomosis can also be a possible areas of foreign body impaction. Computed tomography scanning and diagnostic endoscopy are the preferred diagnostic modalities. 14 But, plain abdominal radiograph is used most of the time as the initial method of diagnosing. Barium study can also be used to identify and estimate their size. 2 In current case, plain abdominal radiography was used to diagnose what is in the abdomen and laparotomy was done to remove them. Conclusion
Case reports of metallic nail ingestion are not uncommon; however, passage of a curved nail through the esophagus is rarely reported. The current case highlights maintaining a high index of suspicion for foreign body ingestion in mentally ill patients with signs of proximal bowel obstruction. In the setting of full thickness gastric inflammatory changes, adhesion to adjacent organs is plausible as was seen in this patient. Close follow up of mentally ill patient is important. Data Sharing Statement
Data on the case clinical information, informed consent form, and images are available for review from the corresponding author upon request. Ethical Approval

Ingestion of Metallic Materials Found in the Stomach and First Part of the Duodenum of a Schizophrenic Man: Case Report

Tadele Regasa,1 Yohannes Dinku,1 Bereket Gezahegn,1 Zegeye Feleke,2 Zegeye Regassa,2 Ayele Mamo,1 Tesfaye Assefa,2 Habtamu Gezahegn,1 Damtew Solomon,1 Daniel Atlaw,1 Mengistu Dessie3
1School of medicine, Madda Walabu University, Goba, Ethiopia; 2School of Health Science, Madda Walabu University, Goba, Ethiopia; 3School of Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
Correspondence: Tadele Regasa, Tel +251922311812, Email [email protected]
Introduction: Acute pancreatitis is auto-cell destruction that is manifested by increased leakage of amylase and lipase into circulation. During pancreatitis, the activity of serum amylase and lipase is elevated three times above the upper limit of the normal range. This elevation was observed in both prediabetic and diabetic patients. Severe acute pancreatitis can result in acute kidney injury and other multi-organ dysfunction, which is one of the reasons for death. Objective: This study aimed to evaluate the elevation of serum amylase and lipase and their distribution at different stages of renal insufficiency among diabetic patients. Methods: This study included 286 diabetic patients (36 type 1 and 250 type 2), and data were collected from May 1 to June 30, 2019. The study design used was an institution-based cross-sectional study. A face-to-face interview was used to collect data, and serum creatinine, amylase, and lipase levels were measured using a chemistry analyzer. For data entry and statistical analysis, respectively, Epidata software version 3.02 and SPSS version 21 were used. Results: The mean serum amylase among diabetic patients suffering from G3b and G4 was 106.79 IU/L ± 118.18 IU/L and 104.85 ± 90.42 IU/L, respectively. Their mean serum lipase activity was 105.07 IU/L ± 127.54 IU/L and 106.98 IU/L ± 88.35 IU/L, respectively. Serum lipase activity was elevated above the normal range and three times above the upper limit of the normal range with a magnitude of 11.2% and 4.2%, respectively. Similarly, 9.1% and 0.7% of diabetic patients had increased serum amylase above the normal range and three-fold above the normal range, respectively. Conclusion: As glomerular filtration decreases, particularly in moderate-to-severe chronic kidney disease, serum amylase and lipase activity rise above the upper limit. Keywords: acute pancreatitis, chronic kidney disease, diabetes mellitus, serum amylase, serum lipase
Introduction
Acute pancreatitis (AP), is self-tissue digestion by activated pancreatic enzymes that results in inflammation, edema, necrosis, hemorrhage, and liquefaction. During the occurrence of AP serum activity of amylase and lipase increases threefold above the upper limit of the normal range (ULN). 1 Diabetic patients experienced two to three times the severity of acute pancreatitis as non-diabetic individuals. 2 , 3 The activity of serum lipase was also elevated between prediabetes and Type 2 diabetes mellitus (T2DM). The existence of pancreatitis was positively correlated with duration of DM, level of fasting blood sugar (FBS), HbA1C, and creatinine level. 4
The combination of acute pancreatitis and chronic kidney disease is common, and most of the time, their combination is misunderstood. 5 Glomerular filtration rate (GFR) is one of the best indicators of renal function. 6 It measures renal clearance of endogeneous filtration markers from blood circulation. 7 Therefore, GFR is used to diagnose and stage the degree of kidney disease and its prognosis. 8 Acute kidney disease and chronic kidney disease are interrelated, and both of them can result in reduction of GFR. 9
Recurrent episodes of acute pancreatitis lead to chronic pancreatitis. Serum pancreatic enzymes elevated three times above ULN during the occurrence of acute pancreatitis and later on reduced to normal range or very low (insufficient) level in chronic pancreatitis. 10 About 27.1% of patients suffering from acute pancreatitis lead to chronic pancreatitis that is manifested by Pancreatic exocrine insufficiency (PEI). 11 PEI among diabetic patients was one of the secondary complications of diabetic neuropathy. 12 They had reduced autonomic function than their matched normal individuals. 13
More than 40% of diabetic patients may suffer from chronic pancreatitis. 10 Due to a decrease in pancreatic enzymes as in the case of chronic pancreatitis, it leads to mal-digestion in the intestine. The prevalence of PEI among Type 1 diabetes mellitus (T1DM) and T2DM was 26–44% and 12–20%, respectively. 14 The magnitude of PEI was higher among T1DM than T2DM (44.44% vs 18.0%). 15 Pancreatic exocrine dysfunction is one of the causes that results in undernutrition in kidney disease due to decreased digestion enzyme activity and their insufficiency. 16
Moreover, severe acute pancreatitis (SAP) can result in acute kidney injury (AKI) and further complications can lead to multiple organ dysfunctions. 17 About 8.4% and 11.1% of patients suffering from acute pancreatitis may have multiple organ failure including kidney and systemic inflammatory response syndrome, respectively. 18 Among various causes of chronic kidney disease (CKD), T2DM and T1DM account for 30–50% and 3.9%, respectively 19 Globally, T2DM is the second leading cause of CKD and CKD-related death in 2019 and the incidence of DM-CKD comorbidity was 2.62 million worldwide. 20
Globally, 34 individuals suffered from acute pancreatitis per 100,000 general populations annually. It varies across the continents with most incidences in Northern and Eastern Europe. Acute pancreatitis kills 1.16 people per 100,000 in the general population each year. The risk of pancreatitis increased with the duration of disease and rate of pancreatic parenchyma cell destruction. The risk of post-pancreatitis DM is 2.54 times higher among those who have acute pancreatitis attacks than those who have not. 21
Significantly, the high mortality causes of diabetic patients were due to multi-organ failure. Among those causes, patients with AP and suffering from acute kidney injury were demonstrated by a sudden rise in serum creatinine and reduced urine output. About half of them (54.16%) completely recovered from renal failure and their pancreatic function resolved. But, 37.5% passed away due to acute-phase health derangements. 22 Even though antidiabetic drugs decrease the risk of pancreatitis, T2DM patients are at a high risk (1.5–3 times) than non-diabetic. 23
A clinical review conducted on pancreas and DM relation indicated that among patients who develop pancreatitis 31% of them suffered from severe pancreatitis and had elevated glycosylated hemoglobin levels, while 7% of them had mild pancreatitis. In addition to this, about 10% to 15% of the cases developed diabetic ketoacidosis (DKA) with AP. 24 According to a cohort study conducted in the UK out of 148, 903 T2DM 301 of them developed AP. T2DM Patients were 2.89 times at high risk for AP than non-diabetic. 25
Objective
This study aimed to evaluate serum amylase and lipase elevation among diabetic patients and their distribution at different stages of renal insufficiency. Methods
The study was included 286 (250 T2DM and 36 T1DM) diabetic patients attending Goba referral hospital diabetic follow-up from May 1 to June 30, 2019. The institution-based cross-sectional study design was used, and all adult diabetic patients were included in the study. Primarily, the data were collected for the assessment of the magnitude and factors associated with pancreatic exocrine insufficiency among diabetic patients, and the current study was extracted from it which focuses on the pancreatic enzymes elevation rather than its deficiency. Therefore, it is a follow-up study to our previous study on
Magnitude of pancreatic exocrine insufficiency and associated factors among adult diabetic patients attending Madda Walabu University Goba referral hospital, South east Ethiopia, 2019. 15
Ethical clearance written by a Ref No: IHRPGD/554/2019 was obtained from Jimma University institutional review board and written consent was obtained from each study participant. The participants were informed about the purpose of the study, and the study was done without violating Helsinki Declaration. The interview was conducted by trained nurses, and venous blood was collected from each study participant by laboratory personnel. Serum creatinine, serum amylase, and serum lipase were analyzed by an automated clinical chemistry analyzer. Principle for amylase measurement: amylase directly reacts with a specific substrate 2-chloro-4-nitrophenyl-maltotrioside (CNPG3). The release of 2-chloro-4-nitrophenol (CNP) from the substrate results in an increase in absorbance. The absorbance read at 405 nm is directly proportional to the serum activity of amylase. Principle for lipase measurement: The chromogen lipase substrate 1,2-0-dilauryl-rac-glycero-3-glutaric acid ester is cleaved by the catalytic action of alkaline lipase solution to form 1,2-0-dilauryl-rac-glycerol and an unstable intermediate, glutaric acid-ester. This decomposes spontaneously into alkaline solution to form glutaric acid and methylresorufin. The color intensity of the red dye formed is directly proportional to the lipase activity and can be determined photometrically. Principle for creatinine measurement: Uses the Jaffe reaction method by which, in an alkaline medium, creatinine forms a yellow-orange-colored complex with picric acid. The rate of color formation is proportional to the concentration of creatinine present and may be measured photometrically. Creatinine in alkaline picrate solution forms a color solution. The rate of formation of complex is measured by using a kinetic procedure. The intensity of the color is proportional to the creatinine concentration at a wavelength of 500 nm. The glomerular filtration rate was calculated by using the MDRD equation. Raw data were entered into Epidata software version 3.02 and checked and cleaned before its export to SPSS version 21 for statistical analysis. Descriptive statistics, cross-tabulation, and mean difference calculation were performed using SPSS statistical software. Staging of CKD was done based on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD by using GFR calculated by the MDRD equation (see Table 1 ). 26
Table 1 Stages of CKD by Using GFR
The normal range for serum amylase and lipase was considered as follows:
Amylase: normal range (28 IU/L – 100 IU/L) 27 , 28 Lipase: normal range (13–60 U/l). 29
Result
Almost half (48.8%) of the diabetic patients had mildly reduced GFR (60–89.99 mL/min/1.73 m2). Even though none of them had renal failure, severe, moderate to severe, and mild-to-moderate reduction accounts for 1.4%, 6.0%, and 9.5%, respectively (refer to Table 2 ). Diabetic patients suffering from G3b and G4 stages glomerular filtration impairment had also increased mean serum amylase and lipase activity. Accordingly, they had a mean serum amylase activity of 106.79 IU/L ± 118.18 IU/L and 104.85 ± 90.42 IU/L, respectively, with a higher variation that was also higher than those having normal glomerular filtration rate. Similarly, the mean of serum lipase activity was 105.07 IU/L ± 127.54 IU/L and 106.98 IU/L ± 88.35 IU/L among those with G3b and G4 stages, respectively (refer to Table 3 ). Table 2 Frequency and Distribution of GFR Category Among Diabetic Patients Attending Goba Referral Hospital
Table 3 Mean and SD of Serum Amylase and Lipase at Different Stages of CKD Among Diabetic Patients Attending Goba Referral Hospital
About 10% of diabetic patients had increased serum amylase activity beyond the normal range. Furthermore, two of them (0.7%) had serum amylase activity increment three-fold above ULN. Moreover, Diabetic patients’ serum lipase activity was significantly elevated than their serum amylase activity. Thus, the increment of serum lipase activity above the normal range accounts for 11.2% without including those who had its increment three times above ULN, which was 4.2% (refer to Table 4 ). Table 4 Descriptive Statistics of Pancreatic Enzyme Abnormalities at Different Stages of Renal Insufficiency Among Diabetic Patients Attending Goba Referral Hospital
Discussion
The current study showed that serum amylase activity among diabetic patients increased above the normal range and more than three times beyond the ULN. However, Jiang et al, 2002 reported a higher proportion of serum amylase activity among patients suffering from end-stage renal disease (ESRD) which was 60.7%, and a similar magnitude of its elevation three-fold above ULN with the current study, which was 1.3%. 30 Albai et al, 2017 also reported 3.7% of diabetic patients had pancreatitis. 31
About 32% of patients with pancreatitis suffered from renal injury. Accordingly, diabetic patients were at high risk of death in SAP with AKI by a factor of 1.62 times in comparison to non-diabetics. The risk of death significantly rises with alcohol abuse, serum amylase >200 IU/L, serum creatinine >2.4 mg/dl. 32 As the severity of renal disease worsens, the serum amylase is also elevated. The mean serum amylase level in control, chronic kidney disease, and end-stage kidney disease patients was 67.12
16.79 U/l, 91.83

The Elevation of Pancreatic Enzymes in Serum and Their Distribution at Different Stages of Renal Insufficiency Among Diabetic Patients Attending Goba Referral Hospital

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