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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2007 | Month : June | Volume : 1 | Issue : 3 | Page : 159 - 162 Full Version

Pyrexia of Unknown Origin Caused by Retained Intra-Abdominal Foreign Body: Report of a case with review of literature


Published: June 1, 2007 | DOI: https://doi.org/10.7860/JCDR/2007/.75
VERMA A, MOHAN S, BAIJAL S S

Department of Radiodiagnosis SGPIMS ,Lucknow – 226 014 U.P, India.

Correspondence Address :
Corresponding Author Dr Baijal S S,
Professor, Department of Radiodiagnosis
SGPIMS ,Lucknow – 226 014 U.P, India.
E Mail: ssbaijal@sgpgi.ac.in ; drsuyash@gmail.com
Phone No.: +91 522 2668700 – Extn: 2574(O), ext 2568(R)

Abstract

Pyrexia of unknown origin (PUO) is a common occurrence in developing countries and has a long list of known etiologies. Many isolated reports and case series suggest new causative factors for PUO. The present report tries to highlight a rare cause of this condition which has been scarcely documented in the literature. It also reinforces the basics of clinical management i.e., detailed clinical history and examination which dictate subsequent investigations.

Keywords

PUO; intra-abdominal foreign body; ultrasonography

Retained intra-abdominal foreign body (RIFB) is an uncommon cause for pyrexia of unknown origin (PUO). The literature from west shows scanty citations of PUO caused by RIFB. A clinician from developing world may however not uncommonly encounter such a cause effect relationship. An important cause of RIFB is septic abortion (1), (2). Though still a common practice, septic abortion is rarely reported being considered a medical malpractice. RIFB secondary to septic abortion is difficult to suspect as no definite history is usually available. Imaging plays a key role in diagnosing the presence of a RIFB. High index of suspicion and knowledge of common appearances is therefore required on the part of radiologist to help the treating physician elicit the complete history for correlation
(2),(3). This would ultimately lead to an evidence based approach for treatment of this rare cause of PUO.

Case Report

A 37 years old female with history of contact with a positive case of pulmonary tuberculosis (PTB) presented to us with moderate grade fever for the past four months. On preliminary blood investigations and a chest radiograph, she was suspected of having pulmonary tuberculosis. Patient refused any further investigations to confirm PTB and anti tuberculous therapy was empirically started on provisional diagnosis, but was lost to follow up. After four months, she again presented with a vague, mildly tender lower abdominal lump associated with an occasional crampy lower abdominal pain. A low grade fever still persisted with no specific pattern. Per abdomen examination revealed a lump in the hypogastrium and umbilical region. The lump was doughy in consistency and tender on deep palpation. In the background of PTB it was thought to be lymph nodal mass or a mass formed due to mesenteric adhesions. On ultrasonography (USG), two parallel echogenic lines with distal reverberation artifacts, suggestive of a foreign body (FB), approximately one foot in length were noted extending from right hypochondrium to the left lumbar region lying transversely through the lower umbilical region (above the dome of urinary bladder) (Table/Fig 1) One end of the FB had penetrated the anterior inferior end of the hepatic parenchyma with a small area of adjacent fluid collection. The other end was lying free. All around this FB fluid collection with internal echoes suggestive of debris was noted, which appeared loculated by surrounding adhesions. A vague heterogeneity was noted at the fundic myometrium. A possibility of intra-abdominal foreign body with surrounded infected fluid collections was raised. A plain radiograph of abdomen (erect and supine) was obtained which confirmed the presence of the FB (Table/Fig 2) No radiological evidence of any bowel perforation or intestinal obstruction was noted.
Detailed menstrual history revealed that she had eight full term normal deliveries.On further probing, she admitted having undergone 5 – 6 pregnancy terminations in the last three years by untrained village personnel. According to her, various instruments were used for the purpose and the last time she underwent such a procedure, she had lots of post procedural pain and bleeding. The fever, for which she had reported, started one month after this procedure. Laparotomy and peritoneal lavage following removal of foreign body was done, followed by post operative care and intravenous antimicrobial therapy. The patient had an uneventful recovery and was asymptomatic at 6 months follow up.


Discussion

Pyrexia of unknown origin (PUO) is defined as ‘when the body temperature is more than 38º C on several occasions in three consecutive weeks with no etiological diagnosis possible in spite of one week of inpatient stay and intelligent investigation’ (1). Recently this has been classified and redefined in four groups i.e., classical, neutropenic, nosocomial and HIV related PUO. The etiology is mainly divided in five groups, hematological malignancies, topping the list. Next comes the role of infective diseases followed by connective tissue disorders. Miscellaneous (10 – 15%) and undiagnosed (10 – 20%) causes account for the rest of the disease load (1). Our experience, however, gives a higher seat to the infectious causes as compared to malignancies. The intraabdominal infections are the most common infective pathology found to cause PUO (2), (5), (6). This is true of our case as well. RIFB is an important cause of intra abdominal septic foci (5), (6). Cases reporting an ingested sharp metallic body perforating the gut, though present in the literature are surprisingly rare (5). Perforation and migration of such a foreign body may be silent. Patients may present with unrelated symptoms and the discovery of foreign of foreign body on radiological examination of the abdomen may come as a surprise (5). History of introduction of FB is usually difficult to obtain. Such intra abdominal FB can lead to insidious unrelated presentation as PUO as seen in the present case or more catastrophic events like perforating the bowel and migrating to almost any intra abdominal or rarely to even extra abdominal sites. Migration to the liver, mesentery or the anterior abdominal wall, however is extremely rare (6), (7), (8). A loop of small bowel may get entangled across the FB and become necrotic. Variable time periods ranging from months to years have been reported between the introduction of a foreign body and the occurrence of symptoms. A case is reported in which a patient seemed to show the clinical picture of a colonic tumor, but was found to have a retained laparotomy pad from an exploratory operation which had been performed nine years earlier (7). Common modes of entry of FB are ingestion, poor surgical technique and accidental introduction. Few case reports of intra abdominal migration of IUD have been reported in literature (8). Few other case reports have also shown attempted illegal abortion as a cause of intra abdominal FB (8).
The patient in the present report had never undergone any other surgical procedure therefore we were left with no other possibility than to assume that a foreign body introduced during one of the abortions might have perforated the uterus. The heterogeneous myometrial echotexture described on USG could be due to an old healed perforation. Metals and glass fragments until extremely small are easily seem while plastic and wood are radiolucent and are only seen by CT scan or USG (3), (4). A plain radiograph of a sample piece of suspected FB, if available, is quite useful. Radiograph with the point of entry marked by a radiopaque marker and immediate preoperative radiograph should also be taken to decide the location and trajectory of removal. This is a useful exercise because certain foreign bodies may migrate or even embolise to distant sites (4). USG has a problem solving and a corroborative role (3). FB usually throws sharp distinct specular echoes with sharp acoustic shadows. Distal reverberation artifacts are a common findi

References

1.
Braunwald et al. Harrison’s Principles of Internal Medicine. 15th edition Mc Graw Hill, 2001: 804-809.
2.
Maggiore E, Cavaliere F. Intra abdominal foreign bodies – sequelae from attempted abortion. Ann Ital Chir. 1975-76; 49 (1-6); 219-225.
3.
Rumack CM et al. Diagnostic ultrasonography, 2nd edition. Vol 1, Mosby, 1998; 321
4.
Sutton D et al. Textbook of Radiology and imaging, 6th edition. Vol 2, Churchill Livingstone, 1998; 1394-1395
5.
Harjai MM et al. Intra abdominal Needles: an enigma (a report of two cases). Int Surg. 2000; 85(2): 130-132.
6.
Quantz MA, Brown R. Late presentation of an intra abdominal foreign body. Can J of Surg. 1997; 40(4); 305-307.
7.
Edinburgh A. An intra abdominal foreign body presenting as a colonoic tumor: review of literature and report of a case. Dis Coilon Rectum. 1979; 22 (5) : 327-327.
8.
Rezgui M, Hamzaoui R, Oueslatiu H, Alioua MF, Zehioua F, Haddad M. Intra abdominal migration of IUDs (apropos of 9 cases). Tunis Med. 1986; 64 (8-9): 709-713.

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