Background: Nonsurgical management of splenic injury has become the standard strategy in hemodynamically stable patients with blunt splenic injury. However the existence of splenic vascular injuries (including extravasations (EXTs), pseudoaneurysms (PSAs), A-V fistula, and vessel truncation) could be a risk factor for nonsurgical management. Although several foreign studies have shown the usefulness of multidetector-row CT (MDCT) in detecting splenic vascular injuries, domestic studies have seldom been seen. To assess accuracy of MDCT in detecting splenic vascular injuries, we compared findings of vascular injuries in MDCT and angiography.
Methods: In patients with blunt splenic injuries managed without surgery between January and December 2007, we retrospectively determined whether vascular injuries demonstrated on angiography had also been apparent on MDCT. In principle, angiography was performed in patients with MDCT findings indicating vascular injuries.
Results: There were nine patients with blunt splenic injuries who were hemodynamically stable and managed without surgery. Ten findings of vascular injury (three EXTs, six PSAs, and one vessel truncation) were detected by MDCT in six cases. Angiography was performed in five of six cases demonstrating MDCT findings of vascular injuries and one patient with severe injury who had not shown MDCT findings of vascular injuries. Five of six cases that underwent angiography required splenic artery embolization. All embolized vascular injuries (3 EXTs, 5 PSAs, and one vessel truncation) were detected on MDCT as well. Especially Multi Planar Reconstruction (MPR) and Maximum Intensity Projection (MIP) images in the arterial phase could detect minute pseudoaneurysms under 5mm and could also detect vessel spasms in another case in which pseudoaneurysm appeared in the lesion on day 4.
Conclusion: MDCT was useful for precisely detecting blunt splenic vascular injuries. MPR and MIP images in arterial phase were especially useful in our cases.

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A 63-year-old woman presented with 3-year history of ocular swelling, otalgia and respiratory discomfort after visiting various medical departments for local symptomatic treatments without receiving comprehensive medical care. Respiratory discomfort gradually worsened and she was found unconscious. By the time emergency services arrived, she was already in cardiopulmonary arrest. After being hospitalized, heartbeat was restarted during resuscitation. However, general condition greatly deteriorated after resuscitation and she died in hospital 5 days later. At the time of hospitalization, auricular deformity and saddle nose were observed and chest radiography showed tracheostenosis. Pathological examination of auricular cartilage indicated the existence of only cartilage matrix, with no cartilaginous tissue. Cartilaginous tissue had been replaced by fibrous connective tissue, infiltrated by a large number of inflammatory cells. Based on these observations, relapsing polychondritis was diagnosed. Relapsing polychondritis is a multiple-organ dysfunction disease that mainly affects cartilage throughout the body. The pathology of the disease is not well known except among specialists, as the disease is relatively rare. Diagnosis of the disease would be easy if the typical exofacial characteristics of the disease, such as auricular chondritis and nasal chondritis, were better known. In addition, treatment is mainly by steroids, and early treatment is quite effective. However, the rare occurrence of the disease may make it difficult to detect. Clinicians need to be aware that airway constriction may occur as a serious complication of chondritis when the disease is left undiagnosed, and is sometimes fatal, as in the present case.

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We report a case of immersion foot syndrome caused by icing treatment for musculoskeletal injury. A 48-year-old woman kept soaking her left leg in cold water for 1 month after fall. During her clinical course, the demarcation line between viable and nonviable area in her leg was clarified without any sign of systemic infection. Finally, below the knee amputation was successfully performed. This rare but serious condition should be taken into consideration among the civilian population.

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In this report, we present an adult case of severe meningococcal sepsis-associated purpura fulminans (MSPF), which is rare in Japan. A 50-year-old female presented with sudden-onset high fever, sore throat, and bilateral gonalgia; subsequently, she developed disseminated intravascular coagulation (DIC), widespread purpura fulminans (PF), severe shock, and respiratory and renal failures. Blood culture findings confirmed sepsis due to Neisseria meningitidis. The initial disease condition was successfully treated with conventional supportive therapies for DIC and septic shock; however, amputation of bilateral lower extremities and all fingers was performed due to extensive soft tissue necrosis that occurred during the clinical course. With improved critical care, the mortality related to MSPF has decreased dramatically, and many unconventional treatment strategies for MSPF have been proposed recently. Nevertheless, whether these strategies have a significant impact on the outcome of MSPF remains unverified. Here, we discuss the therapies for sepsis-associated purpura fulminans along with a review of the relevant literature. Currently, the application of appropriate conventional therapies for sepsis and DIC at an early stage of the disease seems to be the optimal method of improving outcome.

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An 83-year-old woman suddenly experienced abdominal pain and was transferred to hospital. She was suspected of having rupture of abdominal aortic aneurysm (AAA), and was admitted to our hospital for surgical treatment. Following enhanced computed tomography (CT), her vital signs indicated bleeding shock necessitating emergent operation. A prosthesis was implanted from the level below the renal artery to that above the common iliac artery. When the aortic clamp was removed, we observed bleeding from the posterior wall of the abdominal aorta, and found that it was due to an aortocaval fistula. The fistula was repaired by direct suture and covered with fibrin glue sheets. Her postoperative course was unremarkable and no fistula was detected on postoperative enhanced CT. Aortocaval fistula is sometimes observed as a complication of AAA and carries high mortality. Here, we also review the literature with respect to closure methods for such defect.

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