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This 35 year old woman began noticing increasing fatigue in 2014. The fatigue and left lower quadrant pain became increasingly severe so that she went an emergency room. On 19 February 2018, a CT scan was performed that showed an infiltrate into the greater omentum and multiple nodules associated with small bowel mesentery. There was no ascites. Masses were present on both the right and left ovaries. On 14 March 2018, she was taken to the operating room where multiple biopsies were taken. Her left ovary and appendix were removed. Pathology showed a mature cystic teratoma and extensive malignant peritoneal mesothelioma. Multiple biopsies from omentum, surface of uterus, peritoneum from the abdominal wall, and peritoneum from the small bowel showed malignant peritoneal mesothelioma.\nRepeat CT on 2 May 2018 showed malignant peritoneal mesothelioma infiltrating the omentum and accumulating as a diffuse mass in the pelvis. The small bowel mesentery showed multiple prominent lymph nodes. For definitive treatment of her malignant peritoneal mesothelioma, the patient was taken back to the operating room on 3 May 2018. At that time she had a greater and lesser omentectomy, cholecystectomy, pelvic peritonectomy with hysterectomy and right oophorectomy along with cytoreductive surgery of the small and large bowel surfaces. HIPEC was performed with cisplatin, doxorubicin, and systemic ifosfamide with Mesna (2-Mercaptoethanesulfonic acid sodium). During the HIPEC procedure Mayo scissor dissection removed a layer tumor from large and small bowel surfaces along with large and small bowel mesenteric surfaces []. In order to rule out disease within the mesenteric lymph nodes, six of these lymph nodes were harvested during the HIPEC chemotherapy []. Portions of the node were sent for histopathologic analysis and other portions were sent for pharmacologic analysis of the intraperitoneal drug, doxorubicin. The results of the doxorubicin within blood, peritoneal fluid, lymph nodes, and tumor are shown in . The area under the curve ratio of lymph node doxorubicin to plasma doxorubicin was 30. The area under the curve ratio of tumor nodules to plasma was 20 and from peritoneal fluid to plasma was 50.\nAgain in this patient the markedly increased levels of doxorubicin in lymph nodes as compared to plasma were documented.\nThe patient was hospitalized for 15 days and was discharged eating well. An intraperitoneal port was placed at the time of the cytoreductive surgery and will be used to deliver long-term intraperitoneal pemetrexed with systemic cisplatin. Six cycles of treatment are planned. Pathology of resected specimens showed malignant peritoneal mesothelioma; the lymph nodes were negative for cancer. |
A 31-year-old gravida 3 para 1 patient presented to antenatal clinic at 19 weeks and 3 days' gestation to discuss the results of her morphology scan which had demonstrated a grade 4 placenta previa covering the cervical os. She had a medical history significant for Arnold Chiari malformation requiring craniotomy in 2006 as well as correction of a Syringomyelia in 2005. She also suffers from irritable bowel syndrome but was taking no regular medications and had a BMI of 23. Her first pregnancy resulted in a spontaneous miscarriage that did not require dilatation and curettage. Her second pregnancy resulted in a planned elective caesarean due to concerns about raised intracranial pressure during labour, as recommended by her neurologist. She had routine antenatal care this pregnancy which had been unremarkable to date.\nThe morphology scan demonstrated a small omphalocele but otherwise no significant structural defects and estimated foetal weight was noted to be within the normal range. During the clinic review, the fetus was found to have a heart rate well below 100 bpm. Repeat ultrasound the following day confirmed IUFD. This ultrasound also demonstrated evidence of an abnormally invasive placenta with the appearance of dysplastic vascular hypertrophy. An obstetric MRI was performed which supported the diagnosis of morbidly adherent placenta. This showed a low lying inhomogeneous placenta, dysplastic vascular hypertrophy, ill-defined placental bands, and an overall impression of some areas of increta with no overt evidence of percreta.\nOptions were discussed with the patient who decided for conservative management in order to optimise her chance of preserving her fertility. This was balanced against potential complications of prolonged conservative management of an IUFD, including sepsis and coagulopathy. A plan was made for serial ultrasounds as an outpatient, to be followed by induction of labour when placental blood flow was no longer detectable. Twenty-seven days following IUFD confirmation, the patient was admitted to hospital with abdominal cramping and associated small antepartum haemorrhage (APH).\nUltrasound scan at 31 days showed a minimal reduction in blood flow through the anterior placenta and to the cervix. At day 33 she suffered a further 300mL APH. Given her increasing blood loss and minimal changes to placental blood flow on ultrasound, she was administered a dose of 80mg methotrexate intramuscularly with the hope of accelerating devitalisation of the placenta. A repeat dose of methotrexate was planned for five days' time. During the subsequent two days after the administration of methotrexate, the patient continued to suffer moderate bleeds and increasingly significant contractions. 35 days following IUFD she spontaneously delivered a male fetus with only minimal bleeding during delivery.\nA brisk 2 L postpartum haemorrhage (PPH) followed delivery and the patient was immediately taken to the operating theatre for examination under anaesthesia and attempted manual removal. A urinary indwelling catheter was inserted and remained in situ for the entirety of the operation. Due to only partial removal (approximately 80%) of the placenta being achieved manually, the case quickly progressed to laparotomy. Intraoperative findings revealed a full thickness increta at the previous caesarean incision just above the level of the bladder. Hysterotomy was performed with a transverse incision made above the prior caesarean incision, and the remaining placenta was removed manually, creating a 3x3cm plug-like defect anteriorly. This defect was closed with a primary closure separate to the hysterotomy incision. In addition, the placental bed was oversewn to establish haemostasis. A Foley's catheter was inserted vaginally and inflated with 60mL normal saline. Total blood loss was 4 litres (L): 2L immediately postpartum, 1L while attempting per vaginal manual removal of the placenta, and 1L intraoperatively. Massive transfusion protocol was activated with the patient receiving 10 units of packed red cells, 6 units of fresh frozen plasma and 5 units of cryoprecipitate. The patient remained stable throughout the process. A further 3 units of packed cells was given over the next two days for persistent anaemia. The fetus was found to weigh 170g. No cause for foetal demise was identified and the family decided against an autopsy. Pathological examination of the placenta was performed. This was noted to be difficult due to extensive haemorrhage and areas of necrosis commensurate with intrauterine foetal death and prolonged intrauterine retention. There was no evidence of funisitis or umbilical cord vasculitis to support a diagnosis of chorioamnionitis nor were any pathogens observed. The degree of decidual haemorrhage and necrosis made a histological diagnosis of placenta accreta impossible.\nThe patient recovered without significant complication over the following days and was discharged 1 week later on oral antibiotics and aperients. Six weeks after discharge the patient was seen in a postnatal follow-up clinic. She experienced minimal lochia in the postpartum period and was feeling generally well. |
A 33-year-old woman was admitted to psychiatry inpatient with a complaint of suicidal ideation. The patient has a past history of multiple psychiatric disorders like BPD, MDD, and anxiety issues for about last eight to 10 years. She had multiple suicide attempts in the past most recent being two weeks back when she tried to suffocate herself with the help of a medical device tubing. On inquiry, she said she just wanted to feel the pain, not kill herself. On further questioning, she was found to have passive suicidal thoughts as well as an active plan to harm herself. Her plan was to kill herself with the carbon monoxide poisoning by turning on the engines of four cars parked in the garage. According to her, she felt better at the time of the last admission and these suicidal thoughts just returned two to three days back. She had multiple admissions and emergency department (ED) visits related to her psychiatric conditions as well as five suicidal attempts. During one of her admission when she took multiple tablets of Advil® (Pfizer, New York, USA) in an attempt to kill herself, she was evaluated for ECT by a psychiatrist but the decision was made in favor of dialectical behavior therapy (DBT) as they felt these symptoms are because of her BPD. According to the patient she has been compliant with the therapy that has helped her in coping day-to-day issues. The patient also confirmed that she has never recovered from these active and passive suicidal thoughts which have progressed to even worse state in the last four months.\nOn further evaluation, the patient reported feelings of hopelessness and worthlessness most of the time along with a guilt of things for what she has done in the past. She also reported a decrease in sleep to about five hours per night along with difficulty in staying asleep and poor appetite and energy. Her concentration was normal. She continues to engage in her interests in reading and photography. The patient states she has been a "warrior" for years. She endorses a few prior panic attacks where she felt shaky, short of breath, and had chest pain. She could not recall how long they lasted or when her last episode was. Screening for mania, psychosis, and obsessive compulsive disorder was unremarkable. There was no reported history of alcohol, tobacco, or illicit drugs.\nMinnesota multiphasic personality inventory-2 (MMPI-2) results suggested the presence of depression, anxiety, overall distress, and a personality disorder. All of these scores are in the moderate to severe ranges and are rather similar to one another. The psychologist during this visit interpreted that these results do not suggest that the personality disorder is the main factor driving her clinical presentation and that her presenting symptoms are due to MDD. She was recommended ECT as it was determined that these symptoms are due to resistant MDD.\nThe patient had a past history of multiple psychiatric drug trials in the last eight years which included medicines like fluoxetine, sertraline, venlafaxine, amitriptyline and even augmented therapy with antipsychotics was tried with aripiprazole and thyroxine which all proved ineffective in this patient. Considering her condition and beneficial outcomes in such a treatment-resistant patient, a trial of ECT was the consensual decision of all the panelist psychiatrists. The patient agreed to this mode of therapy.\nThe first session was done with the parameters mentioned in Table .\nAfter the first session parameters were changed for the rest of the 12 sessions which are mentioned in Table .\nA total of 16 sessions were conducted with a break after 13 sessions. The frequency of sessions was three per week for the first 10 sessions and then two sessions every week and last three sessions were conducted once a week. The patient was evaluated after every session and there was a remarkable improvement from the sixth session onwards. After 13 sessions there was a thorough evaluation and the patient reported improved mood and no active or passive suicidal ideations and she was discharged. She remained symptom-free for four to five months but then reported again with another suicide attempt. She was restarted on ECT, and 16 more sessions were conducted with the same frequency and same parameters.\nOn her recent visit, she endorsed a significant improvement in her depressive symptoms and denied active suicidal ideations. She also reported an improved quality of life. |
A 33-year-old woman was admitted to psychiatry inpatient with a complaint of suicidal ideation. The patient has a past history of multiple psychiatric disorders like BPD, MDD, and anxiety issues for about last eight to 10 years. She had multiple suicide attempts in the past most recent being two weeks back when she tried to suffocate herself with the help of a medical device tubing. On inquiry, she said she just wanted to feel the pain, not kill herself. On further questioning, she was found to have passive suicidal thoughts as well as an active plan to harm herself. Her plan was to kill herself with the carbon monoxide poisoning by turning on the engines of four cars parked in the garage. According to her, she felt better at the time of the last admission and these suicidal thoughts just returned two to three days back. She had multiple admissions and emergency department (ED) visits related to her psychiatric conditions as well as five suicidal attempts. During one of her admission when she took multiple tablets of Advil® (Pfizer, New York, USA) in an attempt to kill herself, she was evaluated for ECT by a psychiatrist but the decision was made in favor of dialectical behavior therapy (DBT) as they felt these symptoms are because of her BPD. According to the patient she has been compliant with the therapy that has helped her in coping day-to-day issues. The patient also confirmed that she has never recovered from these active and passive suicidal thoughts which have progressed to even worse state in the last four months.\nOn further evaluation, the patient reported feelings of hopelessness and worthlessness most of the time along with a guilt of things for what she has done in the past. She also reported a decrease in sleep to about five hours per night along with difficulty in staying asleep and poor appetite and energy. Her concentration was normal. She continues to engage in her interests in reading and photography. The patient states she has been a "warrior" for years. She endorses a few prior panic attacks where she felt shaky, short of breath, and had chest pain. She could not recall how long they lasted or when her last episode was. Screening for mania, psychosis, and obsessive compulsive disorder was unremarkable. There was no reported history of alcohol, tobacco, or illicit drugs.\nMinnesota multiphasic personality inventory-2 (MMPI-2) results suggested the presence of depression, anxiety, overall distress, and a personality disorder. All of these scores are in the moderate to severe ranges and are rather similar to one another. The psychologist during this visit interpreted that these results do not suggest that the personality disorder is the main factor driving her clinical presentation and that her presenting symptoms are due to MDD. She was recommended ECT as it was determined that these symptoms are due to resistant MDD.\nThe patient had a past history of multiple psychiatric drug trials in the last eight years which included medicines like fluoxetine, sertraline, venlafaxine, amitriptyline and even augmented therapy with antipsychotics was tried with aripiprazole and thyroxine which all proved ineffective in this patient. Considering her condition and beneficial outcomes in such a treatment-resistant patient, a trial of ECT was the consensual decision of all the panelist psychiatrists. The patient agreed to this mode of therapy.\nThe first session was done with the parameters mentioned in Table .\nAfter the first session parameters were changed for the rest of the 12 sessions which are mentioned in Table .\nA total of 16 sessions were conducted with a break after 13 sessions. The frequency of sessions was three per week for the first 10 sessions and then two sessions every week and last three sessions were conducted once a week. The patient was evaluated after every session and there was a remarkable improvement from the sixth session onwards. After 13 sessions there was a thorough evaluation and the patient reported improved mood and no active or passive suicidal ideations and she was discharged. She remained symptom-free for four to five months but then reported again with another suicide attempt. She was restarted on ECT, and 16 more sessions were conducted with the same frequency and same parameters.\nOn her recent visit, she endorsed a significant improvement in her depressive symptoms and denied active suicidal ideations. She also reported an improved quality of life. |
A 31-year-old gravida 3 para 1 patient presented to antenatal clinic at 19 weeks and 3 days' gestation to discuss the results of her morphology scan which had demonstrated a grade 4 placenta previa covering the cervical os. She had a medical history significant for Arnold Chiari malformation requiring craniotomy in 2006 as well as correction of a Syringomyelia in 2005. She also suffers from irritable bowel syndrome but was taking no regular medications and had a BMI of 23. Her first pregnancy resulted in a spontaneous miscarriage that did not require dilatation and curettage. Her second pregnancy resulted in a planned elective caesarean due to concerns about raised intracranial pressure during labour, as recommended by her neurologist. She had routine antenatal care this pregnancy which had been unremarkable to date.\nThe morphology scan demonstrated a small omphalocele but otherwise no significant structural defects and estimated foetal weight was noted to be within the normal range. During the clinic review, the fetus was found to have a heart rate well below 100 bpm. Repeat ultrasound the following day confirmed IUFD. This ultrasound also demonstrated evidence of an abnormally invasive placenta with the appearance of dysplastic vascular hypertrophy. An obstetric MRI was performed which supported the diagnosis of morbidly adherent placenta. This showed a low lying inhomogeneous placenta, dysplastic vascular hypertrophy, ill-defined placental bands, and an overall impression of some areas of increta with no overt evidence of percreta.\nOptions were discussed with the patient who decided for conservative management in order to optimise her chance of preserving her fertility. This was balanced against potential complications of prolonged conservative management of an IUFD, including sepsis and coagulopathy. A plan was made for serial ultrasounds as an outpatient, to be followed by induction of labour when placental blood flow was no longer detectable. Twenty-seven days following IUFD confirmation, the patient was admitted to hospital with abdominal cramping and associated small antepartum haemorrhage (APH).\nUltrasound scan at 31 days showed a minimal reduction in blood flow through the anterior placenta and to the cervix. At day 33 she suffered a further 300mL APH. Given her increasing blood loss and minimal changes to placental blood flow on ultrasound, she was administered a dose of 80mg methotrexate intramuscularly with the hope of accelerating devitalisation of the placenta. A repeat dose of methotrexate was planned for five days' time. During the subsequent two days after the administration of methotrexate, the patient continued to suffer moderate bleeds and increasingly significant contractions. 35 days following IUFD she spontaneously delivered a male fetus with only minimal bleeding during delivery.\nA brisk 2 L postpartum haemorrhage (PPH) followed delivery and the patient was immediately taken to the operating theatre for examination under anaesthesia and attempted manual removal. A urinary indwelling catheter was inserted and remained in situ for the entirety of the operation. Due to only partial removal (approximately 80%) of the placenta being achieved manually, the case quickly progressed to laparotomy. Intraoperative findings revealed a full thickness increta at the previous caesarean incision just above the level of the bladder. Hysterotomy was performed with a transverse incision made above the prior caesarean incision, and the remaining placenta was removed manually, creating a 3x3cm plug-like defect anteriorly. This defect was closed with a primary closure separate to the hysterotomy incision. In addition, the placental bed was oversewn to establish haemostasis. A Foley's catheter was inserted vaginally and inflated with 60mL normal saline. Total blood loss was 4 litres (L): 2L immediately postpartum, 1L while attempting per vaginal manual removal of the placenta, and 1L intraoperatively. Massive transfusion protocol was activated with the patient receiving 10 units of packed red cells, 6 units of fresh frozen plasma and 5 units of cryoprecipitate. The patient remained stable throughout the process. A further 3 units of packed cells was given over the next two days for persistent anaemia. The fetus was found to weigh 170g. No cause for foetal demise was identified and the family decided against an autopsy. Pathological examination of the placenta was performed. This was noted to be difficult due to extensive haemorrhage and areas of necrosis commensurate with intrauterine foetal death and prolonged intrauterine retention. There was no evidence of funisitis or umbilical cord vasculitis to support a diagnosis of chorioamnionitis nor were any pathogens observed. The degree of decidual haemorrhage and necrosis made a histological diagnosis of placenta accreta impossible.\nThe patient recovered without significant complication over the following days and was discharged 1 week later on oral antibiotics and aperients. Six weeks after discharge the patient was seen in a postnatal follow-up clinic. She experienced minimal lochia in the postpartum period and was feeling generally well. |
A 25-year-old Mexican female with family history of ovarian cancer at her maternal side and personal history of a mass on her right breast clinically and radiologically diagnosed as fibroadenoma 2 years ago. The same mass had a growth of 2 cm so an incisional biopsy was performed at another institution. This was positive for mucinous carcinoma, and the patient was referred to our institution for treatment and follow up.\nAt our institution in the biopsy slides revision, we found a tumor composed of mucinous lakes with numerous tumor cells of medium to large size with a moderate amount of eosinophilic cytoplasm confirming the presence of pure mucinous carcinoma. We could not identify the tumor size and surgical margins by no prior radiological and pathological report. []. The tumor was classified as a Low grade tumor (G1) based on the Scarff Bloom Richardson scale. We did not observe perineural or vascular invasion. On immunohistochemistry the results were 100% and 90% positive for estrogen and progesterone receptors respectively with high intensity, and HER2 receptors negative.\nOn physical examination a surgical injury was seen. Upon palpation, this zone felt indurated, edematous and presented as a rough irregular texture. No other lesions were found. An ultrasound was performed, showing avascular distortion and a heterogeneous mass with microcysts (white arrows) []. MRI showed a hypointense irregular mass that indicates a mild enhancement in contrast sequences and a hyperintense sequence in SPAIR. The evaluation of the lymph nodes was not suspicious for metastasis.\nWith the radiological suspicious of residual tumor and pathological findings accomplished at our institution a partial mastectomy and a sentinel lymph node biopsy was performed. Pathological findings showed a residual mass of 25 mm of pure mucinous carcinoma with negative surgical margins. Sentinel lymph node was negative for metastasis.\nMolecular screening with EndoPredict clinic showed a score of 2.7 classifying it as a low risk, reason why this patient was treated with tamoxifen because her positivity to receptors and low risk showed in molecular assay. The clinical and pathological stage IB was confirmed. |
The patient was an 82-year-old female with dyspnea as the primary complaint. She had no particular past or familial history. She used to be a nurse (until the age of 72 years) and had no history of occupational asbestos exposure. There was also no history of residence in an asbestos-contaminated environment.\nRegarding the history of the present illness, she presented with abnormal chest radiographs (a) during a community health screening in July 2006. Still, she left the findings unattended because of the absence of symptoms. On a retrospective review of the plain chest radiographs taken one year before, in July 2005, the right costophrenic angle was already blunted. The plain chest radiographs taken during the community health screening in July 2007 indicated abnormalities again (b). At this time, as the chest radiographs showed a mass in the right thoracic wall in addition to right pleural effusion, the patient was referred to a hospital for close examination. In the chest CT scans taken in July 2007 (), a small amount of pleural effusion was noted on the right side, and pleural masses were found in the right anterior mediastinum and anterior and lateral thoracic regions. A percutaneous pleural needle biopsy was performed for the mass of the right lateral chest wall, and a diagnosis of pleural mesothelioma was made. The pathologist in charge of the needle biopsy described the pathological findings as epithelioid mesothelioma with edematous stroma, and intracytoplasmic mucinous vacuoles are outstanding. However, when we re-evaluated the specimen, it was an epithelioid mesothelioma with abundant myxoid stroma and was completely homogeneous with the histological image at autopsy as described below.\nTherefore, the clinician recommended anticancer drug treatment. However, as the patient did not wish for aggressive treatment, she was followed-up without treatment.\nshows a plain chest radiograph taken in April 2008. Masses were observed in the area corresponding to the right lower lung field's peripheries and the right lateral chest wall. Dyspnea appeared in the middle of May 2010, and the patient was admitted to Toyama Rosai Hospital in late May. |
A 49 year old male presented with Left supracondylar humerus fracture with intercondylar extension (). Patient had sustained this fracture following fall from steps. There was no history of clinical signs or symptoms of tuberculosis and there was no primary focus in the lungs at the time of presentation. The fracture was treated with olecrenon osteotomy and medial and lateral column plating (). The procedure was uneventful and patient was discharged and followed up routinely. Stitches were removed on 14th post-operative day and the incision healed well. Patient resumed back his activities and remained asymptomatic. Fracture healed well without any problems. After one and half years after the index surgery, patient presented with a swelling over the medial side of operated left elbow joint. He has had swelling since one month duration. There was no history of trauma, fever, any other joint pain or any systemic symptoms. There was no tuberculous contact history in family. Physical examination showed a cystic mass measuring 5×5 cm over medial aspect of operated left elbow with mild tenderness without any erythema. There was no induration over incision site. There was no open wound or discharge. There was no neurological deficit. Movements of elbow were normal with limitation of terminal 5 degrees flexion. Plain radiograph of left elbow showed united distal humerus fracture () without any lysis, erosions or reduction in joint space. There were no signs of implant loosening. The white cell count was 5800/mm3, ESR was 20 mm at end of 1 hour, CRP was negative and, all other serum biochemical investigations were within normal limits. Chest X ray was normal. Serology was negative for HIV1 and HIV 2. Diagnosis of infective bursa made. Patient underwent excision of bursa from medial incision (). Aspiration of fluid from cyst just prior to surgery revealed yellowish turbid content. Bursa excision was done which was found to be a cyst arising from synovium of elbow joint and material with cyst wall and synovium was sent for culture and histopathology. Medial plate was removed and fracture was found to be healed. There was no loosening of screws. Articular surface was not involved and there was no bony involvement. Pathological examination of excised material showed granulomatous tissue and extensive areas of fibrinoid necrosis. The granuloma consisted of epitheloid cells and Langhans giant cells suggestive of tuberculosis. The patient was started on standard protocol of antituberculosis drugs for extra pulmonary tuberculosis. Patient responded well to antitubercular chemotherapy. (Figs , )\nThe patient was informed about the use of pertaining data for case report publication. |
A 60 year old male patient presented to us in the outpatient department with complaints of limp and shortening of the right lower limb for the past one year. The patient had sustained fracture neck of femur following a fall while working one and half years back []. He underwent cemented bipolar hemiarthroplasty for the same []. The old post-operative x-rays showed a proud bipolar prosthesis with extravasations of cement from proximal femoral aspect.\nThe patient gave history of lengthening of the operated limb, which he noticed on day one. He had continuous dull aching pain in the right hip with stiffness for a period of six months from the day of surgery. Patient was walking with the support of a walking aid. As the pain & limp persisted, he was advised removal of bipolar prosthesis. Patient underwent the procedure of removal of improperly placed implant & Girdlestone arthroplasty []. Since, last one year he has been walking with pain, limp, shortening and instability. Patient had a Harris hip score of 26. The recent X-ray of the hip [] showed gross proximal migration of femur with osteoporotic greater trochanter and cement mantle without any signs of loosening.\nThe patient was thoroughly investigated to rule out any signs of underlying infection. The markers of infection; CRP was negative and ESR was around 25mm at the end of one hour. The hip joint aspiration under C-arm guidance was done to rule out any infective collection which turned out to be negative. Later an MRI scan of the hip was also done to rule out any possible signs of infection.\nAs the patient’s intention was to have a painless joint with stability, he was advised total hip arthroplasty. With an operative plan of removal of cement mantle and total hip arthroplasty with or without extended trochanteric osteotomy, patient was posted for surgery. The standard posterior approach was used to expose the hip joint. The acetabulum was filled with hard fibrous tissue which was completely cleared and acetabular floor was prepared. Once the preparation of acetabulum was done the proximal femur was exposed without having to do the trochanteric osteotomy, the cement mantle in the proximal part of shaft was removed with some effort enblock, but the distal mantle was impacted in the shaft. The mantle was drilled with 3.2mm drill bit, to remove it in piece meal. But the peripheral part was integrated very well within the canal. The K- nail reamers of 6.0mm, 7.0mm and 8.0mm were used to gradually remove the mantle, in the attempt the antero-lateral wall of the femur was breached. The breach in the wall, which was about 6mm in diameter was identified immediately and the exposure was further extended to visualize it. The break in the cortex was used to remove the distal part of the cement mantle. Once the cement was completely removed the femoral canal was prepared. Long cemented stem was planned to bypass the cortical breach by at least 2 cortical diameters. An undisplaced split in the trochanter was stabilized using a steel cable.\nThe trial prosthesis was placed and reduction was attempted. It was noted that in spite of adequate soft tissue release the reduction was not achievable, unless the vertical offset was decreased. Hence a decision of placing the stem deeper in the shaft, accepting the shortening was taken & executed. Uncemented acetabular cup with a long cemented revision stem total hip arthroplasty was done []. An uncemented stem could not be used as the reduction was difficult, even with the smallest trial offsets.\nThe immediate post-operative period was uneventful and he was made to walk with support on the 3rd day. The patient is ambulant without support, without any significant pain at present though shortening of the limb of about 2.5cms is present, which is compensated by a heel raise. The latest follow up was one year after surgery. The patient was able to walk independently with the help of a stick, has mild pain on walking for more than a kilometer. The postoperative Harris hip score was 64. |
A 12-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry, SGT Dental College, following trauma to the maxillary central incisor. Trauma occurred due to fall while playing 6 months ago. Patient was attended by her general medical practitioner within 1 hour of trauma. On inspection, a swelling on the left side of lip was noticed. A firm nodule measuring approximately 1 cm in diameter in the same region was palpated (). Intraoral examination revealed fractured maxillary permanent central incisors.\nNo mobility of the concerned teeth was recorded and surrounding tissues were healthy. Tooth showed no vitality for pulp tests. Radiograph of the lip confirmed the presence of a tooth fragment in the lower lip (). The treatment plan was surgical removal of the tooth fragment from the lip and reattachment of the fragment to the tooth following root canal therapy with respect to 21 and composite build up with respect to 11.\nSurgical removal of the tooth fragment from the lip: The patient was submitted to surgical excision of the fragment under local anesthesia. The lower lip was incised, tissues were reflected and the tooth fragment was located (). The tooth fragment was carefully removed () and maintained in normal saline. Sutures were placed () and patient was recalled after 7 days for the suture removal.\nReattachment of the fragment to the tooth following root canal treatment: Meanwhile, root canal therapy was completed in 21 and then the adaptation of the fragment was checked. Slight beveling of the tooth was done to increase the surface area for etching and attachment of the tooth fragment 37%. Phosphoric acid gel was applied to the enamel of the fragment and the teeth for 20 seconds. Air-water spray was used to remove the acid and the surface was air-dried. An adhesive system was applied to the tooth fragment, which was then reattached to its proper position. Visible light polymerization was done for 60 seconds to the facial and palatal surfaces of the tooth, while the fragment was kept in position under pressure. The tooth was polished with polishing disks ( and ). |
A 40-year-old male presented to our office in 2017 complaining of chronic left knee pain. This was his first visit to this office and was establishing care after moving to the area. The patient's electronic medical record was obtained from an outside institution which indicated a past medical history of diabetes, hyperlipidemia, and hereditary multiple exostosis. The patient disclosed that he had multiple osteochondroma removal surgeries which included his left knee, lumbar spine, and left foot at an outside institution. In addition, he had a left hip arthroplasty with refractory numbness/tingling of the leg. The patient stated he had left knee pain for years until he had an osteochondroma removed in his left distal femur in 2016 which seemed to help for 6 months. He stated the pain returned at 7/10 and is worse with movements. He had limited range of motion with 70° of flexion, negative pain with varus and valgus movement, and negative secondary tests. Baseline X-rays were ordered for this patient's knee ().\nThere were osteoarthritic changes with significant osteochondroma formation; however, arthroplasty was not recommended at that time because of the patient's young age and his left lower extremity being distally neurovascular intact. The patient was adamant about having his knee replaced and was referred to a specialist at an outside institution where an arthroplasty of the left knee was performed. The patient returned 3 months later with continued limited active and passive range of motion (<90° flexion). Follow-up radiographs were ordered showing good alignment of a Smith & Nephew posterior stabilized prosthesis without subsidence (). It was decided to perform manipulation under anesthesia followed by 6 weeks of physical therapy which improved his range of motion to 110° flexion.\nThe patient continues to have limited range of motion of his left knee with flexion to 90°. The large posteriorly projecting osteochondroma of his left tibia continues to be asymptomatic and painless, and therefore, it was decided not to perform surgical interventions at this time. Performing an arthroplasty helped relieve the patient's pain, however, did not result in significant improvement of active and passive range of motion of the joint. Overall, the patient is satisfied with his knee replacement but still has refractory numbness/tingling of his distal left lower extremity from his prior hip replacement. The patient has chronic pain elsewhere, which is being closely monitored (Figures and ). |
A 65yrs old female came to our department with complaints of pain and swelling of the left hand along the thenar eminence and the proximal aspect of the thumb. She did not have history of any trauma prior to the development of swelling. The swelling was noticed two months ago and was progressive in nature and was painful on movements []. She simultaneously developed multiple swellings in the cervical region which most likely pointed towards cervical lympadenopathy []. She didn’t have any past history of tuberculosis or exposure to tuberculous contact. She did not have any associated symptoms like loss of appetite, weight loss or any evening rise of temperature.\nA plain radiograph of the patient was taken which showed pathological fracture of the base of 1st metacarpal along with lytic lesion at the base of the 1st metacarpal with haziness of the surrounding soft tissue []. On x-ray we came to a provisional differential diagnosis of pathological fracture secondary to a pyogenic infection, tuberculous osteomyelitis or soft tissue swelling, malignancy. An ultrasound revealed presence of an abscess. The USG was done to rule out any malignant involvement of the soft-tissue []. An MRI scan showed a large heterogeneous lesion at the 1st carpo-metacarpal joint space along with joint space widening []. The MRI scan suggested an abscess like picture most likely due to infective etiology and less likely to be neoplastic lesion.\nShe was then posted for drainage of abscess and debridment with stabilization of the fracture fragment. Intra-operatively we found thick caseous material within the soft tissue and the fragment at base of the 1st metacarpal was freely mobile similar to a loose body []. It was not possible to fix that fragment as it looked infected on gross inspection and hence it was removed and sent for biopsy and culture sensitivity along with the surrounding soft-tissue. We also found that after removal of the fragment the joint was unstable and hence a kirschner wire was passed through the 1st carpo-metacarpal joint to stabilize it []. Post-operatively the hand was immobilised in a below elbow POP splint to give added stability. A cervical lymph node biopsy was also taken during the same sitting and sent for histo-pathology to confirm if the lymph nodes were due to tuberculosis or some other cause like malignancy or viral respiratory infection which are common in Indian scenario.\nThe biopsy report came back positive for tuberculous osteomyelitis which suggested fibro-collagenous tissue and few bony fragments showing large caseous necrosis with few epitheloidid cell granuloma. The patient was then started on anti-tuberculous treatment emprerically while awaiting the culture report. A Combination of Isoniazid (300mg), Rifampicin (450mg), Pyrazinamide (1500mg) and ethambutol (800mg) was started as intensive phase for a period of 6 months under the guidance of a chest physician and then the continuous phase for a period of 6 months where Isoniazid (300mg) and Rifampicin (450mg) was given. The culture reports were obtained at the end of 6 weeks and the mycobacterium species showed sensitivity to the primary drugs which were started. Routine liver function tests were repeated every 3 months which were normal in the patient.\nAt the end of 5 weeks the kirschner wire backed out partially which was then removed and range of movement exercises were started. The cervical lymphadenopathy regressed by the end of 3 months. The patient had 1 episode of recurrence of cervical lymphandenopathy at the end of 7 months of treatment which eventually regressed on the continuous phase of AKT. The patient had almost complete range of movement at the end of 3 months with no sequel due to tuberculosis as compared to the opposite hand with no joint instability []. We did not plan any further intervention as the patient was having a stable joint at the end of 3 months and we decided to keep a regular follow up of the patient. The patient was then followed up regularly upto end of 1 year and the ranges of movements were compared with the opposite hand. There was very little restriction of movement of the thumb as compared to the opposite hand with a stable joint not subluxating on movements. Plain radiographs showed some degree of joint remodelling at one year. The grip strength was adequate to do any daily household activity which was the only requirement of the patient []. |
A 49 year old woman complained of abdominal pain in November of 2015 with diagnosis of large uterine fibroid, a myomectomy from within the uterus was performed. No malignancy was associated with the specimens recovered. In December of 2016, the abdominal pain persisted and a mass was palpable on physical examination in the mid-abdomen on the right. Colonoscopy was performed and biopsy showed a moderately differentiated adenocarcinoma of the caecum.\nCT was performed in December of 2016 and the primary right colon malignancy along with bilateral ovarian metastases were imaged. Percutaneous biopsy of the right ovarian mass showed well differentiated adenocarcinoma consistent with a colonic primary. From December of 2016 through December of 2017, the patient was maintained on chemotherapy. Initially, she was treated with FOLFOX. After four cycles, because of neuropathy, the oxaliplatin was stopped. The patient was maintained on 5-fluorouracil and bevacizumab.\nIn December of 2017, a CT documented marked regression of the primary tumor. It was not visible by CT. However, multiple lymph nodes within the mesentery of the distal small bowel were enlarged. Also by CT a pelvic mass showed that the right ovary had increased in size to 15 cm in greatest diameter despite the fact that the primary caecal malignancy was no longer visible by CT.\nOver approximately one month the patient became rapidly more symptomatic with abdominal distention from ascites and an expanding right ovarian mass. On February 1, 2018 the patient underwent cytoreductive surgery and HIPEC in a specialized center for management of peritoneal metastases. At the time of surgery she underwent a greater omentectomy, hysterectomy, bilateral salpingo-oophorectomy, complete pelvic peritonectomy, right colon resection, and small bowel resection. She received HIPEC with mitomycin C and doxorubicin with systemic fluorouracil. In order to determine if the multiple enlarged lymph nodes within the small bowel mesentery were involved by cancer, individual lymph nodes were removed and subjected to histopathologic study by permanent sections at a later time. A portion of each of these lymph nodes was sent for pharmacologic analysis for doxorubicin content. shows the pharmacokinetics of intraperitoneal doxorubicin in peritoneal fluid, mesenteric lymph nodes, and plasma. Clearly, the lymph nodes have taken up large amounts of doxorubicin nearly equal to that which was seen within the peritoneal fluid. The increased amounts of doxorubicin within lymph nodes as compared to the plasma can be measured by the area under the curve ratio. The ratio of lymph nodal tissue concentration times time to plasma concentration times time was 40. The area under the curve ratio (AUC ratio) of peritoneal fluid to plasma was 80.\nAfter the HIPEC chemotherapy and biopsies, an end-to-side coloenteric anastomosis was performed. The patient required a 3-week hospitalization and was discharged eating well and having normal bladder and bowel function. Pathology showed cancer in the right ovary and small amounts of cancer remaining at the primary site. No cancer was present in the mesenteric lymph nodes. |
A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan (Figs. and ) of the liver was performed, and the patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments and extensive regions of necrosis. Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated to attempt radical resection. During the exploration, a voluminous tumor was found attached to the peritoneum. Intraoperative ultrasound was performed and revealed a tumor originating from the gallbladder bed area and reaching up to the area of the hepatic hilum and extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes. The tumor was classified as inoperable due to this finding. But during the exploration, however, a rupture of the fragile tumor occurred with massive eruption of the necrotic mass and the gallbladder content into the abdominal cavity, accompanied by bleeding of the liver parenchyma. We decided that the condition could only be managed by attempting modified resection. We performed cholecystectomy and non-anatomical resection of hepatic segments S5 and S6 and partial resection of S4 without lymphadenectomy as a debulking operation (Fig. ). The course of hospitalization was uncomplicated, and the patient was discharged to home care on postoperative day 9. Histologically, the tumor was confirmed as MINEN of gallbladder (Figs. , , and ), and its non-neuroendocrine component had the character of moderately differentiated tubular gall bladder adenocarcinoma, while the neuroendocrine component had the appearance of small cell carcinoma and was dominant, accounting for more than 65% of the viable tumor. The neuroendocrine component contained extensive necrosis, with mitotic index 64/10 HPF and a proliferation index of 70% (Fig. ). It was therefore obvious that the prognosis and the subsequent biological behavior would be influenced in particular by the neuroendocrine carcinoma component. Six weeks after the discharge, the patient underwent a follow-up CT scan prior to the initiation of systemic therapy, which revealed a large recurrence of the disease at the resection surface of the liver accompanied by hilar lymphadenopathy. The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues with very good radiological effect. We use this regimen as a standard in patients with MINEN of gastrointestinal tract with dominant neuroendocrine component, even with no somatostatin receptors staining available. Now the patient is almost a year after being diagnosed with a tumor, after completion of 6 cycles of adjuvant chemotherapy (carboplatin + etoposide) in combination with biological therapy, the long-acting somatostatin analogues. The patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases, with a solitary metastasis in Th9. The condition was evaluated as disease progression stage according to RECIST criteria, the patient remains in the follow-up care, and it is now 13 months after surgery (Figs. , , and ). |
A 52-year-old woman with adult polycystic kidney disease received a first deceased renal transplant into the right iliac fossa in December 2008. Her medical history included bilateral native nephrectomy of her large polycystic kidneys as well as excision of a malignant melanoma in situ from the anterior chest in 2006. She had remained free of recurrence since then and remained under regular surveillance with a dermatologist. Following transplantation in 2008, her initial immunosuppression had been with tacrolimus, mycophenolate mofetil and prednisolone. There was a period of delayed graft function and renal biopsy showed acute tubular necrosis. Eventually, she was converted to sirolimus. Transplant function improved greatly, and serum creatinine when discharged was 150 μmol/L.\nIn March 2010, the patient presented to the outpatient clinic with a very swollen left leg. On examination, the patient was essentially well and afebrile. There were no signs of infection and no palpable lymph nodes in either groin. There were no clinical signs of deep venous thrombosis or of phlebitis. The remainder of the clinical examination was essentially unremarkable. There was no history of surgery, trauma or infection in the left leg, nor had she ever had a femoral dialysis access. The general practitioner had started compression bandages but the affected leg remained grossly oedematous (). Doppler studies revealed no deep vein thrombosis and left leg venogram confirmed patent veins up to the inferior vena cava. Diuretics were administered, but without any clinical benefit. The patient was seen at the regional referral centre for lymphoedema and a complex regime of bandaging and lymphatic drainage exercises was begun. Computed tomogram of the chest, abdomen and pelvis showed minor lymphadenopathy in the left groin. Around spring, 2010, the cause of her leg swelling was still essentially unclear. Cytomegalovirus and the Epstein–Barr virus polymerase chain reaction were negative, and serum lactate dehydrogenase was normal. Given her previous history of melanoma, we proceeded to a left inguinal lymph node biopsy, which showed no significant abnormality and no tumour cells. Eventually, the possibility of sirolimus-associated lymphoedema was considered. Sirolimus levels throughout this period of follow-up were within the target range (6.3–10.5 μg/L). Lymphoscintigraphy demonstrated the complete absence of tracer drainage from the left lower limb (). A tentative diagnosis of unilateral lymphoedema due to a mammalian target of rapamycin (mTOR) inhibitor was made and sirolimus was withdrawn. Within 2 weeks, the swelling improved dramatically. When last seen in May 2012, she was very well with no discernible leg swelling () and good transplant function (creatinine 156 μmol/L). |
A 41-year-old Asian female presented to the outpatient breast surgery clinic in our hospital with a 7-year history of an enlarging left breast mass. Over the last 8 months, she reported discomfort as well as ulceration with occasional bleeding. The worsening symptoms prompted her to seek medical care. On further review, she stated that she had sought no help as she thought the mass might disappear spontaneously. She was otherwise healthy without prior surgery. She had no family history of breast or ovarian cancer. On physical examination, she had a large nodular mass measuring ∼25 × 20 cm involving the entire left breast with two periareolar areas of skin ulceration measuring ∼2 × 2 and 3 × 4 cm (Fig. ). There was a palpable left axillary lymph node 2 cm in diameter. Her right breast and the rest of her clinical examination were normal.\nDue to pain and size of the right breast mass, the patient was unable to have mammography. Bilateral breast and axillary ultrasonography was performed. This showed a large heterogeneous solid mass with internal vascularity replacing all normal expected left breast tissue (Fig. ). The size was difficult to be accurately defined on ultrasonography due to its large size. In the left axilla, a 1.8-cm nonspecific lymph node was identified with slightly prominent cortices. There were no suspicious findings in the right breast or right axilla. The patient had core biopsies of the left breast and left axillary node. Initial histopathological analysis suggested a fascicular pseudoangiomatous stromal hyperplasia or phyllodes tumor. The left axillary lymph node biopsy revealed chronic lymphadenitis without neoplastic cells. Further workup with a chest and abdomen computed tomography (CT) scan was performed, which showed no evidence of metastatic lesion.\nA left mastectomy was performed. The excised mass was 20 × 20 × 25 cm in size (Fig. ). The tumor did not appear grossly to be invading the chest wall. The pectoralis fascia was free of tumor invasion (Fig. ). The left chest wall defect was covered temporarily with dual layers dermal regeneration template consists of thin outer layer of silicone and thick inner matrix layer of pure bovine collagen and glycosaminoglycan (INTEGRA®) in the same operation, and subsequently replaced with split thickness skin graft 5 weeks later (Fig. ). Final histological examination was consistent with phyllodes tumor with low-grade malignant features with negative margins (Fig. ). |
A 51-year-old man was admitted to our surgical unit with a diagnosis of chronic pancreatitis. He was suffering from episodes of continuous abdominal pain for the last one year. The pain was radiated from the right upper quadrant of the abdomen to the back and was associated with nausea, partially relieved by injectable analgesics and aggravated by food ingestion. This challenge led to the loss of appetite then to weight loss which also worsened by the presence of occasional episodes of malabsorption and the development of insulin dependent diabetes mellitus. There was no family history of the similar condition in parents, siblings or first-degree relatives.\nMoreover, there was no history of abdominal trauma in the past. The patient had a history of admissions to different hospitals for the recurrent pain attacks. However, apart from this illness, he had never been to hospitals for any other medical or surgical condition. He was on analgesics, insulin therapy, and pancreatic enzyme supplementation and had never been allergic to the exposed medications.\nThe physical examination showed an emaciated man looking older than his chronological age, appeared pallor but no clinical evidence of jaundice. Abdominal examination was normal. Chest examination found no remarkable findings, and the rest of the physical examination was normal. The laboratory examination showed an increased level of blood sugar, normal levels of serum amylase, renal function tests and liver function test (LFT). No attempt was made to establish the insufficiency of the exocrine pancreatic function. Chest X-Ray and ECG were normal.\nPlain radiology showed opacities in the middle and right upper quadrant abdomen (a). CT abdomen was performed to rule out other associated pathologies like pancreatic pseudocyst, pancreatopleural, pancreatogastric or pancreatocolonic fistulae as the surgical procedure would have been different in the presence of any of the complications. Contrast-enhanced abdominal CT scan revealed impacted stones at the ampulla within the distal bile duct and pancreatic duct. The remaining parts of the pancreas showed normal result with no associated features of chronic pancreatitis (b). Since the contrast-enhanced abdominal CT scan indicated impacted stones in the distal bile duct at the ampulla, MRCP was performed. Initial MRCP suggested stones within the main pancreatic duct (MPD) in the head of the pancreas and dilated common bile duct suggested stone in the distal part of it (c). |
A 68-year-old male with past medical history of coronary artery disease status post coronary artery bypass graft (CABG), aortic valve replacement along with replacement of the root of the ascending aorta 10 months prior to presentation and recent hemorrhagic cerebrovascular accident (CVA), came to the hospital with complains of acute onset of severe abdominal pain and melena for 1 day. He also attested to chronic abdominal pain and a 30-pound weight loss over the last 8 months prior to these acute symptoms. His physical exam on presentation was positive for severe bilateral lower abdominal tenderness. Apart from a hemoglobin of 10 mg/dl and a positive stool occult blood test, the rest of his basic lab work up was unremarkable (white blood cell/platelet count, comprehensive metabolic panel, and PT/INR included). Hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) testing were negative. The electrocardiogram (EKG) showed sinus rhythm and left ventricular hypertrophy (). An emergent computerized tomography (CT) scan of the abdomen revealed features suggestive of an embolic infarct in the left kidney (Figures and ) and within the mid-one-third of the superior mesenteric artery causing luminal narrowing and also suspected to be extending to the takeoff of small bowel branches. Segmental mural thickening of at least one small bowel loop was noted which strongly favored acute bowel ischemia as a cause of his abdominal pain (). Incidental findings on CT of the abdomen were also strongly suspicious for large eccentric thrombus in the ascending aortic graft and the aortic root which were further investigated and confirmed with a CT scan of the chest (). Cardiology and cardiothoracic surgery were consulted. A CT scan of the head was performed to assess the recent CVA and showed a subacute hemorrhage along the left-sided temporal parenchyma (). CT head imaging was obtained from the facility where the patient presented 3 months prior for cerebral hemorrhage and in comparison, to the most recent CT scan of the head, the hemorrhage appeared stable. The hemorrhage was suspected to be secondary to thromboembolism. After a review of the risks and benefits of anticoagulation to prevent extension of this suspected thrombus, heparin was initiated. An echocardiogram revealed dilatation of the ascending aorta and mild paravalvular leak around the bioprosthetic aortic valve. Gastroenterology was consulted and an emergent esophagogastroduodenoscopy was performed which was negative for any causes of upper gastrointestinal bleed. A hypercoagulable workup was performed which did not reveal any apparent cause of a prothrombotic state. Anticoagulation was held and subsequently, the patient underwent a redo sternotomy under cardiopulmonary bypass with extensive lysis of adhesions, removal of the thrombosed aortic valve and graft, ascending and proximal aortic arch replacement utilizing a 30 mm Dacron graft, and aortic valve replacement with a 25 mm Edwards Magna Ease bovine pericardial valve. The patient also underwent an explorative laparotomy as a part of a staged procedure to address the ischemic bowel caused by the presumed septic emboli. Intraoperatively, the patient was found to have a portion of small bowel that had become necrotic. The necrotic bowel was excised and an end to end anastomosis was performed.\nThe aortic graft and thrombus were sent for culture and pathology. Histopathological examination of the aortic graft and cusps of the aortic valve revealed chronic inflammation and was also notable for abundant acute angle branching septate fungal hyphae (). The patient was immediately started on amphotericin B and voriconazole pending finalization of cultures and sensitivities. On postoperative day four, three culture reports from the graft came back positive for dematiaceous mold, suggestive of Bipolaris species. The minimum inhibitory concentration (MIC) was 0.25 ug/dl for voriconazole and 0.03 ug/ml for amphotericin B. A decision was made to continue the same antifungal regimen on the basis of sensitivities and further speciation was not performed. Patient had a good postoperative course and was later discharged on amphotericin B and voriconazole for at least 1 month with continued follow-up with an infectious disease specialist. |
A 66-year-old female with a BMI of 26 had undergone a primary hybrid left total hip replacement with an ABG acetabular component and a size 35.5 cemented Exeter femoral component with a 22 mm metal head at the age of 48 for debilitating osteoarthritis. Aside from her arthritis, she had no other past medical history of note. There were no intraoperative complications and she made an uneventful recovery.\nSeven years later she noticed increasing pain in her left groin and was unable to weight bear on her left hip. She was found to have radiographic signs of aseptic loosening of the acetabular component of her left total hip prosthesis with accelerated wear of the polyethylene liner and secondary lytic changes in the acetabulum suggestive of loosening. As a result, she underwent urgent revision surgery aged 55. This was revised to a cemented Ogee cup with impaction grafting of the acetabulum. The femoral component was retained and the head changed. She made a good postoperative recovery; all intraoperative cultures were negative.\nShe subsequently also underwent a right total hip replacement for intractable osteoarthritis. After bilateral hip replacements she was independently mobile and led an active life. Radiographs obtained are shown in . Incidental findings of left bifocal pubic rami fractures were found at routine follow-up three years following her left hip revision without any history of traumatic injury. At follow-up aged 61 these fractures had healed and the patient continued mobilizing well.\nShe presented to our institution aged 66, 18 years after her original surgery (11 years after revision), with a 2-week history of worsening pain in her left hip. This had started insidiously without history of trauma. Although able to weight bear, her pain continued to worsen over 2 weeks. Examination findings showed moderate groin tenderness with good active and passive range of motion in the affected hip, with the patient being able to fully weight bear and do straight leg raise.\nRadiographic findings showed fracture of the left Exeter stem and adjacent proximal femur fracture shown in .\nShe underwent revision surgery with an extended trochanteric osteotomy, removal of the femoral component, and replacement with an uncemented, distally loading, tapered fluted stem. Intraoperatively, the Exeter stem was well fixed distally and there were no signs of loosening. The pertrochanteric area was significantly osteopaenic but showed a stable cement mantle. There were no signs of wear to the 22 mm polyethylene liner; the acetabulum was therefore not revised.\nThe patient made a good postoperative recovery. She was discharged home after 10 days of intravenous antibiotics pending the results of extended cultures which were negative. At follow-up she remained well and her mobility had improved. A postoperative AP radiograph is shown in . |
A 66-year-old female was admitted to our hospital in Kermanshah (Iran) in July 2013, with chest pain and congenital thymic cyst (CTC) and characteristic history of flushing and periorbital edema. Her symptom was not positional and was not exacerbated by breathing. Her medical history was remarkable and previous myocardial infarction events were reported. Routine blood tests were normal, and no tumor markers were found. Chest radiography was normal and routine echocardiography for heart revealed no abnormally. Her medical and family histories, clinical status and blood and urine tests, were unremarkable. Postoperative retrospective analysis of signs and symptoms revealed facial edema caused by intermittent obstruction of superior vena cava (SVC) by a cyst. Exploration of mediastinum was performed through a median sternotomy, resulting in a postoperative diagnosis of a mediastinal cyst. A soft and fluctuant cyst was present in the middle mediastinum in residual thymus tissue around the SVC and retro subclavian vein, and was easily dissected from these organs. No pedicle was attached to the inferior aspect of the cyst. The cyst had a thin wall and contained watery fluid. Judging from its anatomic location and contents, the cyst was diagnosed as a congenital cyst. The cyst was resected after dissection of the inferior surface in the left lateral aspect of SVC and retro subclavian vein in mediastinum (). As of the content of the cyst, the number of cells was few and the cell count revealed no lymphocytes. The fluid did not contain of triglyceride. Microscopically, the cyst wall consisted of thin fibrous connective tissue with monolayer cells on its luminal surface. Thus, the cyst was histologically compatible with the congenital thymic cyst ( - ). The patient’s postoperative course was complicated by a transudative left pleural effusion. It emerged on the first postoperative day, decreased gradually on the fifth postoperative day and dissolved spontaneously one week after the operation. The patient was discharged on the 12th postoperative day and had no symptoms eight months later. The surgical specimen was a solitary cyst with a fibrous thin wall, measuring 10 × 6 cm at its maximum width and length. Microscopically, the cystic walls were irregularly lined by keratinized squamous epithelium and focally flattened endothelium ( and ) with varying thickness, and contained scattered nests of thymic tissue including small lymphocytes and epithelial cells. These findings were consistent with a thymic cyst, and the macroscopic features indicated a congenital type. |
A 40-year-old previously healthy woman was admitted to the Service of Plastic Surgery in February 2000 because of an enlarging anterior midline neck mass she had noted some months before. In the previous 2 months the neck mass had been rapidly growing in size. Medical history included a cerebral trauma owing to a car accident, depression treated with fluoxetine and uterine fibroma. The patient had not been previously exposed to radiation or other known carcinogens. Familiar medical history was negative for thyroid gland or neoplastic diseases. Physical examination revealed a painless well-demarcated mass of about 6 cm localized in the midline of the neck above the thyroid gland covered by skin without any signs of inflammation and/or trauma. The thyroid gland was apparently normal in size and consistence and no significant cervical adenopathy was found at physical examination. At entry serum chemistry tests, electrocardiagram and chest X-rays were normal. A neck ultrasonography identified a 4 cm cyst above a slightly enlarged thyroid gland without any significant alteration. A Sistrunk surgical procedure was then performed and a mass of 5 cm was removed including the entire duct from the gland to the level of the foramen cecum and the middle portion of the hyoid bone (Figure ). A small 1 cm wide lymph node close to the cyst was also surgically removed. Post-operative follow-up was uneventful.\nGross examination of the surgical specimen showed a cystic mass of about 3 cm in greatest dimension with a smooth external surface. Microscopic examination showed the presence of papillary carcinoma with small areas of follicular carcinoma inside the thyroglossal duct cyst and metastatic disease in the adjacent lymph node. Further staging with neck sonogram showed an enlarged thyroid gland with a pattern suspicious for neoplastic disease subsequently confirmed by fine-needle aspiration biopsy. CT scan failed to identify distant metastatic disease. The patient underwent total nerve-sparing thyroidectomy with neck lymphoadenectomy. No significant post-surgical complications were recorded and the surgical wound healed regularly. Pathological examination showed a multinodular, moderately differentiated papillary and follicular carcinoma of the thyroid gland with focal invasion of the capsule and metastases in four neck lymph nodes. The main neoplastic nodule has a diameter of 1.8 cm. Post-operative staging according to the TNM classification was pT4b N1a M0. Surgical procedures were followed by iodine scan and radioactive iodine therapy with 131I ablation. Thyroid hormone replacement therapy was given regularly. In May 2003 evidence of iodine positive metastatic neck nodes was confirmed by fine-needle aspiration biopsy. Thyroglobulin levels were very high (355 ng/ml). The patient was rechallenged with 131I radioactive iodine therapy. To date the patient is still alive after 4 years. |
The patient is a 47-year-old male. He was found to have space-occupying lesions on both kidneys during routine physical examination and presented to our hospital for diagnosis and treatment. Laboratory test results including those for thyroid function were within normal ranges. Abdominal computed tomography revealed a relatively homogeneously enhancing mass in the lower pole of the left kidney (4 cm in its greatest dimension) and a cystic lesion in the right kidney (). Part of the wall of the right renal cyst was surgically removed, and intraoperative pathological examination was performed. Histology showed cells arranged in a single or multiple layers, which could be seen in some areas of the cyst wall. Cellular atypia, nucleoli, and mitosis were not obvious (). Obvious necrosis and hemorrhage could be seen in another area, and the fibrous tissue in the cyst wall was perforated; some suspicious infiltrating glands could also be seen in the fibrous stroma (). We suspected cystic renal cell carcinoma. To preserve some kidney function, the patient underwent partial nephrectomy of the right kidney with nephron preservation and left radical nephrectomy. According to the postoperative pathology examination, we observed follicular architecture with micro- and macrofollicles containing eosinophilic secretions or colloid-like material in another area of the right renal cyst wall (). The follicular cells contained moderate eosinophilic cytoplasm and round nuclei (). The left renal tumor was a typical clear cell renal cell carcinoma (). Immunohistochemistry revealed that the tumor cells of the right kidney tumor were positive for cytokeratin 7 (CK7) () and paired Box 2 (PAX2) () but were negative for transcription termination factor 1 (TTF1) (), thyroglobulin (TG), and synaptophysin (Syn). There was no evidence of a mass in the thyroid gland or enlargement of regional lymph nodes on ultrasonography of the neck. Therefore, the right renal tumor was finally diagnosed as thyroid-like follicular renal cell carcinoma with cystic changes, while the left kidney tumor was diagnosed as clear cell renal cell carcinoma. The patient did not receive postoperative adjuvant treatment. He was discharged five days after the procedure, and his serum creatinine level was 110 µmol/L at discharge. At the time of this writing, the patient is 10 months post-treatment with no clinical or histological evidence of recurrence. |
A 22 year old unmarried female, a third year medical student with nil significant family history and a well adjusted premorbid personality had been experiencing sleep onset insomnia for twenty days prior to her exams. She would not sleep till 1 AM and would get up late in the morning. She bought over the counter medication tablet ZPD 10 mg after having seen her consultant prescribe the same for insomnia. After consuming a 10 mg tablet of ZPD, she sat on the floor mat along with another colleague of hers for studying till she felt sleepy. About 30 minutes later she complained to her friend that the letters appeared to be shaking and going out of order. She reported that words no longer stayed in a straight line but appeared in disarray. Few minutes later she raised her hand to alarm that she was about to sink. Following this she had a very weird experience.\nShe felt to be in a lake and surrounded by water; floating with her friend on a boat and her body was bouncing up and down and the surrounding had assumed a bright orange hue. She was very frightened, held her friend asking for help and requesting to park at lakeside.\nThey stopped studying and her friend tried to convince that no such thing is occurring, and took her to TV room. She reported that the characters are coming out of the TV (that was switched off) and she tried to approach them; was talking to them as if they were in their room and unable to delineate with her surroundings though she was oriented to time and to her friend. There was no report of unusual experience in touch, pain, temperature or other modality. The friend convinced her and took her to bed and she fell asleep after 10 minutes. The next morning she had memories of the same and could recollect the events and consulted the physician. On assessment there was no evidence of physical illness, other substance abuse, nightmare or night terror or any other psychiatric disorder or any other concomitant medication use. Assessment of causal association with World Health Organization probability scale and Naranjo’s Algorithm (score=8) revealed a “probable” association of this adverse event with ZPD., She was prescribed tablet nitrazepam 5 mg at bedtime till her examination got over. Her sleep improved without any significant adverse event. After four weeks nitrazepam was tapered off over next two weeks. She was advised to avoid use of ZPD in future, practice sleep hygiene and relaxation techniques. |
A 49 year old woman complained of abdominal pain in November of 2015 with diagnosis of large uterine fibroid, a myomectomy from within the uterus was performed. No malignancy was associated with the specimens recovered. In December of 2016, the abdominal pain persisted and a mass was palpable on physical examination in the mid-abdomen on the right. Colonoscopy was performed and biopsy showed a moderately differentiated adenocarcinoma of the caecum.\nCT was performed in December of 2016 and the primary right colon malignancy along with bilateral ovarian metastases were imaged. Percutaneous biopsy of the right ovarian mass showed well differentiated adenocarcinoma consistent with a colonic primary. From December of 2016 through December of 2017, the patient was maintained on chemotherapy. Initially, she was treated with FOLFOX. After four cycles, because of neuropathy, the oxaliplatin was stopped. The patient was maintained on 5-fluorouracil and bevacizumab.\nIn December of 2017, a CT documented marked regression of the primary tumor. It was not visible by CT. However, multiple lymph nodes within the mesentery of the distal small bowel were enlarged. Also by CT a pelvic mass showed that the right ovary had increased in size to 15 cm in greatest diameter despite the fact that the primary caecal malignancy was no longer visible by CT.\nOver approximately one month the patient became rapidly more symptomatic with abdominal distention from ascites and an expanding right ovarian mass. On February 1, 2018 the patient underwent cytoreductive surgery and HIPEC in a specialized center for management of peritoneal metastases. At the time of surgery she underwent a greater omentectomy, hysterectomy, bilateral salpingo-oophorectomy, complete pelvic peritonectomy, right colon resection, and small bowel resection. She received HIPEC with mitomycin C and doxorubicin with systemic fluorouracil. In order to determine if the multiple enlarged lymph nodes within the small bowel mesentery were involved by cancer, individual lymph nodes were removed and subjected to histopathologic study by permanent sections at a later time. A portion of each of these lymph nodes was sent for pharmacologic analysis for doxorubicin content. shows the pharmacokinetics of intraperitoneal doxorubicin in peritoneal fluid, mesenteric lymph nodes, and plasma. Clearly, the lymph nodes have taken up large amounts of doxorubicin nearly equal to that which was seen within the peritoneal fluid. The increased amounts of doxorubicin within lymph nodes as compared to the plasma can be measured by the area under the curve ratio. The ratio of lymph nodal tissue concentration times time to plasma concentration times time was 40. The area under the curve ratio (AUC ratio) of peritoneal fluid to plasma was 80.\nAfter the HIPEC chemotherapy and biopsies, an end-to-side coloenteric anastomosis was performed. The patient required a 3-week hospitalization and was discharged eating well and having normal bladder and bowel function. Pathology showed cancer in the right ovary and small amounts of cancer remaining at the primary site. No cancer was present in the mesenteric lymph nodes. |
This 35 year old woman began noticing increasing fatigue in 2014. The fatigue and left lower quadrant pain became increasingly severe so that she went an emergency room. On 19 February 2018, a CT scan was performed that showed an infiltrate into the greater omentum and multiple nodules associated with small bowel mesentery. There was no ascites. Masses were present on both the right and left ovaries. On 14 March 2018, she was taken to the operating room where multiple biopsies were taken. Her left ovary and appendix were removed. Pathology showed a mature cystic teratoma and extensive malignant peritoneal mesothelioma. Multiple biopsies from omentum, surface of uterus, peritoneum from the abdominal wall, and peritoneum from the small bowel showed malignant peritoneal mesothelioma.\nRepeat CT on 2 May 2018 showed malignant peritoneal mesothelioma infiltrating the omentum and accumulating as a diffuse mass in the pelvis. The small bowel mesentery showed multiple prominent lymph nodes. For definitive treatment of her malignant peritoneal mesothelioma, the patient was taken back to the operating room on 3 May 2018. At that time she had a greater and lesser omentectomy, cholecystectomy, pelvic peritonectomy with hysterectomy and right oophorectomy along with cytoreductive surgery of the small and large bowel surfaces. HIPEC was performed with cisplatin, doxorubicin, and systemic ifosfamide with Mesna (2-Mercaptoethanesulfonic acid sodium). During the HIPEC procedure Mayo scissor dissection removed a layer tumor from large and small bowel surfaces along with large and small bowel mesenteric surfaces []. In order to rule out disease within the mesenteric lymph nodes, six of these lymph nodes were harvested during the HIPEC chemotherapy []. Portions of the node were sent for histopathologic analysis and other portions were sent for pharmacologic analysis of the intraperitoneal drug, doxorubicin. The results of the doxorubicin within blood, peritoneal fluid, lymph nodes, and tumor are shown in . The area under the curve ratio of lymph node doxorubicin to plasma doxorubicin was 30. The area under the curve ratio of tumor nodules to plasma was 20 and from peritoneal fluid to plasma was 50.\nAgain in this patient the markedly increased levels of doxorubicin in lymph nodes as compared to plasma were documented.\nThe patient was hospitalized for 15 days and was discharged eating well. An intraperitoneal port was placed at the time of the cytoreductive surgery and will be used to deliver long-term intraperitoneal pemetrexed with systemic cisplatin. Six cycles of treatment are planned. Pathology of resected specimens showed malignant peritoneal mesothelioma; the lymph nodes were negative for cancer. |
A 50-year-old female reported to the Periodontology Department of our College with a complaint of dull pain on her left side of the lower jaw, which radiated to her neck since 2 years. The pain was generalized in nature and she felt it to be arising from the gums and deep within the lower jaw. It was intermittent in nature, recurring 2–3 times in succession in the past 3 months and had worsened for the past 15 days. It aggravated on bending forwards and flexing the neck. She also complained of loose teeth in her mouth but said the teeth were not hurting. Medical history revealed that the patient had hypertension and was on tab atenolol 10 mg once daily for the past 2 years. She was also a diagnosed case of type-II diabetes mellitus (fasting blood glucose level was 260 mg/dL) and was on oral hypoglycemic, tablet glibenclamide 500 mg once daily. The patient gave no history of any past trauma.\nOn extraoral examination, no abnormalities were detected with the temperomandibular joint and the regional lymph nodes were not palpable. However, the submandibular areas were tender on palpation bilaterally. Mouth opening was adequate, but patient reported irritation in her throat on opening the mouth wide. Intra-oral examination revealed presence of plaque and calculus. There was generalized bleeding on probing and deep periodontal pockets indicating generalized chronic periodontitis and the pocket formation were more in the maxillary than in the mandibular arch. The maxillary right first and second premolars showed Miller's Grade III mobility. Based on these clinical findings the case was diagnosed as generalized chronic periodontitis. An orthopantomogram (OPG) was taken, which revealed generalized alveolar bone loss and the mandibular right first molar showed advanced periapical bone destruction. Both the maxillary third molars and the mandibular right third molar were impacted. The OPG also revealed the presence of bilateral elongated styloid processes []. A lateral cephalogram was also taken to ascertain the presence and extent of the elongated styloid process []. However, re-examination and palpation of the tonsillar fossae could not detect any bony protuberances. Based on the clinical and radiographic findings, it was established as a case of Eagle's syndrome with associated generalized chronic periodontitis. Following phase-I therapy, the patient was kept under periodontal maintenance and simultaneously she was referred to the Department of Oral and Maxillofacial Surgery and Otorhinolaryngology for the management of the elongated styloid processes. |
A 20-year-old, female university student presented to our outpatient orthopaedic clinic with a two month history of vague pain on the outer border of both legs, and numbness over the dorsum of the feet and big toes. Her symptoms were exacerbated by walking and running and partially relieved by elevation. She had to stop to rest after 30 minutes of walking because of intolerable pain.\nThere was neither history of trauma or surgery to the lower limb nor history of lower back problems. There was, however, a history of severe weight loss of (30 kg) during the previous six months and the patient was diagnosed with anorexia nervosa using criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).\nPhysical examination revealed bilateral tender points approximately 11 cm proximal to the ankle joint on the outer surface of the leg, Tinel sign was also positive bilaterally. There were sensory deficits on the dorsum of both big toes but no muscle weakness or abnormal reflexes.\nExamination of the lumbar spine and lower limbs revealed no clinical abnormalities in the joints and there was neither suspicion of nerve root compression at the level of the lumbar spine nor nerve entrapment at the neck of the fibula.\nRadiographic examination of the lumbar spine, legs and feet were normal and EMG studies were positive for bilateral entrapment neuropathy of the SPN proximal to the ankle joint with no abnormality of the common peroneal nerves or of the proximal nerve roots.\nAfter preoperative assessment, the patient was admitted for surgical treatment with the diagnosis of SPN entrapment. The operation was done under general anaesthesia, using pneumatic tourniquet. Bilateral explorations of the site of tenderness revealed adhesions of both SPNs to the fascia with perineural fibrosis. Careful dissections were done to free the nerves and neurolysis was successfully performed (Figure ). The nerves were freed distally and proximally by splitting the overlying fascia for a few centimetres above and below the site of entrapment.\nSymptoms of bilateral peroneal nerve entrapment were relieved immediately and completely in the postoperative period. Physiotherapy was started immediately to prevent postoperative adhesions. No recurrence was observed in the first year following the operation. |
A 58-year-old male patient presented with high-grade fever, myalgia, and shortness of breath and proved to be COVID-19 positive on the 16th of May 2020. The patient's clinical condition rapidly deteriorated on the second day of admission due to severe pneumonia that required mechanical ventilation support after failure of the conventional support including prone position. He was started on azithromycin 500 mg intravenous, tocilizumab 600 mg intravenous single dose, hydroxychloroquine 400 mg tablets once a day, and methylprednisolone 40 mg twice daily (for five days for all). He developed acute kidney injury requiring renal replacement therapy in the form of sustained low-efficiency dialysis (SLED) through a right femoral vein central line due to hemodynamic instability on the 19th of May. The patient developed deep vein thrombosis on the same side of the hemodialysis catheter despite the prophylaxis with low molecular heparin. A second central line using the left internal jugular was placed under ultrasound guidance on the 24th of May. When the patient was connected to the hemodialysis machine, the venous pressure was high which indicates possible arterial flow. Another line was inserted on the 25th of May on the right internal jugular using ultrasound guidance, and at this time, it worked well (). The left internal jugular catheter was removed, and pressure dressing was applied ().\nThe patient developed left upper arm and supraclavicular swelling, and his hemoglobin dropped by 4-5 to 5 g from the initial 9.5 g. The patient was stabilized by fluid resuscitation and blood transfusion. No melena or any sign of active bleeding was identified. The patient was extubated on the 1st of June, breathing well with retrosternal chest pain with elevated troponin level which was diagnosed as myocardial infarction type II that was treated conservatively. He also had left shoulder pain and was unable to move his left arm; orthopedic consultation was requested and the plan for conservative management as no obvious radiological orthopedic insult.\nA CT scan of the abdomen and upper chest was done to rule out the source of bleeding on the 2nd of June. CT scan confirmed evidence of large intramuscular and extramuscular hematoma involving the muscle of the left side of the chest wall extending to the lateral aspect of the abdominal wall, and there was no intra-abdominal free fluid or collection. The CT scan was limited to the upper chest and abdomen but did not cover the neck and the supraclavicular area. There was a plan for another CT scan of the neck and upper chest, but because of acute kidney injury and risk of more nephrotoxicity, the CT scan was postponed until the 9th of June when his kidney function improved and his last hemodialysis was on the 7th of June. CT angiogram for the head, neck, and chest revealed a large homogenously hyperdense sac-like structure with a tongue projecting superiorly noted posterior to the left clavicle and in close proximity to the anterior wall of the proximal part of the left subclavian artery possibly arising from it with narrow neck, measuring 2.1 × 3.5 × 4.5 cm (). It was seen associated and surrounded with large mixed density area extending from the left lower neck opposite the level of epiglottis towards the left axilla, subscapular region, lateral chest wall, and the left upper abdominal quadrant approximately more than 25 cm in craniocaudal dimension and 8 cm in maximum transverse dimension in the lateral chest wall with more heterogeneous density inferiorly. The rest of the left subclavian artery appeared stretched by the hematoma but otherwise patent. The left internal jugular vein was significantly attenuated and could not be seen in the lower neck. Ultrasound showed pseudoaneurysm originating from the subclavian artery (Figures and ).\nVascular surgery consultation was done on the 12th of June regarding the large hematoma extending from the neck to the left side of the chest. Attempt to evacuate the pseudoaneurysm was postponed because of the fear of rupturing the pseudoaneurysm. The left arm was flaccid with no movement; however, pulses over the brachial and radial arteries were palpable with no sign of ischemia.\nThe patient was transferred from the COVID facility to the tertiary hospital for management of the pseudoaneurysm on the 13th of June with full infection control precautions taken, as the patient's COVID test remained positive for 6 weeks. Due to his general condition and extent of the hematoma, the plan was to use ultrasound-guided thrombin injection of the pseudoaneurysm. This was done under general anaesthesia to reduce the risk of coronavirus transmission in case of the need to proceed with open surgical repair for the pseudoaneurysm. On the 15th of June, under ultrasound guidance with complete aseptic technique and local anaesthesia, micropuncture set was used to puncture the left brachial artery. Using Seldinger technique, access of the aortic arch with a 6-French sheath was obtained. Flush aortic angiogram was done using a 4-French pigtail catheter; it showed pseudoaneurysm arising from the proximal part of left subclavian artery distal to the origin of left vertebral artery and left internal mammary artery (Figures and ). Mapping of the neck of pseudoaneurysm was done, and an 8 mm × 3 cm balloon was used to cover the pseudoaneurysm neck. Bedside ultrasound documented the absence of the flow within the pseudoaneurysm by inflating the balloon (). After inflation of the balloon, injection of 2000 U of thrombin was done under ultrasound guidance (). Follow-up left subclavian angiogram showed good opacification of the left vertebral artery and internal mammary artery with nonopacification of the pseudoaneurysm (). The sheath was removed, and manual compression for 10 minutes was applied at the puncture site. Postcompression ultrasound of the left brachial artery showed good flow distally with no hematoma. Radial and ulnar pulses were intact.\nThe patient was extubated 2 days after the procedure; however, he had no movement in the left arm which was considered secondary to the compression of the brachial plexuses from the hematoma which was confirmed by electromyography (EMG) and nerve conduction studies (). On the 24th of June, the patient was taken to the operating theatre for evacuation of 1.5 litres of hematoma through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient was offered surgical reconstructions for the brachial plexus (grafting and transfer) but he declined. Despite that, the patient's flaccid paralysis did not recover during the three months of follow-up. |
A 52-year-old male epileptic patient was brought to our tertiary care hospital with uncontrolled seizure. He had history of focal epilepsy since 5 years and was on antiepileptic medication. He was on carbamazepine, with a total dose of 1000 mg per day, since 1 year. He was apparently doing alright for some time and his quality of life had improved on carbamazepine. However, the seizures recurred once in every 2-3 weeks for the last 3 months because of which he was admitted in neurology department for further management and drug optimization.\nHis general physical examination was normal. There was no history of prior behavioral problems or cognitive deficits. There was no family history of psychotic disorder. His blood investigations for electrolytes, renal function test, thyroid, liver function and other related tests were within normal limits. His computed tomography (CT) scan of brain showed left frontal calcified lesion suggestive of cysticercosis. His CT brain with contrast showed no further new or active lesions. His EEG was normal. His serum carbamazepine level was 10 μg/ml.\nIn view of his poor seizure control and serum carbamazepine level reaching the upper limits of normal, he was added on LEV with an initial dose of 250 mg twice a day and was planned to increase the dose gradually over 2-4 weeks to reach a dose up to a total 1000 mg per day. However, by day 3 the patient developed severe behavioral abnormality characterized by agitation, emotional liability, hostility and depersonalization. He was evaluated by the psychiatrist and was diagnosed as acute psychosis. His mental state examination was normal except for abnormal mood and thoughts. Psychiatric assessment revealed features of depression, mood and thought abnormality, suspicious and withdrawal state with visual hallucination suggestive of psychosis. Delirium was ruled out as there was no fluctuation in sensorium, focal deficits and meningeal signs. As mentioned earlier, the lab investigations were done to rule out metabolic causes of this clinical presentation.\nConsidering the possibility of drug induced psychosis, LEV was withheld. Within 48 hours, the patient recovered from psychosis, without any treatment. Later, he was added on valproic acid for the management of seizures. The adverse drug reaction causality assessment was done using the Naranjo scale.[] The causal analysis showed a probable association (score 5) of the reaction with LEV. |
A 51-year-old man was admitted to our surgical unit with a diagnosis of chronic pancreatitis. He was suffering from episodes of continuous abdominal pain for the last one year. The pain was radiated from the right upper quadrant of the abdomen to the back and was associated with nausea, partially relieved by injectable analgesics and aggravated by food ingestion. This challenge led to the loss of appetite then to weight loss which also worsened by the presence of occasional episodes of malabsorption and the development of insulin dependent diabetes mellitus. There was no family history of the similar condition in parents, siblings or first-degree relatives.\nMoreover, there was no history of abdominal trauma in the past. The patient had a history of admissions to different hospitals for the recurrent pain attacks. However, apart from this illness, he had never been to hospitals for any other medical or surgical condition. He was on analgesics, insulin therapy, and pancreatic enzyme supplementation and had never been allergic to the exposed medications.\nThe physical examination showed an emaciated man looking older than his chronological age, appeared pallor but no clinical evidence of jaundice. Abdominal examination was normal. Chest examination found no remarkable findings, and the rest of the physical examination was normal. The laboratory examination showed an increased level of blood sugar, normal levels of serum amylase, renal function tests and liver function test (LFT). No attempt was made to establish the insufficiency of the exocrine pancreatic function. Chest X-Ray and ECG were normal.\nPlain radiology showed opacities in the middle and right upper quadrant abdomen (a). CT abdomen was performed to rule out other associated pathologies like pancreatic pseudocyst, pancreatopleural, pancreatogastric or pancreatocolonic fistulae as the surgical procedure would have been different in the presence of any of the complications. Contrast-enhanced abdominal CT scan revealed impacted stones at the ampulla within the distal bile duct and pancreatic duct. The remaining parts of the pancreas showed normal result with no associated features of chronic pancreatitis (b). Since the contrast-enhanced abdominal CT scan indicated impacted stones in the distal bile duct at the ampulla, MRCP was performed. Initial MRCP suggested stones within the main pancreatic duct (MPD) in the head of the pancreas and dilated common bile duct suggested stone in the distal part of it (c). |
A female patient, aged 71 years, was admitted to the Department of TCM in General Hospital of the PLA due to frequent urination and odynuria over 10 years on December 7, 2011. Since the autumn of 2001, the patient complained of frequent urination with no obvious cause. The number of urination during the day was 3 to 4 times per hour (averaging 15–20 minutes), and up to 18 times at night, which had a great negative influence on the quality of sleep in the patient. Subsequently, the patient had odynuria and pain at the site of episiotomy scar. The patient visited the clinic of the work unit for intravenous injection of antibiotics drugs, without obvious effect. A few months later, the patient visited the Department of Urology in Beijing. A polyp was observed during urethra examination, which was then treated by laser excision. The symptoms were still not improved after several courses of physical therapy. In November 2002, an operation was carried out at the site of episiotomy scar, and it was found to be inflammation of muscle tissues at wound site after opening. The patient was given antibiotics and external application of estrogen postoperatively. One month after operation, the patient perceived aggravated pain and restless that affected physical activity. Consequently, the patient visited the Pain Department and was provided with acesodyne to relieve pain. However, the symptom of pain was still not totally relieved. Accordingly, the patient sought medical advices even from folk prescription for years, but was not cured. On September 30, 2011, the patient was admitted to the Department of Urology in Beijing. A routine urine test was performed, and white blood cells were found throughout the visual field under the microscope. Simultaneously the patient still took antibiotics and estrogen after the examination, but had no obvious curative effect for 3 to 4 months. On December 7, 2011, the patient sought TCM treatment in TCM Department of General Hospital of the PLA.\nOn TCM observation, the patient had burning pain in the urethra, lower abdominal pain, and occasional lumbago. Routine urine test was conducted and revealed that leukocytes were found throughout the visual field. Tongue diagnosis revealed pale red tongue, thick white tongue fur and pulse string. Diagnosis of TCM was Stranguria, deficiency of kidney Qi, and evil heat depressed internally. Rules of treatment: Invigorating Qi and tonifying the kidney, as well as clearing away damp-heat material. The Chinese medicines (Table ) were decocted in water for oral dose, 1 dose each day and 2 times a day.\nAfter 1 month of Chinese herbal medicine (CHM) treatment, relevant symptoms were reduced gradually, and there was no obvious abnormality in routine urine test, but the patient still complained of pain in the urethra, urinary stammering and frequent urination. Tongue diagnosis was pink tongue, yellow coating of the tongue fur, and pulse string. Syndrome differentiation of TCM and rules of treatment were similar to those before. Prescription for promoting Qi circulation to relieve pain was added to the original prescription, with the addition of 15 g Corydalis Yanhusuo.\nAfter that, the patient visited the outpatient department for re-examination every 2 weeks. Until in November 2012, the patient reported the disappearance of frequent urination and odynuria, and the condition remained stable except the occurrence of poor digestion. TCM syndrome differentiation indicated diet stagnation, indigestion, and anorexia. Therefore, 15 g processed Massa Medicata Fermentata and Endothelium Corneum Gigeriae Galli was supplemented in the original prescription. The series of urinalysis leukocyte, red blood cell, and pH before and after TCM treatment is summarized on Figure . The patient was ordered to pay attention to diet, regular daily life, and avoid anxiety. Late follow-up was continued to November 2017, and the patient recovered and was in stable condition without recurrence. |
A 20-year-old female presented at our outpatient department with a complaint of pain persisting for 12 months in the right knee. The pain that was mild at the time of symptom onset became slightly worse at night without association with knee effusion or swelling. She had no definite history of trauma and denied any medical history of rheumatoid arthritis or any other arthritic diseases. A year before this presentation, she visited another hospital for the same symptom where plain radiography and magnetic resonance imaging (MRI) of the knee were performed. The patient knew plain radiographs showed normal findings but MRI revealed a widespread signal change in the subchondral bone of the lateral femoral condyle. The initial diagnosis was bone bruise of the lateral femoral condyle, and she was treated conservatively using intermittent nonsteroidal anti-inflammatory drug medication and physical therapy, which did not result in pain relief.\nWhen the patient presented at Dongguk University Gyeongju Hospital, she complained of pain in the anterolateral aspect of the right knee, but joint effusion or tenderness was not evident and the range of knee motion was normal. McMurray and instability tests were negative, and laboratory findings were within normal ranges. Simple radiographs of both knees showed no specific bony abnormality, but the MRI showed a 6 mm × 3.5 mm × 3 mm sized intermediate-low signal intensity nodular lesion on the T1-weighted image and a nodular lesion with central intermediate-low signal intensity surrounded by high signal intensity in the anterosuperior subcortical area of the lateral femoral condyle with adjacent bone marrow edema on the T2-weightedimage (). Computed tomography (CT) of the right knee demonstrated a 5 mm × 3 mm × 3 mm sized lesion with the central nidus and perinidal sclerosis in the anterolateral subcortical area of the distal femur (). Bone scan showed increased uptake at the site corresponding to the lesion in the distal femur (). A diagnosis of osteoid osteoma of the distal femur was established and an arthroscopically assisted excision was scheduled.\nAn arthroscopic examination of the knee was carried out through the standard anterolateral and anteromedial portals, which showed normal meniscus, cruciate ligaments, and articular cartilage, but a slightly elevated lesion of synovium at the bottom of the suprapatellar recess near the superior articular margin of the lateral femoral condyle (). Synovial hyperplasia was minimal. With a 20-gauge needle held in place, C-arm imaging () was performed to confirm the correct location of the lesion identified on CT and plain X-ray images using the image tracing technique. Additional superomedial and superolateral portals were made and the synovium over the lesion was then removed using a punch forceps, an electrocautery device, and a shaver (). The elevated sclerotic rim was removed using small curved osteotomes, and a grossly reddish, dense nidus of osteoid with interconnected trabeculae was observed (). The lesion was excised using small curved osteotomes and arthroscopic curettes and harvested for histopathologic examination (). Reactive bone walls were completely removed using a motorized burr, and complete lesion removal was confirmed arthroscopically through the anteromedial, anterolateral, superomedial, and superolateral portals (). Bone grafting was not performed for the bone defect. Postoperative radiographs and CT confirmed complete removal of the nidus (). Histopathology of the curetted bone specimen confirmed the diagnosis of osteoid osteoma (). The patient recovered uneventfully and pain disappeared immediately after surgery. At the 24 months follow-up, the patient was symptom-free and there was no clinical or radiographic evidence of recurrence of the lesion.\nThe patient provided consent for publication of this case report and accompanying images. |
A 23-year-old female was transferred to emergency department from local hospital, one week after blunt trauma at popliteal fossa while playing with her friends. She reported acute pain in her left knee. On physical examination, her left lower limb showed no evidence of acute ischemia, such as paleness, coldness, or weak presence of a dorsalis pedis artery pulse. According to simple X-ray, there was only soft tissue swelling, with no evidence of knee dislocation, such as posterior subluxation of the proximal tibia. MRI showed bicruciate ligament injury and mild occlusion of popliteal artery at the knee level ().\nTo evaluate the integrity of the popliteal artery, we immediately performed a CT angiography, which showed complete obstruction of popliteal artery, and fortunately, well developed medial genicular artery showing good collateral circulation at the knee joint (). We performed an emergency surgical intervention to salvage the ischemic limb. While exploring the popliteal artery of the left knee, there was thrombotic occlusion from just distal to superomedial genicular artery branch to just proximal to the trifurcation level, and arteriotomy showed 8 cm long tear of intima. She underwent excision of damaged artery, and graft interposition was done by using a reversed saphenous vein graft because thrombectomy and intimal repair were thought of high recurrence of thrombotic occlusion. And then, to acquire stability of the knee joint, posterior cruciate ligament (PCL) reconstruction with a achilles tendon allograft by inlay technique was performed (). Slightly decreased dosalis pedis arterial pulses were postoperatively recovered immediately. Twelve hours after surgery, the anticoagulant was started and maintained until 1 year after surgery, heparin for one week after surgery and warfarin thereafter. Rehabilitation schedule was delayed one week to confirm the circulation persistence after anastomosis. Follow up CT angiography was carried out one week after surgery and showed satisfactory arterial flow without any complication such as postoperative stenosis, pseudoaneurysm and thrombotic occlusion (). Active quadriceps knee motion exercises from 90° to 0° were begun at postoperative one week later. Knee flexion was limited by an adjustable hinge brace and gradually progressed to 110° by five weeks, 120° at seven weeks, and 135° by nine weeks. Patients were allowed toe-touch weight-bearing only until quadriceps control was obtained. At the one year follow up, she could get good stability of her left knee with full range of motion and the doppler examination of the vessel flow revealed normal popliteal flow with a normal brachial/tibial index () and CT angiograph showed normal flow (). |
A 29-year-old male with a diagnosis of type I osteogenesis imperfecta presented to our emergency room with a painful right knee and inability to extend his knee. He had fallen of a folding chair that collapsed when he tried to sit down. This had caused a forced hyperflexion injury of his right knee.\nHis past medical history was significant for numerous fractures of both upper and lower extremities. He had sustained bilateral transverse patella fractures 13 years prior to the present injury. These had been treated with suture repair. He also had sustained an avulsion of the inferior pole of the right patella that was treated with suture fixation 3 years prior. He had done reasonably well but then sustained a new injury to this right knee and was diagnosed with a transverse non-union of the patella. It was unclear if this had been in existence since the initial suture fracture repair 13 years prior. He had developed a 20 degrees extension lag of his knee but was still able to do a straight leg raise. Because of the CT finding of the non-union, he was offered surgery but given his minor symptoms and upcoming school exams he declined surgery.\nHis past medical history also included scoliosis correction T4-L5, operative repair of a left and right (including revision and later hardware removal) olecranon fracture, and a distal humerus fracture. His medication at the time of his presentation included bisphosphonates (risedronate/calcium 35 mg once every week) which he had been taken for years. All his previous orthopedic care had been done at another academic hospital.\nWhen we first saw him, plain radiographs and a CT of his right knee were obtained (). These showed a comminuted fresh fracture of the upper half of the right patella proximal to a long-standing transverse non-union. The non-union had sclerotic edges and a gap of approximately 4 mm. Given his inability to extend his knee, we offered surgical repair and, at the same time, an attempt at fixing the long-standing non-union. After discussing the alternative of only fixing the fresh fracture, the patient chose to address surgically both the fracture and non-union with use of homologous bone graft.\nSurgery was performed under general anesthesia with the patient in supine position on a radiolucent table. A tourniquet was used. The knee was brought in 20–30 degrees of flexion. The old longitudinal incision of 15 cm was used, extending from the tibia tubercle to 3 finger breadths above the superior pole of the patella. Old suture material was removed. There were no signs on infection. Five deep tissue cultures were taken after which the tourniquet was deflated briefly, and he was given IV antibiotics (Cefazolin 2 gr). A lateral parapatellar arthrotomy was done originating from the tear in the lateral retinaculum. The patella was now inverted to directly visualize the comminuted articular surface. The fracture hematoma was irrigated and debrided. The non-union was identified in the lower half of the patella. There was a clear soft spot but the two parts of the non-union were bridged by non-osseous tissue. The non-union was not opened. With a 1.5 mm drill starting from the fracture side, we made a few drill holes perpendicular through the stiff non-union until blood was noticed to egress from the drill holes. We then first reduced the two parts of the comminuted superior aspect of the patella. This was done using curettes, dental pick, irrigation, and suction and pointed reduction clamps. Perfect alignment was obtained as visualized on the articular surface. The fragments were temporarily transfixed with 1.25 mm K-wires.\nA cannulated titanium headless screw (mini Acutrak, Hospital Innovations, Belgium) was then used to fix the two large upper pole fragments. The K-wires were removed. Next this reconstituted superior fragment of the fracture was reduced to the inferior part of the patella including the non-union using two large-pointed reduction clamps and temporary K-wires. From distal two 4.7 mm cannulated headless titanium screws (Acutrak, Hospital Innovations, Belgium) were placed through the non-union from inferior to superior crossing the fracture. Care was taken to bury the screws within the bone as not to irritate the quadriceps or patellar tendon. A figure-of-eight 1 mm steel cerclage wire was then placed through these two 4.7 mm screws, twined, and tightened. The K-wires and reduction clamps were removed. A 2.4/2.7 mm steel Mesh plate (DePuy Synthes, Amersfoort, The Netherlands) was then cut to fit over the dorsal side of the reconstructed patella and fixed with unicortical 2.7 mm locking screws. Each major fragment was fixed by the mesh plate without encroachment of the hardware on the superior and inferior tendinous parts. The superior limb of the plate was placed under the quadriceps, where the inferior part was placed under the patella tendon. Screw placement was observed to be extra-articular through the lateral parapatellar arthrotomy. Two non-absorbable no. 2 sutures were placed through the superior and inferior portion of the plate and then passed through the patellar tendon as a Krackow suture. These sutures were tied with the knee in extension. The retinaculum, subcutaneous tissues, and skin were closed in the usual fashion. The dorsal aspect of the fracture and non-union were covered with 2.5 cc demineralized bone matrix (DBX, DePuy Synthes, Amersfoort, The Netherlands). Total tourniquet time was less than 2 h. The patient was given a hinged knee brace locked in extension for 6 weeks. No active extension was allowed for 6 weeks. After 6 weeks the brace was discontinued, and physical therapy was started. Bisphosphonates were discontinued until there was healing of both the fracture and non-union.\nAt 3 months follow up the patient had regained full range of motion of his knee (140-0-0) and reported no pain ().\nOne year after the right knee surgery he returned to his old hospital where the patella hardware on the right was removed as this was bothering him. The patella had solidly healed with an excellent function ().\nEight months later the patient was diagnosed with an avulsion fracture of the inferior pole of the left patella () for which he underwent suture fixation at an outside hospital. This healed uneventfully within 3 months.\nNine months later he fell off a barstool and sustained an avulsion of the quadriceps tendon of the superior pole of the left patella () in addition to a right ankle fracture dislocation. We performed open reduction and internal fixation of his ankle fracture and suture repair through transpatellar tunnels of his left quadriceps’ tendon avulsion. These two injuries recovered uneventfully. Seven months later he again fell off a chair and was diagnosed with a transverse fracture of the left patella (). As he was still able to do a straight leg raise, we treated him with a hinged knee brace. At 3 months follow up his left patella fracture had healed in anatomic position (), with a good functional outcome (for a chronologic overview of his traumatic knee lesions see ). |
A 69-year-old Turkish Caucasian man was admitted to our urology clinic with recurrence urinary tract infection and chronic intermittent discharge from the ventral side of the penis. He reported that one week before his admission to our clinic he had experienced urinary retention, and was urethral catheterized in another medical center. However, after four days of the urethral catheterization, the patient had withdrawn the urethral catheter himself without deflating the balloon. His medical history included controlled hypertension disease but not diabetes mellitus. Two years before his last presentation to the clinic, he was diagnosed with bladder stone disease, and was treated with diverticulectomy and cystolithotomy. His systemic examination was not significant for any specific disorder. Local examination revealed an orifice of a possible fistula on the ventral side of the penis. His serum glucose level was 93.8 mg/dl, white blood cell count 10.7 × 109/L. Increased leukocyte count and bacteria were observed in the urine analysis. He was admitted to hospital with a possible diagnosis of urethral fistula. In his initial management broad spectrum antibiotics were used to control the urinary sepsis. Bacteriology confirmed a heavy growth of gram negative basil.\nDuring cystoscopy leakage of the serum physiologic from the orifice on the ventral side of the penis was observed, and no other pathology was noted. A fistulography was performed in order to demonstrate the fistula tract (Figure ). Total excision of the fistula tract under spinal anesthesia was performed with the intention of definitive treatment of the patient. During the procedure the urethral fistula tract was observed and totally excised (Figure ). No graft was used during the primary closure after excision of the tract. Urinary diversion was performed with a long-term silastic catheter introduced per urethra. Postoperatively, urine leakage was not observed and the catheter was removed on the third week. Excellent wound healing was seen in figure . The patient was able to void without any problems. He remained well with no recurrence of cellulitis or fistula 24 months postoperatively. |
A 22-year-old man was referred to us for drug resistant atrial tachycardia during exercise since 4–5 years. The rate of the tachycardia had been measured up to 250 bpm inducing marked dizziness. Slower ectopic rhythms around 100 bpm were also recorded. Various degrees of atrioventricular block could also be seen during tachycardia. The patient was initially treated with flecainide 100 mg bid but since 3–4 months the tachycardia recurred many times a week lasting from 1 minute to a couple of hours. There was no past medical history. Physical examination was normal. The echocardiogram was normal, too.\nAn electrophysiological study was performed.\nInitially, only supraventricular premature beats were seen. Compared with sinus rhythm, there was a slight reduction in the amplitude of the positive P in Lead 1, the P waves were more positive in Lead 2, Lead 3, AVF, the P waves were inverted in AVL compared with sinus rhythm and there was a change in polarity of the P wave in V1 from biphasic positive negative to positive ().\nA non-sustained atrial tachycardia at 220 bpm with 2/1 block occurred after atrial burst pacing and showed P waves of the same polarity as the premature beats ().\nAt times, a slow regular atrial rhythm around 45 bpm was seen with alternating sinus and ectopic rhythm ().\nIntracardiac measurements showed that during the premature beats and the tachycardia the high right atrium and the coronary sinus os were activated simultaneously and that the lateral wall of the right atrium was late.\nAt that point of time, the differential diagnosis based on right atrial mapping was: a focus in the right interatrial septum, a focus in the non-coronary aortic cusp, a focus in the left interatrial septum, a focus in the right upper pulmonary vein. The earliest atrial activation during the arrhythmia was found in the high right septal area with a prematurity of minus 30 ms in relation with the beginning of the P wave. Pacing at that site was the best site to reproduce closely the timing and the morphology of the right intra atrial and coronary sinus electrograms during the arrhythmia.\nOne radiofrequency application at that site was unsuccessful. The left atrium was accessed via transseptal puncture. A Biosense Lasso catheter was positioned in the right superior pulmonary vein (RPSV) as well as a Biosense Thermocool Smarttouch D curve ablation catheter. These catheters were connected to a 3D electroanatomical system (Carto3, Biosense Webster, USA).\nAfter placement of the Lasso in the RSPV, at the antero–inferior part of the Lasso (electrodes 7–10), small fragmented potentials with a prematurity of minus 100 ms in relation with the beginning of the P wave during extrasystoles were seen. There was also an inversion of the normal sequence of RPSV activation: the venous potential preceded the far field atrial potential on the premature beats (), demonstrating the pulmonary venous origin.\nWe could also see an alternation of sinus rhythm and RPSV regular atrial rhythm around 43 bpm with inversion of the normal sequence of activation of the pulmonary vein on the abnormal beats ().\nThe RPSV was isolated with an encircling lesion. After isolation was completed, a slow irregular dissociated rhythm with a cycle length between 380 and 680 ms was visible inside the vein. Mapping the dissociated rhythm within the RSPV with the ablation catheter showed fragmented potentials preceding the earliest Lasso activation by 35 ms. These were recorded a few centimeters inside the vein, beyond the right heart radiologic border.\nDuring a 24 hour follow-up only the typical sinus node atrial activation could be seen.\nThe patient remains asymptomatic after a follow-up of 3 years. |
A 16-year-old male patient came to our clinic for pain that was like continuous stabbing and electrical shock in left shoulder and forearm, as well as a and decreased power in hand grip. He had an excision and biopsy operation of chondroblastoma in the left humeral head 1 month previously and developed a continuous pain without any nerve damage on electromyelography. The visual analogue scale for pain (VAS) was 70/100 and hyperalgesia, allodynia, muscular atrophy and tremor of left forearm were observed on physical examination. The delayed phase of a 3 phase bone scan showed an increase of vascular flow on the left humeral head and an infra red image of upper limbs revealed the temperature of the left forearm was lower than the right one by 1.72 degree (). By his symptoms, physical examinations, and the infra red images, we diagnosed the patient as having CRPS type 1 and started oral medication and tried continuous cervical epidural catheterization, thoracic sympathetic ganglion block, cervical nerve root block, brachial plexus block and intravenous injection of local anesthetics and ketamin, so his symptoms were controlled around 40/100 on VAS. However, after summer vacation, while attending school regularly, the patient complained about having severe pain several times a day because of making contact with friends and he was rushed to the emergency room more often than before, and did not respond to any of treatments that we had used before with success. VAS was 80/100 and getting more severe and broadening to the tips of the left hand fingers; especially, he felt a cutting-like pain on the left fifth finger, allodynia even with breeze and squeezing pain, and a limited range of motion with tremor. We initially considered spinal cord stimulator insertion at first, but we were afraid of stimulation electrode migration because the patient was still growing 8 centimeters per year. Therefore we decided to try TSB and explained about the validity of using this procedure for uncontrollerable pain, We also explained the side effects and received informed consents for vascular instability, pneumonia or sepsis from mechanical ventilation and late recovery from unconsciousness and death. After infusing 300-500 ml of normal saline for 30 minutes in the operating room, we monitored continuous arterial pressure on the radial artery, oxygen saturation, electrocardiogram and bispectral index (BIS). While the patient was lying at the right lateral decubitus position, a 25 G spinal needle was inserted between the third and fourth lumbar intervertebral space and cerebrospinal fluid was checked flowing freely; fyrtherfore, and injected 1.5% lidocaine 30 ml by 10 ml was injected incrementally, slower than 1 ml per 1 second for 1 minute. After finishing the injection of local anesthetics and laying the patient in a supine position, we intravenously injected 100 mg Pentothal sodium and 3 mg midazolam intravenously for decreasing the uncomfortable sense the patient might feel during the start of TSB. Supplying 100% oxygen 6 L per minute by mask, we observed the process of loss of consciousness and inserted a laryngeal mask airway (LMA) without muscle relaxant. Ventilating mechanically with a tidal volume of 600 ml and minute volume of 7.2 L, we maintained an end-tidal carbon dioxide level between 35 and 40 mmHg. Following 2 hours of LMA insertion, spontaneous breathing was recovered and we removed the LMA. There was no respiratory problem at the recovery room. Before the procedure, the patient's blood pressure was 150/70 mmHg. Ten minutes later, it decreased to 100/60 mmHg; no further decrease of blood pressure occured and it increased to 140/80 mmHg and remained so along with the patient's recovery of consciousness. The patient was transported to a general ward. Blood pressure and oxygen saturation were normal when we monitored him for 1 day after the procedure. The pain was 10/100 VAS in the left shoulder and forearm, dull and mild. Severe pain on the left fifth finger and dysesthesia in the left forearm disappeared. The range of motion was improved, and the patient didn't complain of tremor any more. After his discharge, the pain scale remained the same, being reduced for 1 month, but it later was increased to 60/100 VAS because of some emotional stress and then was reduced to 40/100 again. |
A 19-year-old man was admitted to our hospital because of recurrence of left pneumothorax. His previous history included left and right pneumothorax at the ages of 15 and 16 years, respectively, which were treated by VATS. In the previous operation, simple resection of apical bullous lesion was carried out without surgical pleurodesis or covering any prosthetic sheets such as polyglycolic acid (PGA) sheets. Although the left lung inflated quite well and air leakage disappeared immediately after chest drainage, VATS was planned for the surgical indication of second postoperative recurrence. A preoperative non-enhanced computed tomography (CT) scan of the chest showed that the abnormally dilated pulmonary artery and pulmonary vein in the lingular segment ran towards the chest wall scar remaining at the surgical port site used at the previous operation (Fig. ). In this operation, a small bullous lesion arising in segment 6 of the left lung was ligated, and the dilated pulsating pulmonary vessels at the periphery of the lingular segment adhered to the aforementioned chest wall scar remaining at the thoracoscopy port site that was previously made in the fourth intercostal space (Fig. ). After this operation, we used contrast-enhanced CT scan for a suspected diagnosis of pulmonary vessel malformation. The examination revealed an abnormal connection between the branch of the systemic artery of the chest wall and the dilated pulmonary artery and pulmonary vein in the lingular segment. Left subclavian selective arteriography also showed hypertrophic blood vessels that arose from the internal thoracic artery, the lateral thoracic artery, and the subscapular artery arising from the axillary artery, which drained into the both the pulmonary artery and the pulmonary vein in the lingular segment (Fig. ). Because the chest CT scan obtained at the first episode of left pneumothorax showed no parietopulmonary fistula, a secondary SAPVF caused by first VATS for the pneumothorax was diagnosed.\nThe patient had no symptoms after the cure of pneumothorax, but the vascular abnormalities might lead to shunt-induced pulmonary hypertension, heart failure, hemoptysis, and possibly rupture. Embolization of the aberrant arteries was therefore performed. Despite of four sessions of embolization, the abnormal blood flow slightly persisted. Partial resection of the left lingular segment was therefore performed 2 weeks after the last session of embolization to avoid recanalization and further neovascularization. The operation was carried out by dissection of the affected lung firstly at proximal side by a surgical stapler, and next, the adhesiolysis was safely done at the distal side of the affected lung by using energy devices such as ultrasonic scalpel and vessel-sealing device without any major bleeding. After the lung resection, the staple line was firstly covered with polyglycolic acid (PGA) sheets (NEOVEIL® Gunze, Tokyo, Japan) to prevent pulmonary fistula and bleeding followed by fibrin glue dripping (Bolheal® Kaketsuken, Kumamoto, Japan), and chest wall side was also covered by same methods. In addition, both staple line and chest wall side was finally covered with an oxidized regenerated cellulose sheet (SURGICEL® Ethicon, Somerville, NJ, USA) to prevent re-adhesion. The patient has been disease-free (both pneumothorax and SAPVF) for 2 years and 2 months after the last operation.\nThe most common abnormalities of the pulmonary vessels are arteriovenous malformation (AVM) or the racemose hemangioma of bronchial artery, while SAPVF is relatively rare. SAPVF was first reported by Burchell and Clagett in 1947 []. To our knowledge, about 150 cases of SAPVF have been reported to date [–]. Secondary SAPVF are caused by pleural adhesions that occur subsequent to inflammatory changes associated with conditions such as pleuritis, empyema, trauma, and surgery. Jabber et al. described in a systematic review about internal thoracic artery to pulmonary vasculature fistula that the 59% of all fistula cases were found after CABG surgery. On the other hand, the case of secondary SAPVF following VATS like our case were just a few []. Traumatic change from dissection of the internal thoracic artery as a bypass graft may lead to internal thoracic artery to pulmonary vasculature fistula as Jabbar’s report []. Several other reports also described the secondary SAPVF usually developed as a consequence of inflammatory processes of the pleura or lung or after blunt, open chest trauma or thoracotomy [–]. Interestingly, our case developed SAPVF regardless of the previous operation carried out without thoracotomy and without using any prosthetic sheets causing adhesion.\nMost cases of SAPVF are unassociated with any symptoms, while SAPVF associated with severe hemoptysis, dyspnea due to cardiac failure, pulmonary hypertension, endocarditis, and chronic chest pain has occasionally been reported [, ]. In the past, the presence of a thoracic murmur or dyspnea provided clues to the diagnosis of SAPVF [, ], but recently, SAPVF has often been detected on the basis of abnormal findings such as increased lung vascularization or parenchymal infiltration on routinely obtained chest X-ray films or CT scans [, ]. The differential diagnoses include intrapulmonary AVM or pulmonary sequestration. However, these vascular abnormalities can be distinguished by angiography. The most common aberrant arteries in SAPVF are the internal thoracic arteries. The intercostal, axillary, diaphragmatic, and subclavian arteries can also be involved. In our patient, the intercostal artery, internal thoracic artery, lateral thoracic artery, and subscapular artery arising from the axillary artery drained into both the pulmonary artery and pulmonary vein in the lingular segment of the left lung.\nGenerally, SAPVF can be managed by embolization, surgical resection, or sometimes observation [–]. Embolization can be more effective in patients with a single or a few aberrant arteries than in those with multiple aberrant arteries. Our patient had many aberrant arteries supplied from the chest wall, which may be the reason for having to perform embolization four times. In patients such as ours who have many aberrant arteries, surgery is the treatment of choice to cure and prevent recurrence of SAPVF. However, some fistulas have an abundant blood flow. In such patients, preoperative embolization is recommended to reduce the risk of intraoperative blood loss. In our patient, although abnormal blood flow remained after embolization, surgical resection could be safely performed without any complications. Another consideration at operation is whether to use a prosthetic sheet to cover the post-resectional surface and thereby prevent re-adhesion and the recurrence of SAPVF. The optimal type of prosthetic sheet remains controversial. The oxidized regenerated cellulose sheet (SURGICEL®) shows to be reasonably well-thickened with minimal or milder adhesion than PGA sheet []. So, we used a PGA sheet firstly to prevent bleeding from dilated pulmonary vessels and aberrant arteries in chest wall and finally used an oxidized regenerated cellulose sheet to prevent adhesion. |
A 51-year-old man was admitted to our surgical unit with a diagnosis of chronic pancreatitis. He was suffering from episodes of continuous abdominal pain for the last one year. The pain was radiated from the right upper quadrant of the abdomen to the back and was associated with nausea, partially relieved by injectable analgesics and aggravated by food ingestion. This challenge led to the loss of appetite then to weight loss which also worsened by the presence of occasional episodes of malabsorption and the development of insulin dependent diabetes mellitus. There was no family history of the similar condition in parents, siblings or first-degree relatives.\nMoreover, there was no history of abdominal trauma in the past. The patient had a history of admissions to different hospitals for the recurrent pain attacks. However, apart from this illness, he had never been to hospitals for any other medical or surgical condition. He was on analgesics, insulin therapy, and pancreatic enzyme supplementation and had never been allergic to the exposed medications.\nThe physical examination showed an emaciated man looking older than his chronological age, appeared pallor but no clinical evidence of jaundice. Abdominal examination was normal. Chest examination found no remarkable findings, and the rest of the physical examination was normal. The laboratory examination showed an increased level of blood sugar, normal levels of serum amylase, renal function tests and liver function test (LFT). No attempt was made to establish the insufficiency of the exocrine pancreatic function. Chest X-Ray and ECG were normal.\nPlain radiology showed opacities in the middle and right upper quadrant abdomen (a). CT abdomen was performed to rule out other associated pathologies like pancreatic pseudocyst, pancreatopleural, pancreatogastric or pancreatocolonic fistulae as the surgical procedure would have been different in the presence of any of the complications. Contrast-enhanced abdominal CT scan revealed impacted stones at the ampulla within the distal bile duct and pancreatic duct. The remaining parts of the pancreas showed normal result with no associated features of chronic pancreatitis (b). Since the contrast-enhanced abdominal CT scan indicated impacted stones in the distal bile duct at the ampulla, MRCP was performed. Initial MRCP suggested stones within the main pancreatic duct (MPD) in the head of the pancreas and dilated common bile duct suggested stone in the distal part of it (c). |
A 11-year-old girl presented to her local hospital with an acute onset of severe abdominal pain, showing signs of hypovolemic shock and requiring emergency resuscitation prior to transfer to a tertiary pediatric center. She had fainted at school earlier in the day and been sent home. That afternoon, she had vomited once and rested in bed. She woke during the night, screaming in pain. An ultrasound scan at the local hospital demonstrated a ruptured spleen with an associated perisplenic hematoma and a large volume of free fluid in the peritoneal cavity. These findings were confirmed on a contrast-enhanced computed tomography scan (\n), which also demonstrated active extravasation of contrast from a branch of the splenic artery. After further resuscitation at the tertiary center, including multiple blood product transfusions, she was transferred to the interventional radiology suite where angiography via a femoral arterial approach showed gross disorganization of the splenic vasculature at the site of parenchymal rupture, with several truncated vessels and active bleed points noted (\n). Distal embolization of individual bleeding vessels proved impossible due to anatomical distortion by the surrounding hematoma and vessel spasm. In view of the emergency nature of the situation, coil embolization of the proximal splenic artery was performed, with complete occlusion of splenic arterial flow. This inevitably involved partial devascularization of the pancreatic tail.\nThe patient's vital signs and transfusion requirements improved immediately after coil deployment. She made a slow but steady recovery on the intensive care unit and was extubated 3 days after admission. Her recovery was complicated by transient pancreatitis that was conservatively managed. She was discharged from the hospital 4 weeks later. Follow-up showed reconstitution of most of the splenic parenchyma, though she was vaccinated and commenced on prophylactic antibiotics in view of presumed hyposplenism.\nThe child's clinical presentation gave no clues as the cause of her splenic rupture. Among other investigations, a referral was made to the children's social care services to explore the possibility of unreported trauma or abuse in view of the lack of any medical explanation for her injury; these enquiries revealed nothing of concern. She was born in the United Kingdom, though her family was from northern Iran; her parents were consanguineous. She was the oldest child of four siblings and had no family medical history of interest. She had been investigated at her local hospital 2 years previously for faltering growth; blood tests had revealed minor anemia, β thalassemia trait, and a spleen at the upper limit of normal for size, but all other tests were normal. She was underweight and was noted to bruise and scar easily. She had no history of fractures or dislocations and no joint pain. On examination, she had thin skin that was slightly hyperextensible and had multiple scars over her knees and elbows. She had blue sclerae. She had no signs of significant hypermobility.\nSubsequent genetics investigations confirmed that she was heterozygous for the de novo c.2194G > A mutation in the COL3A1 gene, in keeping with nonhereditary V-EDS. Imaging investigations showed mild fusiform dilatation of the origin of her superior mesenteric artery but otherwise normal vasculature. Cardiac, rheumatological, and surgical follow-up has been unremarkable. She is maintained on regular β-blockers as a protective measure against arterial dissection/rupture and avoids contact sports. |
Patient is a 65-year-old male, a retired bank manager, who was first seen at the Haematology Day Care Unit in August 2016 having been referred from the Geriatric Center of the University College Hospital on account of a 5-month history of severe (score 7 of 10) and recurrent pain of the rib cage and low back. The pain was nonradiating and severe enough to disturb his normal daily activities. He had no associated constitutional symptoms. He presented to the source of referral at the onset of the illness where his hemoglobin electrophoresis was determined as HbS + C for the very first time ever. Analgesia was prescribed to him and this resulted in significant relief of the pain. Further questioning revealed that he had bone pain crisis in childhood but SCD was not diagnosed. However, the last episode of such was 35 years ago. He was never transfused with blood. He was married in a nuclear family with five children who are all well and alive. He does not smoke cigarette but stopped taking alcohol about 5 years ago.\nExamination at presentation revealed a middle-aged man in no obvious distress, afebrile, tinge of jaundice, fair hydration status, no significant peripheral lymphadenopathy, and no pedal edema. Vital signs were within normal and breath sounds were vesicular. Moderate tenderness was elicited over the lower three ribs bilaterally. He was managed as a newly diagnosed HbS + C patient in moderate bone pain crisis and discharged home to complete investigations on outpatient basis and to return in a week for review with results. He, however, defaulted follow-up appointment only to return 4 weeks after with a more terrible pain and inability to stand from sitting and lying positions. He decided to go to a private facility from where he was referred back to the Hematology Department because an abdominal ultrasonography result revealed splenomegaly and para-aortic lymphadenopathy and hence a lymphoma was strongly suspected. Laboratory investigations revealed a full blood count with anemia (packed cell volume 27%), white blood cell 2700/mm3, and platelet count of 186,000/mm3. He had an elevated prostate-specific antigen of 15.6 ng/ml (0–4). Radiological findings include cervical spondylosis; anterior wedging of L2 vertebral body; and reduction in the height of T9, L1, L2, and L3 vertebral bodies. Further physical examination mainly established moderate tenderness over the anterior lower ribs and the flanks bilaterally and over the lumbosacral spine. At this point, working diagnosis was metastatic prostatic carcinoma rule out lymphoma in an HbS + C.\nHe was admitted for pain control and further evaluation. A bone marrow aspiration carried out revealed bone marrow plasmacytosis of 80% including binucleate forms and a few plasmablasts, which were suggestive of MM []. Further investigations such as serum protein electrophoresis, immunoglobulin quantitation, serum- and urinary-free light chains, skull and pelvic X-rays, urinary Bence Jones protein, and beta-2 microglobulin were requested to further confirm diagnosis. Patient could only afford beta-2 microglobulin and immunoglobulin quantitation. Result of beta-2 microglobulin was 2.7 ng/L (within normal limit) and immunoglobulin quantitation showed elevated immunoglobulin A (IgA) of 17.6 μg/dl; hence, a diagnosis of IgA myeloma was made in International Staging System-stage 1.\nHe was commenced on chemotherapy with melphalan (PO 7.5 mg/m2 × 5 days), prednisolone (PO 60 mg/m2 × 5 days), and thalidomide 100 mg daily in a 42-day cycle. Neurosurgeons equally co-managed on account of the vertebral and lumbar spine lesions and pain. He was initially kept on strict bed rest to stabilize the spine. He later had magnetic resonance imaging of lumbosacral spine and flexion/extension radiological study of the lumbosacral spine which was found satisfactory. He was subsequently commenced on ambulation, after a thoracolumbar spine orthosis was applied.\nHe has tolerated so far, five cycles of chemotherapy, as well as, physiotherapy very well and have made a significant improvement. The bone pain has resolved and he is now fully ambulant without support. He has also received three doses of intravenous zoledronic acid 4 mg monthly. |
A 57-year-old male manual labourer presented with a complaint of a right forearm mass he noticed 3 years prior to presentation. The patient had a history of an open in situ CuTR 5 years previously. The patient reported that he did well in the initial post-op period, had good relief of his neurological symptoms, and was able to perform his daily activities. The mass, which was accentuated with wrist and finger flexion, was located on the ulnar side of his forearm deep to his prior CuTR scar. He also complained of discomfort when resting his forearm on a hard surface which started approximately 3 months prior to presentation with a maximum visual analogue scale (VAS) pain score of 5. He denied any trauma or inciting event. Clinical examination revealed a palpable mass over the ulnar aspect of his forearm deep to the surgical scar, with a tender area of fascia where the CuTR release had ended distally. He denied any exertional compartment syndrome–type symptoms.\nThe patient presented to us with a magnetic resonance imaging (MRI) ordered by his primary care physician, which was normal and did not reveal any masses. After discussing the diagnosis and treatment options, the patient wished to proceed with complete fasciotomy over the FCU.\nThe decision was made to complete the fasciotomy distally to the FCU tendon level in order to remove the painful stimulus as well as the discrete area muscle bulge noted over the ulnar forearm. This was performed open with an endoscopic assist method. A longitudinal incision was made in the skin approximately 2 cm long, 5 cm proximal to this fascial band. The soft tissue spreaders were then placed over the forearm fascia distally to create a working space for the endoscope. The nasal speculum was then inserted into the wound under the skin and the endoscopic camera was inserted. This revealed the leading edge of the fascial herniation (). Using long Mayo scissors, the forearm fascia over the FCU was released from a proximal to distal direction under direct visualization, taking care to preserve cutaneous nerves and veins encountered. The fascia was released distal to the forearm, near the level of the wrist when the FCU tendon was encountered (). The endoscope was then removed from the wound along with the instruments. Palpation of the forearm revealed no fascial band leading to muscle herniation present. The patient tolerated the procedure well.\nAt the 4-month post-op visit, the patient had equal grip and wrist flexion strength, and the pain over the fascial edge had subsided. No discrete mass was evident and the patient was satisfied with the aesthetic appearance. He was able to perform his activities of daily living and occupation without issues or restrictions and his post-op VAS pain score was 0. |
A 65 year old South-Asian female presented to the medical ward with an acute febrile illness with characteristic prodromal symptoms on day 1 of her illness. Being an endemic country to dengue viral infection, clinical suspicion made us prioritize our investigations and a positive dengue NS1 antigen confirmed dengue viral infection. She had a significant past history of symptomatic aortic stenosis which necessitated surgery and had undergone mechanical aortic valve replacement in 1999. She was on oral warfarin and had maintained a therapeutically appropriate internationalized ratio (INR) while on 5 mg with no prior episodes of significant bleeding. She additionally gave a history of hypertension with dyslipidemia and was also an asthmatic on medical management with good compliance. She also had a notable obstetric past history which had required a classical caesarean section.\nPreliminary examination revealed a normotensive patient with a blood pressure of 130 mmHg systole and 80 mmHg diastole and had a regular pulse of 92 beats per minute. Cardiac auscultation revealed a mechanical click coinciding with 2nd heart sound and an ejection systolic murmur favoring a functional mechanical aortic valve in the absence of any other findings favoring decompensation. Though respiratory examination revealed scattered bilateral rhonchi, the patient appeared stable with a respiratory rate of 16 breaths per minute. Abdominal examination revealed a midline scar keeping in with the history of a classical caesarean section. Neurological examination was unrevealing. A decision was taken to continue her routine metered dose inhalers of salmeterol and fluticasone 250/50 micrograms twice daily. Additionally she was also nebulized 8 hourly with oxygen driven salbutamol. Though she had been on oral losartan 50 mg bd for her hypertension and rosuvastatin 10 mg nocte for her dyslipidemia a clinical decision was taken to discontinue both. However in consideration of her mechanical aortic valve, we took the clinical decision to continue her warfarin without dose reduction at 5 mg vesper.\nOn admission, which was day 1 of her illness, whole blood analysis revealed a hemoglobin of 9.3 g/dL (11–15) with a low total white cell count of 3.89 × 109/L (4–11) and a platelet count of 113 × 109/L (150–450). Her INR was 2.7 (<1 normal and target range of 2–3 in her situation). Warfarin was cautiously continued while judiciously following her drop in platelet counts with frequent whole blood analysis. Her liver functions showed a mild but acceptable derangement of transaminases with an aspartate transaminase of 144 (<35 IU) and alanine transaminase of 62 (<40 IU) with a normal reference range for activated thromboplastin time. On day 4 of her illness when her platelet count dropped to below 50 × 109/L (150–450), warfarin was stopped and a clinical decision was taken to change over to intravenous unfractionated heparin (at 1000 IU/h) as the anticoagulant of choice to ensure continued anticoagulation for her mechanical heart valve. She was closely monitored with activated partial thromboplastin time (APTT) at six hourly intervals. However, a rapid and unexpected prolongation of APTT to >200 s (<40 s) prompted us to reconsider continuation of heparin and decision was taken to transiently withhold heparin. During this period she was neither symptomatic nor had clinically evident signs of bleeding or its manifestations. She was continuously monitored and on day 6 her platelets continued to drop to its lowest nadir of 27 × 109/L (150–450). Her deranged APTT had normalized by this point and were within normal reference parameters.\nOn day 7 of illness with an already rising platelet count of 50 × 109/L (150–450), and normal coagulation parameters (an INR of 1.1 and APTT of 35 s) she complained of a continuous lower abdominal pain. However clinical examination was unrevealing. While still being monitored with frequent whole blood analysis an observation was made of a drop in both haemoglobin and haematocrit from 9.3 g/dL (11–15) to 7.9 g/dL (11–15) and from 33 (35–45) to 27 (35–45) respectively, which also coincided with a notable drop in her urine output (<0.5 cc/kg/h) which had maintained till then. Despite a tachycardia of 110 beats per minute her blood pressure remained within acceptable parameters, suggesting compensated shock. A possible intra-abdominal bleed was suspected. Ultrasonographic examination revealed a right sided rectus sheath haematoma measuring 13 mm by 15 mm. There were however no features to favor dengue haemorrhagic fever as features of fluid leakage were absent ultrasonographically. Failure of the parameters to correct, prompted us to do a follow up ultrasound abdomen which confirmed the extension of the haematoma on the right to 71 mm by 53 mm with a new haematoma forming on the contralateral left side as well, measuring 33 mm by 23 mm (Fig. ). No further bleeding sites were identified. Additional occult bleeding was suspected and based on haematological and haemodynamic parameters, she was initially volume resuscitated with normal saline and to err on the side of caution she was also transfused with 3 units of packed red cells to achieve stabilization and counteract blood loss. Post transfusion haemoglobin was 10.1 g/dL (11–15) and haematocrit was 34 (35–45). A decision was taken not to transfuse fresh frozen plasma or platelets as tested coagulation parameters (APTT & INR) were normal, and platelet counts were 50 × 109/L (150–450) and rising. With defervescence of temperature and rising platelets, her haematological parameters stabilized and intensive monitoring was continued. After 72 h of clinical stability she was started on oral anticoagulation and bridged with low molecular heparin until the INR reached acceptable therapeutic range. The patient thereafter made an uncomplicated recovery. |
A 69-year-old woman had undergone total knee arthroplasty eleven prior due to a diagnosis of primary gonarthrosis. She had a history of hypertension and goiter and was 98 kg and 164 cm tall with a calculated body mass index of 36.43 kg/cm2. Her height and weight were approximately the same when the primary total knee arthroplasty was performed. After this initial procedure, she underwent regular follow-ups every year for five years; her last follow-up was conducted six years prior to presentation, and she was not informed of the need for continued follow-up. Her control radiograph revealed varus malalignment of the tibia three year after the primary surgery (). Approximately a one and a half years prior to presentation, she experienced a slight pain in her operated left knee, which increased over the subsequent six months. When she was admitted to the local hospital, an analgesic drug was prescribed to her.\nAs her pain continued to increase over time, she presented to our central hospital; radiographs taken at that time revealed significant osteolysis in the medial condyle of the tibia (). Physical examination revealed a healthy-appearing obese woman in no acute distress and normal examination of the lower extremities. There was a well-healed anterior incision over the left knee without any evidence of skin infection. Active and passive motion of the knee caused pain in the medial part of knee. C-reactive protein, erythrocyte sedimentation rate, thyroid function tests and all other laboratory values were in the normal range. Loosening of the tibial component without any infection was reported on the bone scintigraphy.\nThe patient underwent a revision knee arthroplasty, and the previous incision site was used. There was a medial tibial baseplate fracture in the sagittal and coronal planes and a heavily worn polyethylene insert (A and B). There was no loosening in the lateral part of the tibial baseplate and no evidence of infection. Revision knee arthroplasty was performed after removal of the implants (). There were no post-operative complications, and the patient was ambulating with partial weight-bearing on the second day after the surgery. Significant pain relief and functional improvement was achieved based on early follow-ups. |
An 11-year-old boy was brought to the pediatric emergency department due to a right eyelid injury sustained after falling from a tree. Systemic evaluation was normal and he was referred to the ophthalmology department. The patient reported having fallen onto a branch fragment from the tree approximately one hour earlier. Edema and ecchymosis of the right upper and lower lids, and a cutaneous wound in the nasal aspect of the right upper lid were observed on examination. Visual acuity was suspected light perception in the right eye and 10/10 in the left eye. Color vision and eye movements were normal in the patient’s left eye but could not be evaluated in his right. The right pupil was middilated with intact consensual but no direct light response. The left eye exhibited normal direct but absent consensual pupillary light reflexes. Anterior segment examination of the right eye revealed hyperemic conjunctiva, clear cornea, and +1 cells in the anterior chamber. The fundus could not be evaluated due to vitreous hemorrhage. Anterior and posterior examinations in the left eye were normal. The patient was admitted to our unit for wound exploration, repair of the lid wound, and fundus examination under general anesthesia (). With a prediagnosis of traumatic optic neuropathy, treatment was initiated with systemic steroids, and topical steroids for the anterior chamber reaction, and bed rest in an upright position was recommended.\nThe following day, the patient underwent wound site exploration and primary incision repair under general anesthesia, followed by fundus examination. The vitreous hemorrhage in the right eye had partially regressed. The retina was attached but had a diffuse pale appearance due to retinal arterial occlusion, and there were widespread intraretinal hemorrhages. The optic nerve head was apparently absent ().\nBrain tomography conducted in the emergency department and orbital magnetic resonance imaging (MRI) examination requested by ophthalmology showed no pathology other than sporadic hemorrhages in the vitreous and irregularity at the lamina cribrosa level consistent with right optic nerve avulsion. Based on the results of ophthalmologic examination and imaging, the patient was diagnosed with optic nerve avulsion (). Systemic steroid therapy was not expected to be of benefit to the patient and was discontinued.\nExamination one week later revealed total retinal detachment in the right eye, which was attributed the trauma. No interventions were considered due to the lack of light perception in the right eye and the patient was scheduled for follow-up, but he did not return. |
A 41-year-old non-smoker obese female patient was examined at the Department of Neurology and the Center for rehabilitation. Relevant history of the patient is summarized on a timeline in Fig. . She showed an onset of neuromuscular disorders during early childhood with a delay in motor and written language development. She had a hard time to complete physical exercise at school and always finished last. There was nothing really alarming in terms of muscle disorder until her first pregnancy at the age of 33 during which she experienced shortness of breath (dyspnea) at the 7 months of gestation and showed signs of weakness of lower limbs afterwards. At the age of 34 she showed worsening of breath symptoms, suffered from sleep apnea and started using a mechanical ventilation machine. Alarming symptoms of skeletal muscle disorders occurred immediately after delivery with progressive but rapidly incapacitating weakness of lower limbs. This worsened during the 3 following years, a period during which she first started being unable to get up by herself and then was unable to climb stairs. At the age of 37, she started to use a cane, then a walker for her daily walking needs. At the age of 39, she started using a wheelchair to move outdoors. Despite these signs of progressive muscle weakness, she never had a thorough neuromuscular investigation. It was wrongly thought that her health problems, in general, was mainly related to being overweight. At the age of 41, she had four episodes of lower limb paralysis during which she was completely unable to move her legs and support her weight. She did not seek medical consultation for the first three episodes. For the fourth, she was admitted to the emergency room (ER) and first referred to the Department of Neurology and then to the Center for Rehabilitation.\nThe family history showed that her mother died at the age of 66 from a heart attack associated with non-compaction cardiomyopathy. There is nothing remarkable in terms of muscle disorders in her father, brother, and sister. However, her only daughter, now at the age of 11, shows signs of muscle disorders with congenital muscular torticollis, excessive growing pains as well as underdeveloped muscles in half of the body.\nPhysical examinations conducted following her admission to the ER at the age of 41 showed normal tone/bulk of the arm muscles. However, muscles in shoulders and upper and lower limbs showed bilateral weakness. Deltoids, biceps and triceps showed moderate weakness with MRC scale of 3/5. Fine finger movements were intact. There was no pronator drift. In the lower limbs, all muscles examined showed the same severity of weakness (2/5) except quadriceps which showed mild weakness (4/5). Hip flexors were extremely weak (1/5); hip abductors and adductors were mildly weak (4/5). Knee extensors and flexors were moderately weak (3/5). Dorsiflexion of feet was severely weak (2/5). Plantar flexors were severely weak (2/5). Deep tendon reflexes were 2+ in the arms, absent in the patella and Achilles. The toes were down-going. No sensory deficit was observed. No sign of dysphagia or involvement of ocular muscles was observed.\nAdditional physical examination conducted during the 2-year follow-up (at the age of 43) showed no worsening of muscle strength. However, this brought new information about the weakness of other muscles, notably in the shoulders, with extremely weak abductors and flexors (1/5). The patient showed decreased perception of vibration in the lower limbs. She reported that she experienced occasional dysphagia.\nElectrophysiological exams showed normal nerve conduction velocities for upper and lower limbs, with all SNAP and CMAP amplitudes in the range of normal values. However, needle EMG revealed a tendency of myotonic potentials, generated by needle insertion. Right deltoids, biceps and ulnar-innerved first dorsal interosseus muscles showed myotonic potentials as well. The right tibialis anterior showed 2+ polyphasic motor unit potentials with myotonic potentials. The right medial gastrocnemius, vastus medialis and vastus lateralis showed myotonic tendencies as well.\nExamination of muscle biopsy of left quadriceps showed features of an end-stage process, consistent with a severe, chronic myopathy. There are scattered clusters of viable muscle fibers which showed myopathic features in the form of a marked variation in fiber size and numerous internal nuclei. In addition, there are scattered fibers with abundant intrasarcoplasmic vacuoles (Fig. a, b). Given we could not clearly observe the presence of hyaline bodies on H&E staining we decided to proceed with p62 immunostaining, a well-known technique for revealing the presence of inclusion bodies []. Immuno-histochemical detection of p62 was performed on a Leica Bond III automated stainer. Following digestion in a low pH citrate solution, sections were incubated in a primary mouse monoclonal anti-p62 antibody, diluted 1:50 (BD Transduction Laboratories Catalog Number 610833). Detection of bound antibody was achieved using the Leica Bond Polymer Refine Detection kit, comprising the secondary antibody, the substrate chromogen DAB (3,3′-Diaminobenzidine tetrahydrochloride hydrate) and the Hematoxylin counterstaining solutions. Immunostaining for p62 revealed, in a proportion of the surviving muscle fibers, diffusely distributed, small intermyofibrillar dots or, more commonly, larger central or eccentric sarcoplasmic inclusion bodies (Fig. c, d). Examination of heart function using Holter ECG monitor carried out following her admission to the ER showed no clinically significant implication of cardiac involvement. However, the patient complained about repeated episodes of oppressive chest pain during the following years. Additional examination conducted during the 2-year follow-up showed signs of cardiac involvement with bradycardia of 58 beats per minute.\nRegarding respiratory involvement, the patient suffered from dyspnea since the age of 34. Examination of lung function conducted following her admission to ER and during the follow-ups showed worsening of her respiratory condition. Spirometry test conducted at the age of 44 showed a very weak pulmonary function, with forced vital capacity (FVC) of 27% and forced expiratory volume in a second (FEV1) of 29% of normal values.\nThe blood samples were collected for whole-exome sequencing (WES) to detect mutations potentially involved in the phenotype of neuromuscular disorders observed for this patient. The genomic DNA was extracted from whole blood and subsequently subjected to whole-exome DNA library construction using the Ion AmpliSeqTM Exome RDY panel (Thermo Fisher Scientific) essentially as described in the manufacturer’s protocol, with barcode incorporation. For the sequencing, samples were loaded on an Ion HI-Q PI Chip v3 and placed onto the Ion Proton instrument (Thermo Fisher Scientific) together with an Ion PI HI-Q sequencing 200 Kit (Thermo Fisher Scientific) and sequenced for 520 cycles according to the manual (See Additional file : Table S1 for parameters). All candidate mutations found by WES were validated by direct Sanger sequencing (See Additional file : Figure S1 for the filtering process). DNA sequences were obtained from the University of California Santa Cruz (UCSC) Genome Browser. Predesigned primers were directly purchased from Thermo Fisher Scientific (See Additional file : Tables S2 for details). Amplicons were sent to Genewiz () for Sanger sequencing.\nWhole exome sequencing showed that a novel variant NM_000257.3: c.1370 T > G (p.Ile457Arg) in the MYH7 gene is a missense single nucleotide variant possibly linked to the clinical findings, found in the DNA of the patient as heterozygous (Fig. ). The novel variant has been submitted to ClinVar database; with the assigned accession number SCV000804311. Two other candidate mutations were identified in the DNA of this patient, namely NM_003085.4:c.368C > A (p.Pro123His) in the SNCB gene and NM_001001557.3:c.746C > A (p.Ala249Glu) in the GDF6 gene (Additional file : Table S3). However, both mutations were discarded after filtering only genes involved in neuromuscular functions that potentially cause clinical features of muscle myopathy observed in this patient (Additional file : Figure S1). Regarding the novel variant NM_000257.3: c.1370 T > G (p.Ile457Arg), bioinformatics analyses showed that nucleotide T coding at the position 1370 of the MYH7 gene is highly conserved across 44 vertebrate species (PhyloP at 1.76). Amino acid substitution from Isoleucine (I) to Arginine (R) at the position 457 of MyHCI suggested a high impact on protein structure (Grantham at 97). Results of analyses obtained from VarSome () suggested a classification of Likely pathogenic for this variant, with evidence of Pathogenic computational results coming from 8 various prediction software including DANN, GERP, dbNSFP.FATHMM, MetaLR, MetaSVM, MutationAssessor, MutationTaster and PROVEAN (vs no benign predictions). Also, the results of analyses using the recommendation of the ACMG and the AMP suggested the same classification of Likely pathogenic for this variant, with combined criteria of 2 moderate (PM1 and PM2) and 2 supporting (PP2 and PP3) []. |
A 47-year-old woman was involved in a motor vehicle accident at the age of 16 and suffered a right femoral neck fracture. Open reduction internal fixation of the fracture was not possible, and the primary therapy for the injury was a total hip arthroplasty (THA). The patient required four revisions of her primary total hip. She presented to our center for consideration for a fifth revision surgery secondary to intractable pain. She was taken to the operating room (OR) and received peri-operative cefazolin as per protocol. Complications arose during the revision procedure. A femoral shaft fracture occurred, and a deep pelvic arterial injury resulted in intra-operative hemodynamic instability, requiring suspension of the procedure and arterial embolization. The patient was subsequently transferred to the intensive care unit and, on day 2 in hospital, returned to the OR for completion of the original procedure which was uneventful. Her postoperative course, however, was complicated by prolonged respiratory failure necessitating a tracheostomy.\nOn day 12 in hospital, the patient developed increased pain, redness and new drainage from her surgical wound. She underwent surgical exploration, was found to have a hematoma with evidence of defects in the deep fascia, which required debridement down to the hip prosthesis. The hematoma was evacuated, no antibiotic beads were placed, and she was started on vancomycin. Quantitative cultures were not performed; however, tissue cultures grew ampicillin-sensitive Enterococcus species and A. baumannii (sensitive only to amikacin and imipenem). The patient was switched to imipenem 500 mg IV every 6 hours on day 15 in hospital. She was not considered to be a candidate for removal of her prosthesis because of the recent prior surgical complications.\nOn day 33 in hospital, the patient returned to the OR for debridement because of continued fevers despite imipenem; cultures once again grew MDR A. baumannii, Enterococcus species and coagulase-negative Staphylococci (CNS). The patient improved and was discharged home on day 53 to complete her imipenem therapy at home.\nThe patient was seen weekly in our Orthopedic Infectious Diseases Clinic for blood tests and clinical examination. Due to persistently elevated inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), her antibiotic course was extended. Her ESR and CRP improved but never normalized. The antibiotics were stopped after completing a 4-month course of imipenem. The patient was not placed on oral suppressive therapy since no options existed for the MDR A. baumannii.\nThe patient remained symptom-free for 7 months before noticing pain with walking and swelling at the right hip. She denied having had any new injury or trauma. On exam, she had redness, warmth, swelling and new drainage at the incision site on the right hip, presumed to represent recurrence of her MDR A. baumannii infection. At this time, she underwent surgical debridement and removal of the THA. Intra-operative cultures were obtained but the prosthesis was not sonicated. The operative cultures grew Enterococcus species (sensitive to ampicillin and penicillin), and two types of CNS (resistant to penicillin), which were not thought to be pathogenic. There was no MDR A. baumannii isolated. The patient responded to an 8-week course of therapy directed only toward the Enterococcus species with ampicillin. Twenty-nine months after stopping antibiotics, she remains free of infection at the time of writing. |
A 40-year-old male presented to our office in 2017 complaining of chronic left knee pain. This was his first visit to this office and was establishing care after moving to the area. The patient's electronic medical record was obtained from an outside institution which indicated a past medical history of diabetes, hyperlipidemia, and hereditary multiple exostosis. The patient disclosed that he had multiple osteochondroma removal surgeries which included his left knee, lumbar spine, and left foot at an outside institution. In addition, he had a left hip arthroplasty with refractory numbness/tingling of the leg. The patient stated he had left knee pain for years until he had an osteochondroma removed in his left distal femur in 2016 which seemed to help for 6 months. He stated the pain returned at 7/10 and is worse with movements. He had limited range of motion with 70° of flexion, negative pain with varus and valgus movement, and negative secondary tests. Baseline X-rays were ordered for this patient's knee ().\nThere were osteoarthritic changes with significant osteochondroma formation; however, arthroplasty was not recommended at that time because of the patient's young age and his left lower extremity being distally neurovascular intact. The patient was adamant about having his knee replaced and was referred to a specialist at an outside institution where an arthroplasty of the left knee was performed. The patient returned 3 months later with continued limited active and passive range of motion (<90° flexion). Follow-up radiographs were ordered showing good alignment of a Smith & Nephew posterior stabilized prosthesis without subsidence (). It was decided to perform manipulation under anesthesia followed by 6 weeks of physical therapy which improved his range of motion to 110° flexion.\nThe patient continues to have limited range of motion of his left knee with flexion to 90°. The large posteriorly projecting osteochondroma of his left tibia continues to be asymptomatic and painless, and therefore, it was decided not to perform surgical interventions at this time. Performing an arthroplasty helped relieve the patient's pain, however, did not result in significant improvement of active and passive range of motion of the joint. Overall, the patient is satisfied with his knee replacement but still has refractory numbness/tingling of his distal left lower extremity from his prior hip replacement. The patient has chronic pain elsewhere, which is being closely monitored (Figures and ). |
A 53-year-old female patient consulted physical medicine, rehabilitation and rheumatology department due to the pain radiating from the right inguinal region and the right hip to knee while she was being followed by general surgery clinic because of solid mass in the liver. During the assessment, patient complained of having an intermittent backache for a long time; she described a constant pain in her right hip and groin spreading to right knee that started 1 week ago and was increasing with rest. Patient also reported there was pain and slight swelling in the right ankle 10 days before that lasted for 3 days. In her background no previous illness is noted. Patient had an abdominal pain lasting for the last 6 months and abdominal ultrasound was performed; a solid mass was detected in the liver. We learned that the patient had no history of arthritis, gastroenteritis, urinary tract infection, psoriasis, or previous operation. She has not been using any medication except for analgesic. The patient had no relatives with history of inflammatory disease or malignancy in her family history. In the physical examination loss of lumbar lordosis was detected. Waist movement was slightly restricted to all directions due to pain, hand fingertip-to-floor distance was 10 cm, sacroiliac compression test was positive on the right, FABERE test was positive on the right, her right knee was warm and tender, there was no rash on the skin, local sensitivity was detected in the right upper quadrant with palpation, and other system evaluations were normal. Sacroiliac MRI was seen because of the suspicion of sacroiliitis. The sacroiliac MRI, which was assessed independently by radiology department, showed a signal enhancement consistent with the right iliac focal bone marrow edema adjacent to the right sacroiliac junction () and there were 2 cystic lesions at iliac front adjacent to the right hip joint. Abdomen tomography of our patient, which was requested by general surgery department, showed a well-defined 55 × 48 mm hypodense lesion with a superior calcification (lily symptom) in segment 3 (). Hydatid cyst hemagglutination titer test was 1/320 and the patient was diagnosed as hydatid cyst disease. The patient was taken to our clinic because of development of right ankle arthritis and right knee arthritis.\nIn our clinic, the laboratory tests required for sacroiliitis and arthritis etiology were done. The results of these tests showed that RF was negative, anti-CCP was negative, anti-cardiolipin antibodies were negative, ds DNA was negative, ANA was negative, c-ANCA and p-ANCA were negative, sedimentation was 38 m/h, CRP was 23 mg/L, WBC was 7,31 (103/12.7 g/dL), PLT was 364 (103/μL), tumor markers were negative. In addition, Brucella Wright and Coombs agglutination tests were negative. EBV VCA Ig M, EBV VCA Ig G, and Anti-CMV Ig G were detected as positive; EBV EA, Anti-CMV IG m were detected as negative. The right knee joint was punctured and 60 cc yellow clear liquid aspirated. At the examination of knee joint fluid Tbc DNA, tbc real time PCR, mycobacterial culture were detected as negative and there was no reproduction in cell culture; 8000 leucocytes (30% MNL, 70% PMNL) and 20 erythrocytes were detected in the cell analysis of aspiration fluid. Microscopic examination of the joint fluid showed no protoscolex and hook structures of the Echinococcus parasite. There was no reproduction in the blood culture. Anti-HCV, HBsAg, and Anti-HIV tests were negative. There was no evidence in the ECO for infective endocarditis. The patient consulted pulmonary medicine department. In the assessment PPD test was 5 mm and sputum culture and microscopic examination showed no Tbc Bacillus. HLA-B27 genetic assay was negative for spondyloarthropathy. The patient is diagnosed as reactive arthritis secondary to echinococcal infestation after all tests and no history of other diseases which can cause sacroiliitis and peripheral arthritis like SPA (spondyloarthropathy), familial Mediterranean fever, Behçet's disease, sarcoidosis, inflammatory bowel disease, and malignancy. Symptomatic treatment as 4 × 1 cold pack and TENS treatment were applied to the right knee of the patient. Acemetacin 60 mg capsule 2 × 1 was given as medical treatment. On the 5th day of treatment, right knee and ankle arthritis were clinically regressed and then patient was directed to the general surgery department for surgical treatment of hydatid cysts. |
The patient was a female in her thirties who visited her local clinic complaining chiefly of pain in the left occipital to temporal regions of the head, rotational vertigo, and vomiting. Although she had a history of depression and floating dizziness, her symptoms had subsided in recent years and were not a hindrance to her daily life. There was no family history of inheritance vascular wall disease.\nOn the morning of the day of symptom onset, she developed rotational vertigo of no apparent cause. In the afternoon, she developed pain in the left occipital to temporal regions of the head while driving and subsequently started vomiting in the night. Hence, she visited her local neurology clinic on the second day of symptom onset and underwent a computed tomography (CT) scan of the head and plain radiography of the neck; however, there were no obvious abnormal findings and a diagnosis of suspected herpes zoster was made. The woman was prescribed with valaciclovir, pregabalin, and acetaminophen but with no symptom improvement. Carbamazepine and aspirin that were added to the prescription were also ineffective and, hence, she was referred to our anesthesiology pain clinic for examination.\nThe patient had a severe headache during the examination, which she rated 100 mm on a visual analog scale (VAS). Every few hours, she developed throbbing, pulsatile pain that prevented her from sleeping and rendered her practically bedridden during the day. The associated vomiting also prevented her from eating. There was no allodynia of the head, trigeminal paresthesia, or motor symptoms in the region of the facial nerve. She also showed no other abnormal neurological findings in the spinal nerve region and had no skin rash over the left occipital to temporal regions of the head. There were no bulbar conjunctival congestion, fever, or symptoms of meningeal irritation. Her blood pressure was, however, elevated to 160/100 mmHg.\nHer symptoms were considered to be in line with the diagnostic criteria for migraine without aura according to the International Classification of Headache Disorders 3rd edition (Beta version) [], defined as severe unilateral, pulsatile headaches that come in cycles every few hours. The headaches were also accompanied by vomiting. Hence, she was prescribed with 2.5 mg of zolmitriptan. At this point, although the therapeutic effect was inadequate, another zolmitriptan dose of the same amount led to an improvement of her symptoms. Treatment was consequently commenced for migraine without aura. However, since the severe headache was sudden and unprecedented, a differential diagnosis of secondary headache was also simultaneously made.\nTreatment after hospitalization involved regular oral lomerizine with zolmitriptan and loxoprofen as needed. From day 2 after admission, the patient showed a decrease in her VAS score to 50 mm. She nonetheless continued to experience recurrent, severe headache attacks rated 100 mm on the VAS every few hours. Despite the partial efficacy of as-needed use of zolmitriptan, loxoprofen had both a better effect and longer duration of action. Finally, the persistent high blood pressure despite the apparent improvement in her symptoms led us to consult the department of cardiology on day 3, after which antihypertensive therapy with calcium antagonists was commenced. Furthermore, although secondary headache caused by intracranial disease had been ruled out because the patient had been referred to us by a neurology clinic and showed no abnormalities on cranial CT, we decided to perform magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) on day 8 because of the inadequate effect of zolmitriptan on the migraines and the atypically long duration of the headaches. Imaging revealed the findings of left VAD and occlusion, right VAD and an aneurysm related to dissection (Fig. ). There was absence of ischemic change in the brain on the imaging. Since she required specialist treatment for the VAD, she was transferred to the department of neurosurgery, where treatment with fluid replacement and oral antiplatelet drugs was commenced. The headache in the present case met the diagnostic criteria for headache caused by VAD in the International Classification of Headache Disorders 3rd edition (Beta version) []. The headaches subsequently subsided for a short time and her condition stabilized, although she once again presented with an increase in headaches on day 18, together with further vertigo, nausea, vomiting, motor ataxia (positive result in the finger-to-nose test), hiccups, hoarseness, dysphagia, and thermal hypoalgesia in the right upper and lower limbs, suggesting the development of Wallenberg syndrome. Repeat MRI examination revealed progression of the left VAD, occlusion of the left posterior inferior cerebellar artery, and findings suggestive of cerebral infarction in the left cerebellum and lateral medulla oblongata. She was treated conservatively with edaravone, argatroban, and glycerine, and was discharged home with ongoing rehabilitation and was reintegrated into society 6 months after symptom onset. |
A 31-year-old gravida 3 para 1 patient presented to antenatal clinic at 19 weeks and 3 days' gestation to discuss the results of her morphology scan which had demonstrated a grade 4 placenta previa covering the cervical os. She had a medical history significant for Arnold Chiari malformation requiring craniotomy in 2006 as well as correction of a Syringomyelia in 2005. She also suffers from irritable bowel syndrome but was taking no regular medications and had a BMI of 23. Her first pregnancy resulted in a spontaneous miscarriage that did not require dilatation and curettage. Her second pregnancy resulted in a planned elective caesarean due to concerns about raised intracranial pressure during labour, as recommended by her neurologist. She had routine antenatal care this pregnancy which had been unremarkable to date.\nThe morphology scan demonstrated a small omphalocele but otherwise no significant structural defects and estimated foetal weight was noted to be within the normal range. During the clinic review, the fetus was found to have a heart rate well below 100 bpm. Repeat ultrasound the following day confirmed IUFD. This ultrasound also demonstrated evidence of an abnormally invasive placenta with the appearance of dysplastic vascular hypertrophy. An obstetric MRI was performed which supported the diagnosis of morbidly adherent placenta. This showed a low lying inhomogeneous placenta, dysplastic vascular hypertrophy, ill-defined placental bands, and an overall impression of some areas of increta with no overt evidence of percreta.\nOptions were discussed with the patient who decided for conservative management in order to optimise her chance of preserving her fertility. This was balanced against potential complications of prolonged conservative management of an IUFD, including sepsis and coagulopathy. A plan was made for serial ultrasounds as an outpatient, to be followed by induction of labour when placental blood flow was no longer detectable. Twenty-seven days following IUFD confirmation, the patient was admitted to hospital with abdominal cramping and associated small antepartum haemorrhage (APH).\nUltrasound scan at 31 days showed a minimal reduction in blood flow through the anterior placenta and to the cervix. At day 33 she suffered a further 300mL APH. Given her increasing blood loss and minimal changes to placental blood flow on ultrasound, she was administered a dose of 80mg methotrexate intramuscularly with the hope of accelerating devitalisation of the placenta. A repeat dose of methotrexate was planned for five days' time. During the subsequent two days after the administration of methotrexate, the patient continued to suffer moderate bleeds and increasingly significant contractions. 35 days following IUFD she spontaneously delivered a male fetus with only minimal bleeding during delivery.\nA brisk 2 L postpartum haemorrhage (PPH) followed delivery and the patient was immediately taken to the operating theatre for examination under anaesthesia and attempted manual removal. A urinary indwelling catheter was inserted and remained in situ for the entirety of the operation. Due to only partial removal (approximately 80%) of the placenta being achieved manually, the case quickly progressed to laparotomy. Intraoperative findings revealed a full thickness increta at the previous caesarean incision just above the level of the bladder. Hysterotomy was performed with a transverse incision made above the prior caesarean incision, and the remaining placenta was removed manually, creating a 3x3cm plug-like defect anteriorly. This defect was closed with a primary closure separate to the hysterotomy incision. In addition, the placental bed was oversewn to establish haemostasis. A Foley's catheter was inserted vaginally and inflated with 60mL normal saline. Total blood loss was 4 litres (L): 2L immediately postpartum, 1L while attempting per vaginal manual removal of the placenta, and 1L intraoperatively. Massive transfusion protocol was activated with the patient receiving 10 units of packed red cells, 6 units of fresh frozen plasma and 5 units of cryoprecipitate. The patient remained stable throughout the process. A further 3 units of packed cells was given over the next two days for persistent anaemia. The fetus was found to weigh 170g. No cause for foetal demise was identified and the family decided against an autopsy. Pathological examination of the placenta was performed. This was noted to be difficult due to extensive haemorrhage and areas of necrosis commensurate with intrauterine foetal death and prolonged intrauterine retention. There was no evidence of funisitis or umbilical cord vasculitis to support a diagnosis of chorioamnionitis nor were any pathogens observed. The degree of decidual haemorrhage and necrosis made a histological diagnosis of placenta accreta impossible.\nThe patient recovered without significant complication over the following days and was discharged 1 week later on oral antibiotics and aperients. Six weeks after discharge the patient was seen in a postnatal follow-up clinic. She experienced minimal lochia in the postpartum period and was feeling generally well. |
A 35-year-old multiparous woman with no history of surgery or illness presented with a genuine stress related urinary incontinence. She had normal urethral closure pressure and no bladder instability. The patient was selected for TVT placement under spinal anesthesia. Just after insertion of the TVT trocar, the bladder was examined by cystoscopy and there was no sign of perforation. We did not perform an additional cystoscopy after extraction of the trocar. The remainder of the procedure was uneventful. A 16-Fr urethral Foley catheter was used to drain the bladder, and the patient was hospitalized overnight. The next morning, approximately 24 h after surgery, the catheter was removed and she voided without residual urine. Approximately one hour after removing the catheter, she developed acute abdominal pain and a fever. An examination of the suprapubic area revealed diffuse abdominal rebound tenderness without any discharge from the operation site. Vital signs, urinary drainage and laboratory studies showed normal results. Computerized tomography of the abdomen and pelvis demonstrated multiple dilated bowel loops and abnormal fluid collection in the peritoneal space (). A cystogram demonstrated a leakage of contrast media into the peritoneal cavity (). Cystoscopy also revealed a pinhead-sized ulcerative lesion on the right lateral wall, but with no visible perforation into the peritoneal cavity (). Emergency exploratory laparotomy via a lower midline incision revealed general peritonitis, as well as a large intraperitoneal hematoma, with the tape penetrating the pelvic peritoneum without concomitantly causing bowel injury. The right tape penetrated the deep layers of the bladder muscle and mucosa, close to the site of right trocar's passage. The hematoma around the perforated lesion was removed. The retroperitoneal portion of the right tape, just below the bladder rupture site, was cut as low as possible and the tape above the cut area was removed. We did not remove the periurethral and left portions of the tape. The bladder and peritoneum were repaired. The patient recovered with antibiotic management and was discharged one week after laparotomy. The patient's stress-related urinary incontinence remains resolved. |
A 50-year-old man presented with right knee locked in hyperextension after falling with the knee extended. He had a severe knee pain and was unable to bend his knee. Initially, the patient was diagnosed as ruptured patellar tendon and was managed by immobilization with a long leg splint at a community hospital. The patient was referred to our hospital 5 hours after the injury. He had persistent anterior knee pain, inability to bend his knee, high-riding patella, anterior tilt of superior part of the patella, and skin dimple inferior to patella (). The lateral radiograph of the right knee showed high-riding patella with inferior patellar osteophyte locked to osteophyte at the superior aspect of femoral condyle (Figures and ). The physical examination and lateral radiographs of the knee represented superior patellar dislocation, but the patellar tendon integrity cannot be confirmed. Subsequently, the bedside ultrasonography, performed by an orthopedic surgeon, is used to evaluate the extensor mechanism of the knee. The patient was in supine position with his knee fixed in extension. Under high frequency transducer (GE healthcare, LOGIC Book, 8 MHz linear transducer), longitudinal ultrasound was performed through the entire length and width of the patellar tendon. Transverse scan was subsequently performed to complete the evaluation of patellar tendon in two perpendicular planes. The multiple, parallel echogenic lines of the patellar tendon were demonstrated between the lower pole of the patella and the tibial tuberosity (). This ultrasound finding confirmed that the patellar tendon was intact. The dynamic study was not performed because the patient's knee was fixed in extension. The images were reviewed by a senior orthopedic surgeon and a radiologist, and the diagnosis of patellar dislocation with intact patellar tendon was agreed upon. After intravenous sedation, closed reduction was performed by using thumb and index finger to elevate the patella and gently move the patella into superior and lateral directions. The patella was easily relocated. The patient was able to achieve full active range of motion immediately after reduction. A follow-up ultrasound evaluation and lateral radiograph of the knee confirmed the anatomic reduction without any complication. Compression dressing was applied and partial weight walking with axillary crutch was advocated for 2 weeks. At 18 months' follow-up he had no pain or recurrent dislocation. |
A 2 years 6 months old girl presented with a week’s history of paraplegia and defecation difficulties. The history started two months prior to referral to our hospital with a trivial fall at home on the stairs, in which she managed to break her fall with her hands. There was no trauma to her head, chest, back or pelvis. There was no immediate complaint of pain nor neurological deficit and she was well thereafter.\nTwo days after the fall, she developed low grade fever, persistent back and abdominal pain aggravated by movement. She was taken to a general practitioner who had found no abnormality in radiographs of the spine and pelvis. A diagnosis of acute gastroenteritis had been made and she was prescribed antibiotics and analgesic. Her symptoms worsened and she was taken to a district hospital, where the doctors confirmed no abnormalities in her spinal and pelvic radiographs and also found urine microscopy examination normal. The diagnosis of gastroenteritis was retained and symptomatic medication prescribed.\nA week later, she had difficulty passing motion, in addition to her low grade fever and back pain. The mother took her to another general practitioner and was diagnosed as constipation and treated with laxatives.\nTwo weeks later, her lower limb weakness worsened and she was no longer able to walk. She was then taken to a general hospital and subsequently referred to our center for further management.\nShe had no loss of weight nor any significant past medical or surgical history. She was the youngest child with four older healthy siblings. She was being taken care of by her father at home and there was no family history of tuberculosis.\nClinical examination revealed an alert and generally healthy child. She was comfortable with no syndromic facies, skin blemishes or birth marks. She had fever of 37.7 degrees Celsius. Vital signs were normal. Pupils were 3mm bilaterally and reactive with no photophobia. Examination of her back was normal with no step deformity, bruises, gibbus, cutaneous lesion nor paravertebral muscle spasm.\nNeurological examination revealed motor power MRC grade 0 from L2 myotome down. Her lower limbs were hypertonic, hyper-reflexic, with clonus and up going Babinski reflex. Sensory evaluation revealed numbness below the level of her xyphisternum.\nBlood investigations were within normal range, ESR was 30mm/hr. Thoracic spine radiograph revealed reduced T10/T11 disc height and end plate erosion (, , ). CT brain scan with contrast was normal.\nThe key features of her MRI were partially collapsed T10 and T11 body with posterior cortex destruction and bulging posterior longitudinal ligament.\nMarrow signal within T10 and T11 was hypointense in T1, hyperintense in T2 weighted sequence and post-gadolinium heterogenecity. There was no blooming artifact on gradient recalled echo (GRE) images. Alignment was intact.\nPosterior half of her T10/11 disc was destroyed and end plates eroded. There was presence of thick walled paravertebral soft tissue collection with epidural extension from T9-T12 with cord compression and oedema (, , ).\nThe MRI features were suggestive of an infective process with differential diagnosis of tuberculosis, Langerhans cell histiocytosis, leukaemia, lymphoma and metastatic tumour.\nMantoux test was positive at 12mm.\nAfter analysing her clinical features and investigations, we came to the working diagnosis of spinal tuberculosis with thoracic myelopathy with the differential diagnosis of haematological malignancies.\nPosterior decompression surgery was decided as there was no significant anterior column destruction and instability. Emergency laminectomy at T10 and T11 levels was carried out, which however was technically challenging.\nSpecial efforts were made to preserve the facet joints to avoid post-operative instability. There was no frank pus nor slough present. A thick walled whitish soft tissue of firm consistency was identified (). This tissue was found encasing the spinal cord. Gentle and careful dissection separating the soft tissue off the spinal cord was done, with a neurosurgeon on standby. The risk of dural tear was high with the presence of infection and tissue adhesions. Manipulation of her cord to allow clearance of the infective cord encasing tissue also posed risks of neurological complications.\nSuccessful clearance of the soft tissue exposed an intact, healthy, shiny and pulsating dura (). Bone fragments and epidural soft tissue were sent for histopathological examination, culture and sensitivity. A body cast was applied postoperatively.\nHPE was reported as caseating granulomatous inflammation (, ). No organisms were cultured. Ziehl-Neelson staining was negative. It was concluded that this child had extradural tuberculoma with neurological manifestation without any spinal deformity and relatively normal radiographs.\nPostoperatively, anti-TB chemotherapy was initiated. On the 2nd post-operative day, her motor power at L2 myotome improved by two grades; however L3 and below were still grade 0. Her rehabilitation was continued. On the 12th week post-operative follow-up, the body cast was removed. She was able to ambulate independently with ataxic gait. Neurological assessment revealed MRC grade 4 power for L2 to L4, grade 3 for L5 and S1 bilaterally. Sensation was normal for from L1 to L3, reduced for L4 and L5 and absent for S1.\nAt 25th week post-operative follow-up, neurological assessment revealed MRC grade 5 power and intact sensation from L2 to S1 bilaterally. She was able to ambulate independently with normal gait.\nAlthough she has now been successfully treated with full neurological recovery, she is still under our follow-up to monitor her local spinal vertebral growth which may have been by the inflammatory process. Currently her spinal alignment is still maintained and there is no evidence of late onset deformity at 2 years follow-up. |
A 43-year old, asymptomatic woman was admitted to our hospital by her family doctor after receiving a chest-x-ray during routine clinical examination. The x-ray showed a mediastinal mass overlapping the aortic arch region (Fig. ). For verification a computed tomography (CT) was performed and revealed incidentally a type B dissection, which was most likely chronic without information of the index date, originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm (Fig. ). The left renal artery, the coeliac trunc and the main part of the superior mesenteric artery branched from the false lumen without a sign of malperfusion of the organs. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Before intervention the patient got a blood pressure adjustment by ACE inhibitor. Betablocker was not necessary because of a resting pulse under 60 beats per minute. For neurological online monitoring, sensitive and motor evoked potentials were monitored. Spinal drainage was installed 1 day before the procedure. Surgical access was carried out through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space (Hemi-Clemshell). Simultaneously to the preparation of the aneurysm, partial cardiopulmonary bypass was installed in the left groin by cannulation of the femoral artery and vein under echocardiographic guidance. During selective ventilation of the right side, the left lung was mobilized by transsection of the Ligamentum pulmonale and preparation of the perianeurysmatic tissue and adhesions. After identification and preparation of the recurrent and phrenic nerve and the supraaortal branches, the descending aorta was clamped and a distal anastomosis performed with a straight graft (20 mm). The visceral arteries partially branched from the false and true lumen without a sign of malperfusion. Before the final distal anastomosis, we performed a fenestration of the dissection membrane about a length of 5 cm to keep the perfusion of both lumina. The left carotid artery originated from the aortic arch with a distance of only 1 cm from the aneurysm. The left axillary artery branched directly from the aneurysm and was dissected and reimplanted with a separate 8 mm sidegraft to the 20 mm straight graft between the distal arch and proximal descending aorta. (Fig. ). The procedure was performed with partial cardiopulmonary bypass (CPB) of 87 min, aortic clamp time of 62 min under normothermic condition. The patient was extubated on first postoperative day and recovered well.\nBiopsy of aortic tissue showed a picture consistent with arteriosclerosis and loss of smooth muscle cells, rupture of the elastic fibres and fibrosis of the media. The intima could not be visualized in detail.\nThe patient was discharged to cardiac rehabilitation at 13th postoperative day and recovered well. Last follow up with computed tomography was performed 3, 5 years after initial operation with a good and stable result of the dissection membrane and a perfusion of both lumina. The patient is able to resume a normal life without limitations. |
A 13-year-old white boy born with a complete unilateral cleft lip and alveolus was receiving orthodontic treatment. He was referred for surgical treatment. A clinical examination showed his left middle incisor in an ectopic position in his frontal vestibule. The root was twisted to the midline and the crown was heavily displaced to the lateral side (Fig. ). The occlusion was not acceptable. An orthodontic tooth movement would be too difficult and cause side effects, such as periodontal problems, or reabsorption of the root or adjacent permanent teeth. An immediate removal of the tooth and insertion of a dental implant was not the treatment of choice due to his young age and incomplete jaw growth. Our main long-term aim was to preserve as much bone as possible in his compromised cleft area.\nThe psychological aspect of this condition should not be underestimated because he was ashamed of his front teeth and was not able to smile. He describes the appearance of his maxillary anterior teeth as unaesthetic. In cooperation with the Department of orthodontics, a decision for surgical intervention was made.\nThe transplantation of the incisor was performed using the standard treatment protocol according to Kirschner and the updated protocol by Pohl [, ]. The operation procedure included a careful preparation of the tooth so that the periodontal ligament could be preserved vital (Fig. ). A dental splint fixed the tooth for 3 weeks. His postoperative course was uneventful and without complications. The orthodontic treatment to align the remaining teeth followed after 7 months. The transplanted central incisor was included in the fixed multibracket appliance and our patient did not show any atypical symptoms or reactions. In the follow-up 24 months later, the tooth was still functional without any clinical signs of pain or infection (Fig. ). Radiography illustrated a reintegration of the root in the surrounding bone and the periodontal gap could be seen (Fig. directly after transplantation, Fig. after 24 months). No bone loss or reabsorption of the root in terms of replacement or infection reabsorption could be diagnosed. The soft tissue around his frontal teeth at the cleft site was stable; even his vestibule developed positively and was deeper than before.\nThe guidelines of the International Association of Dental Traumatology (IADT) for the success or failure of replantation describe the success criteria as clinically asymptomatic, normal mobility, no apical lesion in a radiograph, and no reabsorption or ankylosis of the root []. The presented case fits all the criteria; however, the mobility could not be tested due to orthodontic treatment. |
The patient, a 32-year-old Caucasian woman, presented to the West Virginia University Hospital Emergency Department via Emergency Medical Services. The patient had been at her usual baseline state of health with no significant past medical history prior to visiting the chiropractor for neck adjustment earlier that day for tension like soreness. The patient underwent neck manipulation after which she immediately complained of neck pain, diaphoresis, and proceeded to experience cardiac and respiratory arrest. Emergency Medical Services was called, and cardiopulmonary resuscitation was performed with one round of epinephrine administered. It was reported that the patient was pulseless and apneic for 3 minutes prior to EMS arrival. The patient was intubated on transport and her Glasgow Coma Scale score was 3T prior to arrival. Mean arterial blood pressure was 80 with palpable femoral pulses at arrival to the emergency department. Upon arrival in the emergency department, a CT stroke protocol was performed which demonstrated bilateral severe distal cervical vertebral artery dissections with acute thrombotic emboli seen in the left cervical vertebral artery ( and ). This was accompanied by complete occlusion of the basilar tip including the proximal posterior cervical arteries.\nThe patient received an initial bolus of intravenous tissue plasminogen activator (IV rtPA) at this time and the decision was made to proceed with endovascular intervention given the recent onset of occlusion. The patient was brought to the neurovascular angiography suite and femoral access obtained. Angiography of the left vertebral artery demonstrated severe dissection involving the distal cervical vertebral artery segments at the C1-C2 level with presence of sub occlusive thrombi. There was an occlusive clot in the left Posterior Inferior Cerebellar Artery (PICA). Intracranial imaging demonstrated occlusion at the basilar apex with absent filling into the right Posterior Cerebral Artery (PCA). There was occlusion of the distal left PCA. Angiography of the right vertebral artery demonstrated severe dissection of the distal cervical vertebral artery at C1-C2 with the presence of trickle-like flow into the vertebrobasilar junction. No filling was observed in the right PICA territory (). At this point, it was decided that the left vertebral artery offered the best access to the basilar trunk.\nSubsequently, distal aspiration was begun with a Penumbra 5 Max ACE distal aspiration catheter which initially demonstrated slow flow through the suction tubing. The 5 Max ACE was withdrawn into the proximal basilar artery until flow was seen within the suction tubing. Repeat angiography at this time demonstrated recanalization of the basilar apex and proximal PCAs. TICI3 perfusion was seen in the right PCA. Occlusive clot remained in the left distal P2 segment. Given the large size of the PCA, timing of events, and patient’s age, the decision was made to attempt clot retrieval of this. At this time, the Trevo ProVue microcatheter was navigated into the left distal PCA distal to the clot. The Trevo 4 mm × 30 mm stent retriever was deployed for approximately 3 minutes. The suction canister was attached, and the stent retriever was pulled with distal aspiration. No significant recanalization was achieved with what amounted to TICI0 perfusion to the left PCA territory. No further attempts were made as it was believed that the left PCA territory had completed its infarction.\nFollowing completion of endovascular therapy, the patient was taken for immediate MRI Brain with and without contrast for assessment of brainstem integrity and cerebrovascular status prior to transport to the intensive care unit. MRI demonstrated extensive areas of restricted diffusion accompanied by perfusion abnormalities consistent with acute infarction of the posterior circulation, specifically within the bilateral cerebellar hemispheres, right medulla, pons bilaterally, midbrain, thalami, and left occipital lobe (). The following day, additional CT Brain imaging was acquired and demonstrated signs of elevation of intracranial pressure with hydrocephalus, worsening of cerebral edema diffusely, hemorrhagic transformation of the left occipital lobe, continued infarct evolution within the posterior circulation, and cerebellar tonsillar herniation. |
A 37-year-old man visited a private ophthalmic clinic because of diplopia that was aggravated during his upward gazing. No significant abnormalities were found upon ophthalmologic examination except for a mild conjugation problem occurring during his upward gazing. He was referred to the department of neurosurgery of our institute and he underwent a brain CT. The brain CT showed acute hemorrhage in the third ventricle and there were also spots of calcification (). This hemorrhage showed mixed signals that indicated different ages of the pathology, but there was no hemosiderin rim on the T1- and T2-weighted MR (). The clinical differential diagnosis was primarily split between intratumoral hemorrhages originating from a pineal germ cell tumor, specifically choriocarcinoma vs. hemorrhage from a pineal cyst. The presence of a cavernous malformation was considered to be a less likely diagnostic possibility. We were easily able to rule out the possibility of vascular malformations because MR angiography revealed no such abnormalities (). Two weeks later, he experienced an improvement in the diplopia, but the headache that he had been experiencing became progressively more severe. Brain CTs, performed weekly after the first attack of symptoms, revealed a resolving hemorrhage and the progressively enlarging ventricles (). We performed VP shunting using the HAKIM programmable valve without the prechamber Shunt System, and it was adjusted to an opening pressure of 120 mm CSF. Two days after the shunting, he complained of a sudden aggravation of his diplopia. The follow-up brain CT revealed rebleeding from the previous lesion (). The patient underwent an emergency operation consisting of an occipital-transtentorial approach to the pineal region, and this resulted in the complete excision of a discovered tumor and the removal of the hematoma. The lesion mass was composed of acute and subacute hematomas and it was well encapsulated. These surgical findings corresponded to a cavernous malformation. The mass was easily separated from the surrounding tissues that included the midbrain. Although the mass had some fibrous connection with the internal cerebral vein, it was successfully removed in its entirety without any violation of the deep venous structures. After surgery, his conjugation problem was not completely resolved right away, but he was otherwise in good health (). The pathology of this case was confirmed as being a cavernous malformation (). |
Our patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.\nThe foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.\nTaking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.\nAs far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.\nConsidering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an immediate transfer to the Gynaecology and Obstetrics unit of our structure. Due to the critical care panel and the low clinical conditions, the patient was intubated and housed in the ICU department. Considering the acute distress syndrome, a chest CAT scan was performed highlighting the presence of a left pAVM expanded, associated with a massive hemothorax that compressed the correspondent lung. The vital signs panel showed systolic blood pressure of 70 mmHg, diastolic blood pressure of 35 mmHg, pulse rate of 150/min, pulse oximetry saturation 88% on 100% inspired oxygen, afebrile temperature, and respiratory rate of 40/min. Initial labs revealed normal platelets, normal coagulation panel, and haemoglobin of 7 gm/dL. Critical care panel showed pH of 7.4, pCO2 of 43 mm hg, pAO2 60 mmHg, and saturation of 88%. After the placement of a chest tube, 3 litres of frank blood were removed; this action resulted in a normalization of the blood pressure and improved oxygenation on the monitor. The successive management was the clinical observation of the patient's conditions as well as the vital signs and labs test in order to perform the pAVM embolization when the patient clinical conditions will be stable. After three hours from the drainage, worsening of the patient conditions was observed reporting a severe collapse of the vital signs as well as a decrease of antithrombin III, fibrinogen, and haemoglobin values, with parameters of 33%, 122 mg/dl, and 5.8 gm/dl, respectively. Moreover, considering the postoperative caesarean course, the gynaecologic clinical evaluation showed a low uterine fundus contraction and the presence of conspicuous abnormal lochia. Uterine fundal massage was performed as first approach to solve the uterine low contraction followed by Credè's manoeuvre. Due to the failure of both, a pharmacological treatment was attempted starting with a simultaneous administration of intravenous Oxytocin (10-40 UI per 1 litre saline solution) and intramuscular Methylergometrine (0.2 mg one dose). The latter pharmacological approach involves the use of intravenous Sulprostone (0.5 mg per 1 litre saline solution) that was administered within half an hour from the signs of low uterine contraction and abnormal lochia. None of the previous pharmacological treatments succeeded.\nConsidering the reproductive age of the patients, procedures as appositions of tamponade-balloon and embolization of the uterine arteries were taken into account but were not applicable in order of the unstable and precipitant parameters of the woman. Due to the patient's life-threating condition, a simultaneous surgical intervention of thoracic surgeons and gynaecologists had been necessary to solve the urgency, with the performance of a contemporaneous surgical reparation of the pAVM and resection of damaged left lower lobe (LLL) as well as a preventive hysterectomy to avoid the risk of disseminated intravascular coagulation (DIC). The surgical interventions were performed successfully but intraoperative blood transfusions and administration of antithrombin III and fibrinogen were necessary. The postoperative treatment showed a normalization of vital signs and labs panel as well as patient's clinical conditions. Due to the stable condition of the woman, the anaesthetist established the patient's autonomous breathing. After one week from the intervention, chest CT with intravenous contrast was performed showing a 4 cm area of active contrast. Pulmonary angiography confirmed the presence of a pAVM with feeding branch of a basilar left pulmonary artery supplying aneurysmal AVM and dilated draining vein. Transcatheter embolotherapy (TCE) of the culprit vessel was performed by placement of a nonadhesive liquid embolic agent (Onyx 34®). Repeated chest X-ray and chest CT after one week from TCE showed expansion of remaining left lung and signs of pAVM embolization and pulmonary resection of LLL, respectively (). The patient course was subsequently uncomplicated and the discharging home happened after 14 days. MRI evaluation was performed in order to detect any head AVM but the result was negative. The genetic testing for HHT was not performed during this hospitalization period but the genetic examination performed a few months afterwards showed no association. |
A 33-year-old woman was admitted to psychiatry inpatient with a complaint of suicidal ideation. The patient has a past history of multiple psychiatric disorders like BPD, MDD, and anxiety issues for about last eight to 10 years. She had multiple suicide attempts in the past most recent being two weeks back when she tried to suffocate herself with the help of a medical device tubing. On inquiry, she said she just wanted to feel the pain, not kill herself. On further questioning, she was found to have passive suicidal thoughts as well as an active plan to harm herself. Her plan was to kill herself with the carbon monoxide poisoning by turning on the engines of four cars parked in the garage. According to her, she felt better at the time of the last admission and these suicidal thoughts just returned two to three days back. She had multiple admissions and emergency department (ED) visits related to her psychiatric conditions as well as five suicidal attempts. During one of her admission when she took multiple tablets of Advil® (Pfizer, New York, USA) in an attempt to kill herself, she was evaluated for ECT by a psychiatrist but the decision was made in favor of dialectical behavior therapy (DBT) as they felt these symptoms are because of her BPD. According to the patient she has been compliant with the therapy that has helped her in coping day-to-day issues. The patient also confirmed that she has never recovered from these active and passive suicidal thoughts which have progressed to even worse state in the last four months.\nOn further evaluation, the patient reported feelings of hopelessness and worthlessness most of the time along with a guilt of things for what she has done in the past. She also reported a decrease in sleep to about five hours per night along with difficulty in staying asleep and poor appetite and energy. Her concentration was normal. She continues to engage in her interests in reading and photography. The patient states she has been a "warrior" for years. She endorses a few prior panic attacks where she felt shaky, short of breath, and had chest pain. She could not recall how long they lasted or when her last episode was. Screening for mania, psychosis, and obsessive compulsive disorder was unremarkable. There was no reported history of alcohol, tobacco, or illicit drugs.\nMinnesota multiphasic personality inventory-2 (MMPI-2) results suggested the presence of depression, anxiety, overall distress, and a personality disorder. All of these scores are in the moderate to severe ranges and are rather similar to one another. The psychologist during this visit interpreted that these results do not suggest that the personality disorder is the main factor driving her clinical presentation and that her presenting symptoms are due to MDD. She was recommended ECT as it was determined that these symptoms are due to resistant MDD.\nThe patient had a past history of multiple psychiatric drug trials in the last eight years which included medicines like fluoxetine, sertraline, venlafaxine, amitriptyline and even augmented therapy with antipsychotics was tried with aripiprazole and thyroxine which all proved ineffective in this patient. Considering her condition and beneficial outcomes in such a treatment-resistant patient, a trial of ECT was the consensual decision of all the panelist psychiatrists. The patient agreed to this mode of therapy.\nThe first session was done with the parameters mentioned in Table .\nAfter the first session parameters were changed for the rest of the 12 sessions which are mentioned in Table .\nA total of 16 sessions were conducted with a break after 13 sessions. The frequency of sessions was three per week for the first 10 sessions and then two sessions every week and last three sessions were conducted once a week. The patient was evaluated after every session and there was a remarkable improvement from the sixth session onwards. After 13 sessions there was a thorough evaluation and the patient reported improved mood and no active or passive suicidal ideations and she was discharged. She remained symptom-free for four to five months but then reported again with another suicide attempt. She was restarted on ECT, and 16 more sessions were conducted with the same frequency and same parameters.\nOn her recent visit, she endorsed a significant improvement in her depressive symptoms and denied active suicidal ideations. She also reported an improved quality of life. |
A 13-year-old female was admitted to hospital for acute demyelinating polyneuropathy confirmed by electromyography and nerve conduction studies; later on a diagnosis of Guillain Barré Syndrome was confirmed. A complementary MRI performed as part of in-hospital management showed an incidental finding of a cystic lesion in the vertebral body of C2 (). The only symptom reported by the patient was cervical pain irradiated to shoulders. The physical exam was unremarkable, and no deformities nor neurologic alterations were noted. The patient started using a Philadelphia collar and restriction of exercise was recommended.\nThe case was discussed at the neurosurgery, spine surgery, and neuroradiology service meeting and extension studies such as angiotomography of carotid arteries and vertebrobasilar system and bone scintigraphy were requested to determine the etiology of the lesion because the management and prognosis vary according to the type of tumor. Studies concluded it was a tumoral lesion with benign characteristics. Additionally, correlation with computed tomography (CT scan) revealed a focal hypodense lesion in the right half of the vertebral body of C2 with disruption of the inferior cortical. Because of the elevated risk of fracture and collapse of the vertebra due to the thinning of the cortical the optimal treatment considered was surgical resection of the tumor to prevent further neurological lesions. Cervical curettage followed by tumor excision was performed. A lateral submandibular approach to the upper cervical spine was used and bone resection was performed with a radiofrequency assisted burr, no instrumentation or fixation was required. Intraoperatively a cystic lesion with fibrotic and nodular material was evidenced; later histologic examination ruled out giant cell tumor and aneurismatic bone cyst (). The stability of the defect was ensured by filling it with cortical/cancellous allograft and by prescribing a postsurgical plastic cervical collar to maintain neck immobilization.\nPostoperative evolution was satisfactory. The patient remained with a CTLSO immobilization for 4 months. At 6 and 12 months, the patient presented no symptoms and the postoperative CT scan showed adequate integration of the graft as shown in . |
A 41-year-old non-smoker obese female patient was examined at the Department of Neurology and the Center for rehabilitation. Relevant history of the patient is summarized on a timeline in Fig. . She showed an onset of neuromuscular disorders during early childhood with a delay in motor and written language development. She had a hard time to complete physical exercise at school and always finished last. There was nothing really alarming in terms of muscle disorder until her first pregnancy at the age of 33 during which she experienced shortness of breath (dyspnea) at the 7 months of gestation and showed signs of weakness of lower limbs afterwards. At the age of 34 she showed worsening of breath symptoms, suffered from sleep apnea and started using a mechanical ventilation machine. Alarming symptoms of skeletal muscle disorders occurred immediately after delivery with progressive but rapidly incapacitating weakness of lower limbs. This worsened during the 3 following years, a period during which she first started being unable to get up by herself and then was unable to climb stairs. At the age of 37, she started to use a cane, then a walker for her daily walking needs. At the age of 39, she started using a wheelchair to move outdoors. Despite these signs of progressive muscle weakness, she never had a thorough neuromuscular investigation. It was wrongly thought that her health problems, in general, was mainly related to being overweight. At the age of 41, she had four episodes of lower limb paralysis during which she was completely unable to move her legs and support her weight. She did not seek medical consultation for the first three episodes. For the fourth, she was admitted to the emergency room (ER) and first referred to the Department of Neurology and then to the Center for Rehabilitation.\nThe family history showed that her mother died at the age of 66 from a heart attack associated with non-compaction cardiomyopathy. There is nothing remarkable in terms of muscle disorders in her father, brother, and sister. However, her only daughter, now at the age of 11, shows signs of muscle disorders with congenital muscular torticollis, excessive growing pains as well as underdeveloped muscles in half of the body.\nPhysical examinations conducted following her admission to the ER at the age of 41 showed normal tone/bulk of the arm muscles. However, muscles in shoulders and upper and lower limbs showed bilateral weakness. Deltoids, biceps and triceps showed moderate weakness with MRC scale of 3/5. Fine finger movements were intact. There was no pronator drift. In the lower limbs, all muscles examined showed the same severity of weakness (2/5) except quadriceps which showed mild weakness (4/5). Hip flexors were extremely weak (1/5); hip abductors and adductors were mildly weak (4/5). Knee extensors and flexors were moderately weak (3/5). Dorsiflexion of feet was severely weak (2/5). Plantar flexors were severely weak (2/5). Deep tendon reflexes were 2+ in the arms, absent in the patella and Achilles. The toes were down-going. No sensory deficit was observed. No sign of dysphagia or involvement of ocular muscles was observed.\nAdditional physical examination conducted during the 2-year follow-up (at the age of 43) showed no worsening of muscle strength. However, this brought new information about the weakness of other muscles, notably in the shoulders, with extremely weak abductors and flexors (1/5). The patient showed decreased perception of vibration in the lower limbs. She reported that she experienced occasional dysphagia.\nElectrophysiological exams showed normal nerve conduction velocities for upper and lower limbs, with all SNAP and CMAP amplitudes in the range of normal values. However, needle EMG revealed a tendency of myotonic potentials, generated by needle insertion. Right deltoids, biceps and ulnar-innerved first dorsal interosseus muscles showed myotonic potentials as well. The right tibialis anterior showed 2+ polyphasic motor unit potentials with myotonic potentials. The right medial gastrocnemius, vastus medialis and vastus lateralis showed myotonic tendencies as well.\nExamination of muscle biopsy of left quadriceps showed features of an end-stage process, consistent with a severe, chronic myopathy. There are scattered clusters of viable muscle fibers which showed myopathic features in the form of a marked variation in fiber size and numerous internal nuclei. In addition, there are scattered fibers with abundant intrasarcoplasmic vacuoles (Fig. a, b). Given we could not clearly observe the presence of hyaline bodies on H&E staining we decided to proceed with p62 immunostaining, a well-known technique for revealing the presence of inclusion bodies []. Immuno-histochemical detection of p62 was performed on a Leica Bond III automated stainer. Following digestion in a low pH citrate solution, sections were incubated in a primary mouse monoclonal anti-p62 antibody, diluted 1:50 (BD Transduction Laboratories Catalog Number 610833). Detection of bound antibody was achieved using the Leica Bond Polymer Refine Detection kit, comprising the secondary antibody, the substrate chromogen DAB (3,3′-Diaminobenzidine tetrahydrochloride hydrate) and the Hematoxylin counterstaining solutions. Immunostaining for p62 revealed, in a proportion of the surviving muscle fibers, diffusely distributed, small intermyofibrillar dots or, more commonly, larger central or eccentric sarcoplasmic inclusion bodies (Fig. c, d). Examination of heart function using Holter ECG monitor carried out following her admission to the ER showed no clinically significant implication of cardiac involvement. However, the patient complained about repeated episodes of oppressive chest pain during the following years. Additional examination conducted during the 2-year follow-up showed signs of cardiac involvement with bradycardia of 58 beats per minute.\nRegarding respiratory involvement, the patient suffered from dyspnea since the age of 34. Examination of lung function conducted following her admission to ER and during the follow-ups showed worsening of her respiratory condition. Spirometry test conducted at the age of 44 showed a very weak pulmonary function, with forced vital capacity (FVC) of 27% and forced expiratory volume in a second (FEV1) of 29% of normal values.\nThe blood samples were collected for whole-exome sequencing (WES) to detect mutations potentially involved in the phenotype of neuromuscular disorders observed for this patient. The genomic DNA was extracted from whole blood and subsequently subjected to whole-exome DNA library construction using the Ion AmpliSeqTM Exome RDY panel (Thermo Fisher Scientific) essentially as described in the manufacturer’s protocol, with barcode incorporation. For the sequencing, samples were loaded on an Ion HI-Q PI Chip v3 and placed onto the Ion Proton instrument (Thermo Fisher Scientific) together with an Ion PI HI-Q sequencing 200 Kit (Thermo Fisher Scientific) and sequenced for 520 cycles according to the manual (See Additional file : Table S1 for parameters). All candidate mutations found by WES were validated by direct Sanger sequencing (See Additional file : Figure S1 for the filtering process). DNA sequences were obtained from the University of California Santa Cruz (UCSC) Genome Browser. Predesigned primers were directly purchased from Thermo Fisher Scientific (See Additional file : Tables S2 for details). Amplicons were sent to Genewiz () for Sanger sequencing.\nWhole exome sequencing showed that a novel variant NM_000257.3: c.1370 T > G (p.Ile457Arg) in the MYH7 gene is a missense single nucleotide variant possibly linked to the clinical findings, found in the DNA of the patient as heterozygous (Fig. ). The novel variant has been submitted to ClinVar database; with the assigned accession number SCV000804311. Two other candidate mutations were identified in the DNA of this patient, namely NM_003085.4:c.368C > A (p.Pro123His) in the SNCB gene and NM_001001557.3:c.746C > A (p.Ala249Glu) in the GDF6 gene (Additional file : Table S3). However, both mutations were discarded after filtering only genes involved in neuromuscular functions that potentially cause clinical features of muscle myopathy observed in this patient (Additional file : Figure S1). Regarding the novel variant NM_000257.3: c.1370 T > G (p.Ile457Arg), bioinformatics analyses showed that nucleotide T coding at the position 1370 of the MYH7 gene is highly conserved across 44 vertebrate species (PhyloP at 1.76). Amino acid substitution from Isoleucine (I) to Arginine (R) at the position 457 of MyHCI suggested a high impact on protein structure (Grantham at 97). Results of analyses obtained from VarSome () suggested a classification of Likely pathogenic for this variant, with evidence of Pathogenic computational results coming from 8 various prediction software including DANN, GERP, dbNSFP.FATHMM, MetaLR, MetaSVM, MutationAssessor, MutationTaster and PROVEAN (vs no benign predictions). Also, the results of analyses using the recommendation of the ACMG and the AMP suggested the same classification of Likely pathogenic for this variant, with combined criteria of 2 moderate (PM1 and PM2) and 2 supporting (PP2 and PP3) []. |
A 59-year-old Asian male presented to the gastroenterology office for a follow-up of a previously found duodenal lesion. He had an EGD at an outside facility 2 years earlier for evaluation of abdominal pain which showed a 1.2 cm duodenal polypoid lesion in the second portion of the duodenum. Pathology of the polyp revealed heterotopic gastric mucosa with benign lobules of gastric glands. He also was found to have chronically active H. pylori gastritis with numerous Helicobacter organisms and atrophic gastritis with patchy areas of intestinal metaplasia. At that time, he was instructed to follow up for a repeat endoscopy for surveillance in two years. As recommended, two years later he presented to our office for surveillance of his duodenal lesion. Due to his history of atrophic gastritis and a large duodenal lesion, we performed an upper endoscopy that showed atrophic gastritis, duodenitis, and a single 10 mm polyp in the second portion of the duodenum. The duodenal polyp was biopsied. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypia including nuclear enlargement, stratification, nucleoli, and few mitoses. The patient was referred for endoscopic ultrasound to further characterize the lesion and complete resection. Several weeks later he underwent an endoscopic ultrasound that revealed a 13-mm pedunculated and sessile polyp on the lateral wall opposite to the major papilla in the second portion of the duodenum (). The polyp was removed en bloc using a hot snare following a 4-mL saline lift. Two endoclips were placed for hemostasis. Pathology revealed a pyloric gland adenoma (Figures , , and ) with predominantly low grade dysplasia (Figures and ) and some small areas of focal high grade dysplasia. The slides were read by the in-house pathologist and were also reviewed by a GI expert pathologist at the University of Michigan. The patient was recommended to follow up for surveillance upper endoscopy in 6 months due to the areas of high grade dysplasia found on pathology. He was lost to follow-up for over one year. Fifteen months after the PGA was removed, the patient did follow-up for a surveillance upper endoscopy. A duodenal scar was found at the site of the PGA and a biopsy was taken from the site. There was no evidence of residual pyloric gland adenoma. The patient was then recommended to follow up for surveillance endoscopy in 5 years in accordance with the ASGE guidelines for surveillance of gastric adenomatous polyps. |
A 7-year-old boy was referred to the Pediatric Dentistry Department of Mashhad University of Medical Sciences with the chief complaint of severe rotation of the upper anterior tooth. There was no relevant and remarkable medical history reported. The clinical examination showed good facial symmetry and competent lips at rest. Intraoral examination showed Class П molar relationship with about 90° rotation of left maxillary central incisor. The rotated tooth was not fully erupted [Figure and ]. Class I skeletal pattern with no vertical problems was confirmed by cephalometric analysis and there were no transverse problems. Radiographic examination confirmed severe rotation of left maxillary central incisor and early stage of root development []. Space analysis on the study models shows a lack of space in both jaws. At the first visit, an alginate impression was taken from upper arch and a removable appliance consisting of acrylic base plate, circumferential clasps on the maxillary primary canine and Adams clasp on the maxillary permanent premolar and first molars was made. In the later appointment, a bonded mandibular first molar buccal tube (Dentaurum, Germany) was placed on the labial surface of the rotated central incisor. Whip spring was constructed with a segment of 0.4 mm stainless steel orthodontic wire (0.0016 inches) (Dentaurum, Germany) ligated into place. In order to protect buccal mucosa and gingiva from irritation the patient was instructed to wear the appliance fulltime and only to remove the appliance for tooth brushing after eating.\nIn every follow-up appointment, with a month interval, a new whip spring was fabricated. After 5 times replacement of the spring, rotation was almost corrected []. At the end of treatment, supracrestal fiberotomy was performed and alginate impression was taken of the upper jaw in order to construct a removable appliance for retention. This appliance was made of acrylic base plate, labial bow on anterior segment and Adams clasp on the maxillary permanent first molars []. There were no pathologic findings in the radiographic view []. |
A 69-year-old male patient was admitted for right hip pain. The patient had been healthy until he developed a cardiogenic cerebral infarction in 5 years prior to this presentation. Although the details were unclear, the patient had suffered a gunshot wound to the right thigh and the superficial femoral artery had been ligated to achieve hemostasis 40 years previously. He had also been thrown from a bridge of approximately 40 m in height. At that time, he injured his waist and back, however, he successfully recovered while being conservatively treated. The relationship between these traumatic events and the current event was unknown; however, he had been aware of a pulsatile mass in his right groin for at least 20 years. Subsequent contrast-enhanced abdominal computed tomography revealed the presence of an irregular aneurysm from the right common iliac artery to the right common femoral artery, the maximum diameter of which was 50 mm (Fig. , ). Since the patient had no history of connective tissue disorders or vasculitis, and a blood analysis revealed no inflammatory findings, we clinically diagnosed the patient with a right iliac arterial pseudoaneurysm, which was thought to have been caused by an old infection or past trauma. We performed surgery to resect the aneurysm and performed in situ reconstruction with a bifurcated vascular prosthesis (Hemashield 16 × 8 mm; MAQUET Holding B.V. & Co. KG, Rastatt, Germany). Since the right common femoral artery was enlarged and showed severe adhesion to the surrounding tissues due to previous surgery for the gunshot wound, we decided to use the right deep femoral artery for peripheral anastomosis. On entering the abdominal cavity, the right iliac arterial aneurysm was irregular, with a whitish surface, and it adhered to the small intestines. These findings were suggestive of chronic inflammation. According to the usual procedure, the prosthetic bifurcated graft was anastomosed to the transected aorta, distal of the inferior mesenteric artery, and the left limb of the graft was anastomosed to the left common iliac artery. When the right limb of the graft was introduced to the right inguinal region through the incised common iliac arterial pseudoaneurysm, we found that the right external iliac arterial aneurysm had penetrated the right common iliac arterial aneurysm. Part of the aneurysmal wall was excised and submitted for culturing and microscopic examination. The reconstructed prosthetic bifurcated graft was wrapped with the remaining aneurysmal wall and omentum. No bacteria were detected in the resected aneurysmal wall tissue, and a pathological examination showed that the arterial wall structure had disappeared and been replaced by fibrous tissue with hyalin, hemosiderin, and macrophage infiltration (Fig. , ). No recurrence of any other infection or inflammation was observed during the 1-year follow-up period (Fig. ).\nPseudoaneurysms are often caused by infection or trauma. The number of iatrogenic cases has increased in recent years; however, the patient in our case had never undergone laparotomy or interventional procedures in the past. Furthermore, symptoms due to aneurysms are likely to appear early after trauma, and the rupture of a pseudoaneurysm represents a life threatening event [, ]. Few cases describe symptoms that appeared several years later [, ]. Our case had experienced traumatic events 40 years previously and had been aware of a pulsatile mass in his right groin for at least 20 years. Based on this evidence, it is assumed that the pseudoaneurysm of the iliac artery increased chronically. Although stent grafts have been reported to be effective for the treatment of pseudoaneurysms [, ], we decided to perform open surgery because the aneurysm extended to the common femoral artery, which meant that there was not enough landing zone for stent graft.\nNo pus or ascites was observed during surgery, and there were no findings of infection from cultures or resected specimens. Additionally, the iliac arterial aneurysms had penetrated each other and a pathological examination showed that the arterial wall structure had disappeared. We considered that the iliac arterial aneurysm had been caused by past trauma and that it might have been sealed by surrounding tissue in the retroperitoneal cavity and gradually increased in size. Thereafter, the pseudoaneurysm gradually expanded and became associated with local infection and inflammation from the common iliac artery to the common femoral artery. The possibility of infectious aneurysms was ruled out based on the lack of inflammatory findings and the negativity of the blood culture. Indeed, no apparent infections were observed intraoperatively or in an examination of the excised specimens. As a result, the postoperative course was uneventful, and no recurrence of any other infection or inflammation was observed during the 1-year follow-up period. |
A two-week-old female was brought in with an initial complaint of multiple masses that failed to regress since birth. She was born from a nonconsanguineous union and the mother’s pregnancy was uneventful. The baby was delivered vaginally at 37 weeks of gestation and multiples masses were found over the body. The treating physician advised follow-ups on discharge. However, the parents decided to seek more medical help for the child and she was admitted for more investigations.\nOn physical exam, the child was alert and active. She was not jaundiced and no pallor was noted on the extremities. Her vitals were all within the normal range and the birth weight and changes in weight corresponded properly. Two masses measuring 26 mm by 19 mm and 19 mm by 17 mm were observed on the forehead and the scalp (Figures -). One smaller mass was seen on the abdomen, measuring 11 mm by 10 mm (Figure ). All three masses were red and non-hemorrhagic. The parents reported that the size of the masses did not change since birth. No similar family history was found and both parents were healthy. Any hepatosplenomegaly was not observed on palpation nor were any other cutaneous lesions detected. She did not present with any other systemic abnormalities. An ultrasound was performed, and it revealed a normal liver, spleen, and kidneys with no masses or lesions. A Doppler examination also showed a fast-flow vascular lesion, as reported by many other articles []. The full blood count showed normal levels of white blood cells, platelets, hematocrit, and red blood cells.\nThe diagnosis of congenital hemangioma was confirmed and the family was properly educated about the condition as well as possible complications. A wait and watch approach was adopted and the child was scheduled for regular visits at three months. The family was asked to properly monitor the size of the masses and informed that appropriate surgical treatment would be provided if the masses fail to regress or if they continue to grow. |
A 2-year-old boy presented to our unit with facial deformities from birth. He was the first child of non-consanguineous parents born after a regular pregnancy and delivered by caesarean section. The mother suffered no medical conditions and did not use any drugs or consume alcohol during her pregnancy. The family history was negative for craniofacial or other congenital malformations. An echocardiogram performed immediately following delivery showed a small defect in the peri-membranous portion of the patient's ventricular septum. A magnetic resonance imaging of the brain performed 26 days after birth showed normal findings. Abdominal ultrasound was also normal.\nThe patient's developmental milestones were normal. On clinical examination, a circumferential band of scarring was noted on the face. The band of scarring extended from the base of the right side of the nose toward the outer canthus of the right eye, extending in an oblique direction toward the scalp and then curving in a circular manner to involve the left supra-orbital ridge and extend to the base of the nose on the left side.() The upper and the lower eyelids of the right eye together with the lower palpebral conjunctiva and globe were involved in the scarring, causing proptosis, corneal opacity, prolapse of the lower palpebral conjunctiva, and loss of vision in the right eye.() The vision in the left eye was intact, although mild traction of the lower eyelid caused increased scleral exposure of the left eye. No other abnormalities were noted.\nA computed tomography scan of the brain and facial bones revealed that the right orbit was smaller in volume than the left.() The anterior fontanelle was excessively large due to defects observed in the frontal bone on the left side. () No other significant findings were observed.\nThe patient was operated on by a team consisting of a cleft surgeon, a plastic surgeon, and an oculoplastic surgeon, and the constriction band of scarring in relation to the base of the nose was excised and closed in a straight line. In the second surgical stage, the bilaterally exposed scleral was reduced by performing bilateral oculoplastic surgery using advancement flaps.() These procedures were carried out solely to improve the patient's aesthetic appearance. Postoperative healing was uneventful although some degree of right palpebral conjunctival prolapse was still present. The child is scheduled for future reconstructive procedures to further improve his overall facial appearance. |
A 68-year-old male with past medical history of coronary artery disease status post coronary artery bypass graft (CABG), aortic valve replacement along with replacement of the root of the ascending aorta 10 months prior to presentation and recent hemorrhagic cerebrovascular accident (CVA), came to the hospital with complains of acute onset of severe abdominal pain and melena for 1 day. He also attested to chronic abdominal pain and a 30-pound weight loss over the last 8 months prior to these acute symptoms. His physical exam on presentation was positive for severe bilateral lower abdominal tenderness. Apart from a hemoglobin of 10 mg/dl and a positive stool occult blood test, the rest of his basic lab work up was unremarkable (white blood cell/platelet count, comprehensive metabolic panel, and PT/INR included). Hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) testing were negative. The electrocardiogram (EKG) showed sinus rhythm and left ventricular hypertrophy (). An emergent computerized tomography (CT) scan of the abdomen revealed features suggestive of an embolic infarct in the left kidney (Figures and ) and within the mid-one-third of the superior mesenteric artery causing luminal narrowing and also suspected to be extending to the takeoff of small bowel branches. Segmental mural thickening of at least one small bowel loop was noted which strongly favored acute bowel ischemia as a cause of his abdominal pain (). Incidental findings on CT of the abdomen were also strongly suspicious for large eccentric thrombus in the ascending aortic graft and the aortic root which were further investigated and confirmed with a CT scan of the chest (). Cardiology and cardiothoracic surgery were consulted. A CT scan of the head was performed to assess the recent CVA and showed a subacute hemorrhage along the left-sided temporal parenchyma (). CT head imaging was obtained from the facility where the patient presented 3 months prior for cerebral hemorrhage and in comparison, to the most recent CT scan of the head, the hemorrhage appeared stable. The hemorrhage was suspected to be secondary to thromboembolism. After a review of the risks and benefits of anticoagulation to prevent extension of this suspected thrombus, heparin was initiated. An echocardiogram revealed dilatation of the ascending aorta and mild paravalvular leak around the bioprosthetic aortic valve. Gastroenterology was consulted and an emergent esophagogastroduodenoscopy was performed which was negative for any causes of upper gastrointestinal bleed. A hypercoagulable workup was performed which did not reveal any apparent cause of a prothrombotic state. Anticoagulation was held and subsequently, the patient underwent a redo sternotomy under cardiopulmonary bypass with extensive lysis of adhesions, removal of the thrombosed aortic valve and graft, ascending and proximal aortic arch replacement utilizing a 30 mm Dacron graft, and aortic valve replacement with a 25 mm Edwards Magna Ease bovine pericardial valve. The patient also underwent an explorative laparotomy as a part of a staged procedure to address the ischemic bowel caused by the presumed septic emboli. Intraoperatively, the patient was found to have a portion of small bowel that had become necrotic. The necrotic bowel was excised and an end to end anastomosis was performed.\nThe aortic graft and thrombus were sent for culture and pathology. Histopathological examination of the aortic graft and cusps of the aortic valve revealed chronic inflammation and was also notable for abundant acute angle branching septate fungal hyphae (). The patient was immediately started on amphotericin B and voriconazole pending finalization of cultures and sensitivities. On postoperative day four, three culture reports from the graft came back positive for dematiaceous mold, suggestive of Bipolaris species. The minimum inhibitory concentration (MIC) was 0.25 ug/dl for voriconazole and 0.03 ug/ml for amphotericin B. A decision was made to continue the same antifungal regimen on the basis of sensitivities and further speciation was not performed. Patient had a good postoperative course and was later discharged on amphotericin B and voriconazole for at least 1 month with continued follow-up with an infectious disease specialist. |
In this report, we present a case of a 57-year-old female patient with a 10 × 15 cm2 mesenteric cyst of the sigmoid colon that was excised laparoscopically and histopathology reported a cystadenoma. A 57-year-old female attended rapid access clinic complaining of left iliac fossa pain and swelling for ten months. She was reviewed by the Obsteric and Gynaecology team and an ultrasound scan of the pelvis was arranged which found a 116 × 94 × 76 mm3 cystic lesion probably from the left ovary. Following further investigations, (which were all normal) the patient was listed and consented for laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oopherectomy and peritoneal washing. During the operation the Gynaecologist found a large 10 × 15 cm2 cyst attached to the mesentery of the sigmoid colon free from the ovaries. The operation was suspended and the on call general surgical team were called into theatre. A diagnostic laparoscopy was performed; all other organs were normal, however, due to the size it was difficult to assess the anatomy of the cyst and which other organs were involved, the only thing that was certain was this was not an ovarian cyst, therefore proceeding to operate would be risky. The on call consultant general surgeon did not see this as an emergency and suggested that the operation should be aborted and further investigations were required before proceeding with an operation on the cystic mass. An outpatient CT abdomen and pelvis scan plus a flexible sigmoidoscopy was arranged with an outpatient follow up appointment with the general surgeons. The flexible sigmoidoscopy came back as normal and the abdomino-pelvic CT scan revealed an 11 × 10 × 8 cm3 likely benign cyst but could not determine its origin (Figs and ).\nDue to the persisting discomfort the patient was booked and consented for an elective laparoscopic removal of cyst with possibility of converting it to an open procedure due to the size of the mass. The operation was approached laparoscopically using two 12 mm ports and a 5 mm port. The two 12 mm ports were placed through the umbilicus and also in the right iliac fossa (RIF) and the 5 mm port was placed suprapubically. The cyst was then excised entirely using diathermy. To help remove the cyst 400 ml of fluid was drained using an aspiration needle. The 12 mm port in the RIF was then replaced by a 15 mm port to allow us to place an endocatch into the abdominal cavity and extract the cyst. This was done successfully with no complications (Figs –).\nThe rest of the abdominal cavity was washed with normal saline and closed. Since, the patient has made a full recovery and is completely symptom free. The histology report suggests the mass to be a borderline mucinous cystadenoma with either ovarian or appendiceal origin. |
A 21-year-old G1P1, female was admitted to the hospital with abdominal pain and syncope. She experienced sudden onset severe, sharp, localized pain in the left lower quadrant which gradually spread to become diffuse lower abdominal pain. She reported vaginal bleeding consistent with the time of her normal menses, though heavier than usual. Her past medical history was significant for left tubal ectopic pregnancy six months prior, medically managed with methotrexate. On admission, her hemoglobin was found to be 6.3 g/dL and she was transfused two units of packed red blood cells (pRBCs).\nNine days prior to her current admission, she presented to a local hospital with a similar episode. At that time, she was diagnosed with a ruptured ovarian cyst and managed conservatively. Six days prior to her current admission she was re-admitted to the local hospital after experiencing the same abdominal pain with a near syncopal episode. The outside facility performed a diagnostic laparoscopy which revealed intraperitoneal blood without active bleeding. She received transfusion of two units pRBCs at that time.\nHer menstrual history was significant for menarche at age 15 followed by a history of heavy, long, irregular menses sometimes lasting up to two weeks. She reported a history of frequent urinary tract infections since childhood. She denied tobacco or alcohol use. She reported an allergy to penicillin, was not on any oral contraceptives, and reported no other medications or supplements. Further history did not reveal any bleeding dyscrasia. She had no family history of vascular anomalies such as aneurysms or vascular malformations.\nTransvaginal pelvic ultrasound was suspicious for complex ascites versus hemoperitoneum and a complex cystic structure adjacent to the right ovary was thought to be a hemorrhagic ovarian cyst. A CT scan of the abdomen and pelvis revealed complex free fluid within the pelvis thought to be blood and a focus of high attenuation near the right ovary thought to be pooling of contrast or prominent vascularity (Figure ).\nShe was taken to the operating room for laparoscopy and peritoneal fluid evacuation. Blood was found in the pelvis which raised the question of a hemorrhagic ovarian cyst as a probable cause, and no active bleeding was identified. She was discharged from the hospital but presented the following day with another episode of abdominal pain and syncope. Transabdominal pelvic ultrasound revealed more complex pelvic fluid suggestive of blood and the increased vascularity adjacent to the right ovary. Further operative management with a salpingo-oophorectomy was considered, however, given the patient’s age and unclear diagnosis, the patient was managed conservatively. Interventional radiology was consulted and a CT angiogram of the pelvis was performed revealing abnormal arteriovenous vascularity of the right adnexa highly suspicious of an AVM. Subsequently, a right uterine arteriogram was performed which clearly outlined a right adnexal AVM with dual ovarian and uterine arteries feeding into a nidus (Figure ).\nThe nidus of the AVM was then selectively embolized via the right uterine artery using a microcatheter and gel-foam alcohol slurry. Follow-up CT angiogram of the pelvis three months later showed resolution with no further abnormal arteriovenous shunting and the patient had no further episode of hemoperitoneum. |
A 33-year-old woman was admitted to psychiatry inpatient with a complaint of suicidal ideation. The patient has a past history of multiple psychiatric disorders like BPD, MDD, and anxiety issues for about last eight to 10 years. She had multiple suicide attempts in the past most recent being two weeks back when she tried to suffocate herself with the help of a medical device tubing. On inquiry, she said she just wanted to feel the pain, not kill herself. On further questioning, she was found to have passive suicidal thoughts as well as an active plan to harm herself. Her plan was to kill herself with the carbon monoxide poisoning by turning on the engines of four cars parked in the garage. According to her, she felt better at the time of the last admission and these suicidal thoughts just returned two to three days back. She had multiple admissions and emergency department (ED) visits related to her psychiatric conditions as well as five suicidal attempts. During one of her admission when she took multiple tablets of Advil® (Pfizer, New York, USA) in an attempt to kill herself, she was evaluated for ECT by a psychiatrist but the decision was made in favor of dialectical behavior therapy (DBT) as they felt these symptoms are because of her BPD. According to the patient she has been compliant with the therapy that has helped her in coping day-to-day issues. The patient also confirmed that she has never recovered from these active and passive suicidal thoughts which have progressed to even worse state in the last four months.\nOn further evaluation, the patient reported feelings of hopelessness and worthlessness most of the time along with a guilt of things for what she has done in the past. She also reported a decrease in sleep to about five hours per night along with difficulty in staying asleep and poor appetite and energy. Her concentration was normal. She continues to engage in her interests in reading and photography. The patient states she has been a "warrior" for years. She endorses a few prior panic attacks where she felt shaky, short of breath, and had chest pain. She could not recall how long they lasted or when her last episode was. Screening for mania, psychosis, and obsessive compulsive disorder was unremarkable. There was no reported history of alcohol, tobacco, or illicit drugs.\nMinnesota multiphasic personality inventory-2 (MMPI-2) results suggested the presence of depression, anxiety, overall distress, and a personality disorder. All of these scores are in the moderate to severe ranges and are rather similar to one another. The psychologist during this visit interpreted that these results do not suggest that the personality disorder is the main factor driving her clinical presentation and that her presenting symptoms are due to MDD. She was recommended ECT as it was determined that these symptoms are due to resistant MDD.\nThe patient had a past history of multiple psychiatric drug trials in the last eight years which included medicines like fluoxetine, sertraline, venlafaxine, amitriptyline and even augmented therapy with antipsychotics was tried with aripiprazole and thyroxine which all proved ineffective in this patient. Considering her condition and beneficial outcomes in such a treatment-resistant patient, a trial of ECT was the consensual decision of all the panelist psychiatrists. The patient agreed to this mode of therapy.\nThe first session was done with the parameters mentioned in Table .\nAfter the first session parameters were changed for the rest of the 12 sessions which are mentioned in Table .\nA total of 16 sessions were conducted with a break after 13 sessions. The frequency of sessions was three per week for the first 10 sessions and then two sessions every week and last three sessions were conducted once a week. The patient was evaluated after every session and there was a remarkable improvement from the sixth session onwards. After 13 sessions there was a thorough evaluation and the patient reported improved mood and no active or passive suicidal ideations and she was discharged. She remained symptom-free for four to five months but then reported again with another suicide attempt. She was restarted on ECT, and 16 more sessions were conducted with the same frequency and same parameters.\nOn her recent visit, she endorsed a significant improvement in her depressive symptoms and denied active suicidal ideations. She also reported an improved quality of life. |
A 34-year-old Japanese woman in her second spontaneous pregnancy was referred to Takeda General Hospital at 17 weeks of gestation and diagnosed with a MCDA twin pregnancy. She was admitted to our hospital at 30 weeks' for management of potential premature delivery. She was regularly monitored by conventional ultrasound to assess growth and amniotic fluid volume, and by Doppler ultrasound of the umbilical artery (Table ). No TTTS complications were observed during hospitalization. The final routine monitoring before delivery was performed at 35 weeks and 5 days of gestation; and the maximum vertical pockets of the MCDA twins were observed to be 4.2 and 3.6 cm, respectively, with cardiotocography showing reassuring fetal status patterns for both. However, she complained of diminished fetal movement at 35 weeks and 6 days of gestation (approximately 12 h later; at the final confirmation of normal cardiac sound for both twins by fetal Doppler ultrasonography), and the IUD of one fetus was confirmed by ultrasonography. Emergency cesarean section was performed, and the patient delivered a 2306 g surviving twin male infant, and a 1994 g dead twin male infant without any definite anomalies. No autopsy was performed as consent could not be obtained from the parents. The surviving infant's hemoglobin was 13.9 g/dL, and ultrasonography of the head revealed no abnormal findings at birth. Although he showed no cardiac or renal dysfunction after birth, he was diagnosed with large cystic periventricular leukomalacia (PVL) on the basis of magnetic resonance imaging findings at 13 days after birth (Fig. ). His placenta was peculiar in that both UCIs were observed to be centrally located and in close proximity on the placenta (Fig. A). We did not observe any specific placental and umbilical cord findings during the fetal period. The placenta was 24 × 19 cm and weighed 778 g. The umbilical cords were found to be of unusual thickness and of 45 and 48 cm in length, respectively. Both umbilical cords were composed of double arteries and a single vein, with neither wrapped around the fetus's neck. There was no overcoiling or undercoiling of the umbilical cord vessels. After delivery, placental injection studies using milk and indigotindisulfonate sodium were performed. The vein and arteries of both umbilical cords were cannulated successively with a 3.5-mm umbilical catheter, and milk and indigotindisulfonate sodium were injected into the umbilical vein of the surviving infant and umbilical arteries of the dead infant, respectively. The presence of several dynamic superficial venovenous (VV) and arterio-arterial (AA) anastomoses was confirmed (Fig. B). A cross-section of the placenta showed no calcification, hematoma, or infarction. |
Our patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.\nThe foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.\nTaking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.\nAs far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.\nConsidering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an immediate transfer to the Gynaecology and Obstetrics unit of our structure. Due to the critical care panel and the low clinical conditions, the patient was intubated and housed in the ICU department. Considering the acute distress syndrome, a chest CAT scan was performed highlighting the presence of a left pAVM expanded, associated with a massive hemothorax that compressed the correspondent lung. The vital signs panel showed systolic blood pressure of 70 mmHg, diastolic blood pressure of 35 mmHg, pulse rate of 150/min, pulse oximetry saturation 88% on 100% inspired oxygen, afebrile temperature, and respiratory rate of 40/min. Initial labs revealed normal platelets, normal coagulation panel, and haemoglobin of 7 gm/dL. Critical care panel showed pH of 7.4, pCO2 of 43 mm hg, pAO2 60 mmHg, and saturation of 88%. After the placement of a chest tube, 3 litres of frank blood were removed; this action resulted in a normalization of the blood pressure and improved oxygenation on the monitor. The successive management was the clinical observation of the patient's conditions as well as the vital signs and labs test in order to perform the pAVM embolization when the patient clinical conditions will be stable. After three hours from the drainage, worsening of the patient conditions was observed reporting a severe collapse of the vital signs as well as a decrease of antithrombin III, fibrinogen, and haemoglobin values, with parameters of 33%, 122 mg/dl, and 5.8 gm/dl, respectively. Moreover, considering the postoperative caesarean course, the gynaecologic clinical evaluation showed a low uterine fundus contraction and the presence of conspicuous abnormal lochia. Uterine fundal massage was performed as first approach to solve the uterine low contraction followed by Credè's manoeuvre. Due to the failure of both, a pharmacological treatment was attempted starting with a simultaneous administration of intravenous Oxytocin (10-40 UI per 1 litre saline solution) and intramuscular Methylergometrine (0.2 mg one dose). The latter pharmacological approach involves the use of intravenous Sulprostone (0.5 mg per 1 litre saline solution) that was administered within half an hour from the signs of low uterine contraction and abnormal lochia. None of the previous pharmacological treatments succeeded.\nConsidering the reproductive age of the patients, procedures as appositions of tamponade-balloon and embolization of the uterine arteries were taken into account but were not applicable in order of the unstable and precipitant parameters of the woman. Due to the patient's life-threating condition, a simultaneous surgical intervention of thoracic surgeons and gynaecologists had been necessary to solve the urgency, with the performance of a contemporaneous surgical reparation of the pAVM and resection of damaged left lower lobe (LLL) as well as a preventive hysterectomy to avoid the risk of disseminated intravascular coagulation (DIC). The surgical interventions were performed successfully but intraoperative blood transfusions and administration of antithrombin III and fibrinogen were necessary. The postoperative treatment showed a normalization of vital signs and labs panel as well as patient's clinical conditions. Due to the stable condition of the woman, the anaesthetist established the patient's autonomous breathing. After one week from the intervention, chest CT with intravenous contrast was performed showing a 4 cm area of active contrast. Pulmonary angiography confirmed the presence of a pAVM with feeding branch of a basilar left pulmonary artery supplying aneurysmal AVM and dilated draining vein. Transcatheter embolotherapy (TCE) of the culprit vessel was performed by placement of a nonadhesive liquid embolic agent (Onyx 34®). Repeated chest X-ray and chest CT after one week from TCE showed expansion of remaining left lung and signs of pAVM embolization and pulmonary resection of LLL, respectively (). The patient course was subsequently uncomplicated and the discharging home happened after 14 days. MRI evaluation was performed in order to detect any head AVM but the result was negative. The genetic testing for HHT was not performed during this hospitalization period but the genetic examination performed a few months afterwards showed no association. |
A 53-year-old male presented with pain and swelling in the left thigh for a duration of 2 weeks, following a trivial trauma. The patient had a significant history of smoking. Local examination revealed hard, tender, circumferential bony swelling arising from diaphysis of the femur. The knee range of movements was normal without any distal neurovascular deficit. Radiograph of the femur revealed an aggressive lytic lesion with wide zone of transition, involving almost entire lower 2/3 of the femur with associated pathological fracture. Magnetic resonance image done at an outside center showed a lesion arising from diaphysis with a circumferential extraosseous soft tissue component, with disease involving almost the entire length of the femur []. This raised the suspicion of primary neoplasm of the bone. Detailed case history and imaging were discussed in multidisciplinary tumor board meeting, and core needle biopsy was planned with differential diagnosis of primary neoplasm of the bone or a metastatic secondary from a primary elsewhere. The limb was immobilized with Thomas splint to prevent fracture displacement. The patient was bedridden due to pathological fracture, pain, and splint and depended on the family for basic hygiene care.\nHistopathological evaluation of core needle biopsy revealed metastatic adenocarcinoma, positive for thyroid transcription factor and cytokeratin 7 and to suspect primary from the lung. Further workup with computed tomography of the thorax revealed a primary in left lung and Tc-99m methylene diphosphonate bone scan showed additional skeletal metastasis in vertebrae. Epidermal growth factor receptor mutation tested on biopsy specimen showed positive for exon 19 in-frame deletion.\nIn view of gefitinib-sensitive EGFR mutation being positive, the patient was planned to treat with palliative intent with gefitinib and palliative radiation to symptomatic metastatic skeletal lesions. The patient received palliative radiation of 20 Gy to femur lesion and 8 Gy to vertebrae. Bisphosphonates (zoledronic acid) were also added to decrease pain and treat skeletal-related events. On treatment, the patient showed significant improvement in general condition, regression in the lung lesion, and healing of the femur pathological fracture.\nIn view of good response to gefitinib and improvement in general condition, it was decided to treat the femur lesion surgically to improve his QOL. As the disease was involving entire femur, it was excised with oncological principles and the defect was reconstructed with a total femur megaprosthesis []. Postoperative period was uneventful. The patient was made full weight bearing right from the first day after surgery with the help of walker. Along with that knee range of motions were also initiated.\nPatient's QOL improved dramatically. He was pain-free and could manage his daily activities independently. His musculoskeletal tumor society score at the last follow-up was 25. Finally, the patient expired with disease progressive after 12 months of surgery. |
A 32-year-old man, who played nonprofessional baseball, consulted our hospital for chronic low back pain. Within the last year he had experienced a severe episode of pain during flexion, for which he was successfully treated with an intradiscal steroid injection. His diagnosis was discogenic pain with an HIZ in the posterior corner of the L4-5 disc. After experiencing a second episode of severe low back pain during flexion, he was referred to our hospital. He complained of low back pain during lumbar flexion and slight pain during extension. However, no leg symptoms were present and all neurological signs were normal.\nshows the MRI findings just after the second episode. The disc showed degeneration with a slight protrusion; however, the HIZ was not so obvious. We conducted discography and administered a steroid injection at the disc (). Discography revealed contrast media leakage into the annular tear. At this time, the patient reported concordant low back pain, which was completely relieved by the intradiscal injection. The patient then returned to baseball practice. During a practice session at spring camp, 2 weeks after the second injection, he again experienced mild discomfort in his back. The next day, he could not move because of severe pain, so he took analgesic medicine. However, as no pain relief was obtained for a week, he visited us again.\nshows the MRI findings just after the third episode of severe low back pain. The sagittal and axial images both showed that the size of the disc protrusion was similar to that on the first MRI, with the exception of the obvious HIZ. As this was the third episode, we decided to perform minimally invasive endoscopic surgery with PED and TA, instead of the previous conservative care.\nSurgery was conducted on the basis of a review article on the PED procedure []. For the present case, the transforaminal approach was selected and an 8 mm lateral skin incision was made about 8 cm from the midline. After providing sufficient local anesthesia around the disc, a needle was inserted into the disc through the safety triangle. Next, discography was conducted with indigo carmine to dye the NP and the displaced fragment blue. A guide pin was inserted into the disc through the puncture needle, and the obturator and cannula were inserted sequentially. After inserting the cannula, PED and TA were initiated.\nDuring surgery, the scope was inserted into the posterior annulus where it revealed a migrated NP dyed blue (, left panel). After removing the displaced NP, the annular tear was clearly evident due to being filled with the blue NP. When the scope was moved to the site of the HIZ through the annular tear, a slightly red migrated NP was found (, right panel), suggesting inflammation and/or new vessels penetrating the mass. After removing the slightly red migrated NP, the HIZ site was ablated with a radiofrequency coagulator (i.e., TA) ().\nshows the histological findings of two kinds of tissue, the displaced NP with (right panel) and without (left panel) an HIZ. On hematoxylin and eosin staining, the NP without the HIZ was found to be filled with cartilaginous tissue, with an extracellular matrix consisting of proteoglycan-based cartilage (alcian blue staining). On the other hand, the migrated mass with the HIZ contained many fibroblast-like cells, not chondrocytes, and the matrix was fibrotic (Masson trichrome staining).\nWithin 6 weeks of surgery, the severe low back pain during lumbar flexion had resolved, although slight pain during extension persisted. The patient initiated trunk muscle isometric training and stretching, and walking and jogging were allowed as light exercise. |
An 8-year-old male with no significant past medical, surgical, or social history initially presented to an emergency department in October 2013 with a chief complaint of right, radial-sided wrist pain after a fall on his right arm while playing soccer. No fracture was seen on radiographs, and he was placed in a removable splint for comfort and discharged. The patient was scheduled for follow-up but would not present to an orthopaedic clinic until three years post injury, at age 11. At age 11, when the patient was seen at an outside orthopaedic clinic, he reported continued wrist pain from his initial injury three years prior. He described dull pain in his right wrist with intermittent swelling after several minor falls while playing soccer. Radiographs did not reveal a fracture or other pathology, and the patient was again diagnosed with a wrist sprain and given a brace for comfort. He was compliant with the brace, but 8 months later, he again returned to his pediatrician with continued pain. Interval radiographs revealed a right-sided, displaced scaphoid waist fracture (). He was referred to our clinic for further management. He was noted to have tenderness located at the anatomic snuffbox but full range of motion. A magnetic resonance imaging (MRI) scan was ordered to further evaluate for AVN and osseous bridging given the chronicity of his symptoms, and he was placed in a thumb spica wrist brace. His MRI demonstrated the scaphoid waist nonunion with concerns for AVN (). At this point, the patient and parents elected to undergo surgical fixation of his nonunion. Due to the concern for AVN on MRI, utilization of a vascularized bone graft was considered. However, it was felt that given the young age of the patient, drilling of the bone would be sufficient to stimulate bone growth and avoid the more aggressive procedure.\nThe patient underwent surgery at 11 years and 3 months of age. Open reduction and internal fixation was performed using a dorsal approach centered over the scapholunate interval, using 14 and 16 mm headless compression screws to achieve fixation. The patient was placed in a thumb spica splint and discharged home the same day. Two weeks later, he presented to clinic with resolution of pain and intact hardware on imaging (). He was transitioned to a thumb spica short arm cast. Six weeks postoperatively, he was placed in a removable thumb spica brace for one month. The patient returned to full activity by 4 months postoperatively. One year postoperatively, the patient remained asymptomatic and maintained a full physical activity level without difficulty or pain. |
A 31-year-old gravida 3 para 1 patient presented to antenatal clinic at 19 weeks and 3 days' gestation to discuss the results of her morphology scan which had demonstrated a grade 4 placenta previa covering the cervical os. She had a medical history significant for Arnold Chiari malformation requiring craniotomy in 2006 as well as correction of a Syringomyelia in 2005. She also suffers from irritable bowel syndrome but was taking no regular medications and had a BMI of 23. Her first pregnancy resulted in a spontaneous miscarriage that did not require dilatation and curettage. Her second pregnancy resulted in a planned elective caesarean due to concerns about raised intracranial pressure during labour, as recommended by her neurologist. She had routine antenatal care this pregnancy which had been unremarkable to date.\nThe morphology scan demonstrated a small omphalocele but otherwise no significant structural defects and estimated foetal weight was noted to be within the normal range. During the clinic review, the fetus was found to have a heart rate well below 100 bpm. Repeat ultrasound the following day confirmed IUFD. This ultrasound also demonstrated evidence of an abnormally invasive placenta with the appearance of dysplastic vascular hypertrophy. An obstetric MRI was performed which supported the diagnosis of morbidly adherent placenta. This showed a low lying inhomogeneous placenta, dysplastic vascular hypertrophy, ill-defined placental bands, and an overall impression of some areas of increta with no overt evidence of percreta.\nOptions were discussed with the patient who decided for conservative management in order to optimise her chance of preserving her fertility. This was balanced against potential complications of prolonged conservative management of an IUFD, including sepsis and coagulopathy. A plan was made for serial ultrasounds as an outpatient, to be followed by induction of labour when placental blood flow was no longer detectable. Twenty-seven days following IUFD confirmation, the patient was admitted to hospital with abdominal cramping and associated small antepartum haemorrhage (APH).\nUltrasound scan at 31 days showed a minimal reduction in blood flow through the anterior placenta and to the cervix. At day 33 she suffered a further 300mL APH. Given her increasing blood loss and minimal changes to placental blood flow on ultrasound, she was administered a dose of 80mg methotrexate intramuscularly with the hope of accelerating devitalisation of the placenta. A repeat dose of methotrexate was planned for five days' time. During the subsequent two days after the administration of methotrexate, the patient continued to suffer moderate bleeds and increasingly significant contractions. 35 days following IUFD she spontaneously delivered a male fetus with only minimal bleeding during delivery.\nA brisk 2 L postpartum haemorrhage (PPH) followed delivery and the patient was immediately taken to the operating theatre for examination under anaesthesia and attempted manual removal. A urinary indwelling catheter was inserted and remained in situ for the entirety of the operation. Due to only partial removal (approximately 80%) of the placenta being achieved manually, the case quickly progressed to laparotomy. Intraoperative findings revealed a full thickness increta at the previous caesarean incision just above the level of the bladder. Hysterotomy was performed with a transverse incision made above the prior caesarean incision, and the remaining placenta was removed manually, creating a 3x3cm plug-like defect anteriorly. This defect was closed with a primary closure separate to the hysterotomy incision. In addition, the placental bed was oversewn to establish haemostasis. A Foley's catheter was inserted vaginally and inflated with 60mL normal saline. Total blood loss was 4 litres (L): 2L immediately postpartum, 1L while attempting per vaginal manual removal of the placenta, and 1L intraoperatively. Massive transfusion protocol was activated with the patient receiving 10 units of packed red cells, 6 units of fresh frozen plasma and 5 units of cryoprecipitate. The patient remained stable throughout the process. A further 3 units of packed cells was given over the next two days for persistent anaemia. The fetus was found to weigh 170g. No cause for foetal demise was identified and the family decided against an autopsy. Pathological examination of the placenta was performed. This was noted to be difficult due to extensive haemorrhage and areas of necrosis commensurate with intrauterine foetal death and prolonged intrauterine retention. There was no evidence of funisitis or umbilical cord vasculitis to support a diagnosis of chorioamnionitis nor were any pathogens observed. The degree of decidual haemorrhage and necrosis made a histological diagnosis of placenta accreta impossible.\nThe patient recovered without significant complication over the following days and was discharged 1 week later on oral antibiotics and aperients. Six weeks after discharge the patient was seen in a postnatal follow-up clinic. She experienced minimal lochia in the postpartum period and was feeling generally well. |
A 45-year-old female presented with three months' history of passing bright red blood per rectum, associated with tenesmus, but no history of abdominal pain, weight loss, or anorexia. She had a swelling on the right side of her neck for two years. No comorbid conditions were reported nor was there any family history of CRC. The physical examination showed a cervical lymphadenopathy on the right side of her neck. Chest and cardiovascular examination yielded normal results. Abdominal examination did not reveal any tenderness, organomegaly, or palpable masses. Digital rectal examination and rigid proctosigmoidoscopy revealed a rectal lesion that was 8 cm from the anal verge and was confirmed by colonoscopy. The rest of the colon was clear. Magnetic resonance imaging of the pelvis showed a rectal cancer confined to the wall. No evidence of any extrarectal involvement or regional lymphadenopathy was noted. Computer tomography (CT) of the abdomen and the chest did not reveal any metastasis. A rectal lesion biopsy showed the moderate development of adenocarcinoma. Unfortunately, transrectal ultrasonography was not performed because of the unavailability of the technology. Fine needle aspiration (FNA) of the cervical lymph node revealed a metastatic adenocarcinoma of colorectal origin []. The results of FNA were not convincing and were disregarded, especially as the lesion was more than two years old, with no other constitutional symptoms apart from the recent history of bleeding per rectum. A second physical examination of the neck was performed which revealed the same findings: cervical lymphadenopathy and no palpable thyroid mass. Neck ultrasonography was performed and confirmed a presence of nodularity in the right thyroid lobe []. FNA was performed again for both the thyroid nodule and the cervical lymphadenopathy. A second pathologist was asked to examine both FNA specimens and confirmed the diagnosis of a papillary carcinoma of the thyroid that had metastasized to the cervical lymph nodes []. The patient underwent open low anterior resection; pathology results were T2N0MX, moderate adenocarcinoma, and no lymphovascular invasion. Three weeks later, she underwent total thyroidectomy and a radical cervical lymphadenectomy. A final pathological examination confirmed the presence of a primary papillary carcinoma of the thyroid. Although no further adjuvant chemoradiotherapy was needed for the rectal cancer, the patient required radioactive iodine therapy for her thyroid disease. |
A 15-year-old female patient was urgently admitted with symptoms of dehydration, loss of appetite and persistent vomiting for 10 weeks. For four months she was vomiting two to three times weekly and this increased to three to four times daily during the last week before admission. The vomitus consisted of undigested meals eaten recently without any blood. During the last four months the patient reported a significant weight loss (21 kg). Her past medical history was free. On admission the patient was very thin and extremely weak with signs of severe dehydration. A nasophagogastric tube was inserted and the fluid and electrolyte balance was corrected by parenteric infusion of crystalloid fluids with electrolytes. Two days later the patient was subjected to gastroscopy which showed mild inflammation of the lower esophageal mucosa and gastritis. The instrument could not pass further than the third part of the duodenum, due to extraluminal pressure on the duodenal wall. Barium meal follow through confirmed the extrinsic obstruction of the third part of the duodenum and proximal dilation of the stomach and duodenum [] with normal motility of the upper GI tract. CT scan of the upper and lower abdomen excluded the possibility of a tumor or an annular pancreas being the cause of the compression of the duodenum. Thus based on the history, the clinical and imaging findings of the patient, the diagnosis of Wilke’s syndrome was concluded.\nThe patient denied the initially suggested conservative treatment and therefore she was subjected to laparotomy. The first and second parts of the duodenum were dilated and hypertrophied. The dilated duodenum was abrupted at the point where the superior mesenteric artery crossed the third part of the duodenum []. These findings confirmed the diagnosis and a site to site duodenojejunostomy in two layers was performed []. The postoperative course was uneventful and barium meal a month postoperatively showed unobstructed passage of the contents from the duodenum to the jejunum. One year later the patient gained the lost weight and remained asymptomatic. |
A 38-year-old man was diagnosed with pancreatic cancer and was scheduled to undergo pancreaticoduodenectomy. He had an unremarkable medical history. A combination of general anesthesia and epidural anesthesia was considered. Epidural tubing was performed at T8/9, and general anesthesia was induced with 100 μg fentanyl, 100 mg propofol, and 50 mg rocuronium. They were administered intravenously through a peripheral venous catheter inserted in his left cephalic vein near the wrist.\nRadial artery catheterization was planned for measuring continuous arterial pressure during surgery. A left radial arterial line was successfully placed on the first try. A wrist split was used to obtain a good arterial pulse waveform.\nThe surgery was completed on schedule. The total operation time was 7 h 55 min. After the surgery, he was transferred to an intensive care unit (ICU) where he stayed for 4 days and had a wrist-extension split placed.\nThe radial artery catheter was removed when he was transferred to a general ward. He experienced numbness and a tingling sensation in his left palm during his ICU stay that he considered transient and insignificant and did not report it to the ICU staff. This continued after ICU discharge. On the 10th postoperative day, he complained about his numbness to the physician in charge. The physician consulted a pain specialist, and the medical examination revealed that numbness and paresthesia were present in the left thumb, the second and third fingers, and the lateral half of the fourth finger. His left hand had a weak grip. The patient doubted that these symptoms resulted from an incident during placement of the indwelling radial artery catheter because he recalled irritable lightning and burning pain in his left wrist during the induction of general anesthesia.\nUltrasound examination revealed no hematomas and a normal appearance of the radial artery and radial nerve, but an enlargement of the left median nerve compared with the right median nerve at the pisiform bone level was observed (cross section areas of the left and right median nerves were 12 and 9 mm2, respectively) (Fig. ). The physical examination showed a positive Tinel’s sign, positive Phalen’s sign (20 s), and positive Flick sign. Considering the present findings, carpal tunnel syndrome was strongly suspected.\nContrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were performed. There were no hematomas and no abnormality or deformation of the radial artery and carpal bones on contrast-enhanced CT. There was an enlargement of the median nerve at the pisiform bone level on fat suppression T2-weighted MRI (Fig. ). There was no thickening of the flexor tendon, but there was fluid stagnation in the deep part of the bursa and intense signals around the flexor tendon; these are typical findings in carpal tunnel syndrome even though the patient has no past medical history of carpal tunnel syndrome. During interviews, some ICU nurses recalled that his wrist-extension split had been fixed in a relatively hyperextended position for 4 days to obtain a good arterial pulse waveform.\nNeurological diagnosis revealed iatrogenic carpal tunnel syndrome due to hyperextension of the wrist. The patient’s recollection of burning pain in his left wrist during induction of general anesthesia was considered a side effect of propofol. We started to administer 75 mg pregabalin daily and injected 4 mg of dexamethasone steroid into the carpal canal. He was discharged on the 12th postoperative day. The numbness in his palm interfered with his ability to type and impacted his quality of life. However, it gradually subsided. He was medicated and followed up at the outpatient pain clinic for 6 months before he made a complete recovery. |
This is a 30-year-old Hispanic female with a history of mild intellectual delay and temporal lobe epilepsy with postictal psychosis complicated by poor medication adherence. She has an extensive chart history in the hospital system, with numerous admissions in the emergency, internal medicine, obstetrics/gynecology, and psychiatry departments. Her earliest documented EEG in the hospital chart at 22 years of age showed spikes with phase reversing in the left and right temporal regions, indicative of an underlying structural abnormality, with moderate generalized slowing. She came to our attention in the department of psychiatry as a consult request for the evaluation of psychosis, also at the age of 22. She was admitted for birth out of asepsis, having given birth at home, and brought to the hospital for further care, whereupon a consult was placed for the reported presence of psychotic symptoms. As she did not meet the criteria for any psychiatric disorders at the time, psychiatry deemed her symptoms a manifestation of ictal episodes due to her temporal lobe epilepsy. Collateral information from the patient’s mother revealed that she began having seizures at 13 years of age, with increasing frequency of seizures during her pregnancy. The patient’s mother also noted that she was poorly adherent to her then-current antiepileptic medications of valproic acid 250 mg and oxcarbazepine 600 mg. From the information given by the mother, it was unclear whether or not this regimen changed for the patient during pregnancy.\nThe psychiatry team encountered the patient two years later, the patient was brought to the emergency department on a 72-hour involuntary psychiatric hold for danger to self and danger to others. She was found to be walking in the middle of oncoming traffic and was seen attempting to kidnap a child from a gas station, mistaking her as her own. The patient was discovered to have been nonadherent with her antiseizure medications in the interim, with increasing frequency of seizures occurring, and had been seen in the emergency department four days prior for a seizure with fall, with right facial trauma. Medications per chart were levetiracetam 1000 mg BID, and valproic acid 250 mg QHS. On evaluation, the patient was disorganized, confused, and paranoid, making accusatory statements to the nursing staff, “you are the one that was beating me, even though my husband had asked you to stop, you continued to beat me and you brought me here.” In regards to the attempted kidnapping, the patient stated she thought she was taking “her own daughter.” She stated that she had been depressed since delivering her most recent child last month (per chart, she had a normal spontaneous vaginal delivery recorded three months prior) and because she lost all her children (per chart, children were in custody of child protective services). She was started on valproic acid 250 mg BID and diazepam 2 mg BID for seizure prophylaxis; levetiracetam was held at this time due to the possibility of worsening psychosis and depression. During her psychiatric hospitalization, the patient suffered a witnessed tonic-clonic seizure lasting for at least a minute and a half after screaming and falling out of a chair; subsequent facial and cranial X-rays showed no fractures or apparent injury. According to the Diagnostic and Statistical Manual of Mental Disorders Four (DSM-IV) criteria, the patient was given an Axis I diagnosis of psychosis not otherwise specified (NOS), with ruling out of postpartum depression with psychosis. The patient was transferred to the medicine floor for the intravenous (IV) administration of antiseizure medication and further observation. EEG showed multiple sharp phases reversing in the left frontotemporal area, less frequently in the right temporal area, with moderate slowing. Valproic acid was increased to 500 mg BID per neurology recommendations. The patient was ultimately discharged with a diagnosis of psychosis NOS, with additional ruling out of postictal psychosis and postpartum depression with psychotic features.\nFive months later, the patient was again seen by psychiatry while in the emergency department for an involuntary psychiatric hold evaluation due to reports of the patient attempting to pick up children that did not belong to her from a school. The patient at this time was found to have a subtherapeutic valproic acid level of 40, was selectively mute, and was pregnant with unknown gestational age. She was admitted inpatient for the management of her seizures and the resolution of her altered mental state. She reported delusions of “children in the room, seven of them” upon evaluation by the psychiatry consultation team. Prior to discharge, she was restarted on oxcarbazepine 600 mg BID, and valproic acid was decreased from 500 mg BID to 250 mg BID for one week and then discontinued.\nThree years later, at the age of 27, the patient saw an outpatient neurologist for the evaluation of her refractory epilepsy. She was recently switched to levetiracetam 1000 mg BID from valproic acid 500 mg BID but continued having one to three seizures a week, with intermittent seizure clusters in a day. Follow-up visits the next month showed a worsening of seizures to twice a day; levetiracetam was increased to 1500 mg BID and a one-day course of phenytoin 100 mg TID was given.\nThe psychiatry team was reconsulted two years after this (at the age of 29) after the patient was transferred to the emergency department from another hospital with seizure with altered mental status, presenting with disorientation and flight of ideas. The patient was pregnant during this encounter at nine weeks gestation. On the initial visit, the patient was disorganized and provided with haloperidol 2.5 mg intramuscular and diphenhydramine 25 mg IV for agitation. At a later encounter, the patient was more cooperative but still disoriented, endorsing voices in the room of “10 people that talk about everything and can talk about her.” Collateral information from her mother at this time revealed that the patient typically becomes altered after a seizure and has presented in a similar manner in the past, with courses lasting 15 days to one month after experiencing a seizure. Considering the new collateral information, the patient was given the diagnosis of temporal lobe epilepsy with postictal psychosis upon this admission.\nDuring the next month, the patient was once again seen by the psychiatry team. She was taken to the emergency department by the ambulance after being found trying to break into another person’s home. When speaking to law enforcement at the scene, the patient stated that she was trying to enter her own home to get her children but could not provide context for the situation. She was also displaying “strange behavior” per the chart and thus was taken to the emergency department for further evaluation. The patient was currently pregnant at 15 weeks at this admission and found to have been noncompliant with her seizure medications. levetiracetam 500 mg BID was started while inpatient, and a 48-72 hour video EEG was recommended for the patient per neurology (Figures -). Although postictal psychosis was discussed on previous admissions, efforts were made to rule out psychosis unrelated to seizure activity with computed tomography (CT) brain without contrast; neuroimaging results showed no acute or structural abnormalities with the exception of hypodensities in the periventricular white matter region (Figures -). Lacosamide 150 mg IV Q12H was started and levetiracetam discontinued. Further psychiatric evaluation ruled out the possibility of a psychiatric cause of the patient’s current presentation.\nSince then, the patient has continued to have repeated encounters in the hospital system, twice for episodes of seizures with no presentation of psychoses in her postictal state. This is typical of the patient’s overall history, as she has had numerous emergency department visits since the age of 24 for either seizure episodes or seizure medication refills. The current medication on record for the patient is levetiracetam 1000 mg BID. |
An eighty-four year old man attended our accident and emergency department with a severe headache, runny nose and confusion. Detailed history taking was not initially possible at first, but with the arrival of the patient’s relatives, we were able to elucidate further details of his history. The patient’s illness had started two weeks ago with symptoms of sinusitis. He was diagnosed with an upper respiratory tract infection by his general practitioner, and treated with oral antibiotics. We were informed by the relatives that the patient had been “blowing his nose” with increasing frequency over the last two weeks and had not responded to the treatment given by his general practitioner. His rhinorrhoea got much worse, and he then developed a severe headache with worsening confusion over the 24 hours preceding admission. He had sustained severe craniofacial fractures 43 years ago after a serious fall.\nHe had undergone neurosurgery for this, but the precise details of the procedures performed were not clear although he had been left with a large scar on the right side of his forehead and an oculomotor nerve palsy. He had otherwise made an excellent recovery from this operation, and had a normal quality of life in full employment until retirement at the usual age. On examination, the patient was very confused. There have been no signs of recent trauma or head injury. Clinical examination revealed neck stiffness and photophobia. His white blood cell count (WBC) and C-reactive protein (CRP) slightly elevated. His chest radiograph was normal. Laboratory testing of the fluid from his nose confirmed it to be CSF; positive for glucose and beta 2-transferrin. The patient was confused and would not allow a lumbar puncture to be performed. Apart from confusion, system examination did not reveal any signs of focal neurological deficit.\nAn urgent CT head was performed which showed a pneumocranium and fractures of the frontal bone to the right side of the frontal sinus, involving the superior and medial orbital walls (). It was initially thought that the patient had an acute head injury, but the absence of physical signs on examination made us question this diagnosis.\nUrgent neurosurgical advice was sought. The skull fractures were considered to be old injuries on review of the scans and a diagnosis of occult dural injury with endocranial complications was made.\nWe were advised to treat the patient conservatively with intravenous antibiotics and admission. He recovered rapidly and was discharged after three weeks with advice to avoid straining and maneuvers which could acutely raise intra-abdominal and intrathoracic pressure. He remains well on review 1 year later. |
A 30-year-old African-American female was referred during her second trimester of pregnancy for surgical management of persistent primary hyperparathyroidism. The patient had a history of multiple episodes of acute pancreatitis requiring more than twenty hospitalizations for the treatment of that condition. She also had a history of nephrolithiasis, but no personal or family history of MEN syndromes and was normotensive. Prior to her pregnancy, the patient had initially underwent a neck exploration for what was diagnosed as primary hyperparathyroidism at another institution, which was unsuccessful in finding the abnormal parathyroid gland. The operative report from the first surgery was reviewed. The surgeon who performed the first operation extensively described a thorough dissection during the first operation. The dissection included bilateral neck exploration, opening both carotid sheaths, and intraoperative selective venous sampling. The patient continued to have evidence of hypercalcemia postoperatively due to persistent primary hyperparathyroidism, with a serum level of calcium of 11 mg/dL, albumin of 3.6 g/dL, and an intact parathyroid hormone level of 140 pg/mL. The rest of her blood laboratory workup was within normal limits. The preoperative localization workup was performed at Tulane University Hospital and included a repeat neck ultrasound that revealed a 1.0 cm previously missed hypoechoic mass in the tracheo-esophageal groove. CT scanning was not utilized because of the risk to the fetus.\nDue to the previous failed detailed dissection, the needle localization technique was chosen for this pregnant patient. This technique offered a targeted focused approach without the need for bilateral neck exploration. After obtaining informed consent from the patient, the skin was prepped in the standard fashion and local anesthesia administered. A Homer needle was introduced under ultrasound guidance and the tip guided to an appropriate position within the mass. A 22-gauge Chiba needle was passed in a tandem fashion and aspiration of the lesion was attempted. The specimen obtained was sent for intact PTH assay. Subsequently, 0.5 mL of methylene blue was instilled through the Homer needle. Under ultrasound guidance, a hook wire was passed through the Homer needle, confirming placement of the wire tip within the lesion. Both the Homer needle and wire were left in place and secured, and the wire was taped in place. The patient was then taken directly to the operating room.\nThe neck was prepped and draped in the standard fashion, including the localization wire. Surgical exploration was done under general anesthesia. A small skin incision was made which included the point of entry of the guide wire (), and the wire was followed with meticulous dissection and guidance by the presence of methylene blue until the parathyroid adenoma was identified. All the tissue impregnated with methylene blue was excised, along with the mass containing the hook wire. PTH serum levels, monitored intraoperatively, decreased from 143 to 23.6 pg/mL after ten minutes following the removal of the mass. This significant drop confirmed the surgical correction of her disease and eliminated the possibility of hyperplasia. The procedure was done in seventy-five minutes including the waiting time for reporting the results of the intraoperative PTH assays monitoring. The patient tolerated the procedure well. Throughout the procedure, the fetus showed good movements by ultrasound. The patient did well and was discharged home the next day. The patient′s postoperative course was uneventful and she has maintained normocalcemia for six months postoperatively. |
We describe the case of a previously healthy, 31-year-old woman, who presented in the last trimester of her pregnancy with pain between the shoulder blades. She was admitted to the obstetrics department because of this pain, and the neurology department was consulted. The pain had started in the sixth month of her pregnancy with her first child. The pain arose each night 2 h after she went to sleep, and it was described as unbearable. Our patient would wake up every night because of the pain. The pain was not correlated with breathing. There was no pain radiating to her arms or legs. At the first neurological examination, no abnormalities could be found, and no final diagnosis was made. Muscle and joint complaints were thought to be the most likely explanation. After childbirth, she presented to the outpatient clinic. The pain had spontaneously decreased. She still experienced pain, mainly at night, but sometimes also during the day. She still reported no pain in her arms or legs. Her family history was not contributory. She did not smoke or drink alcohol. She did not use any medication. Because she was breastfeeding her newborn baby, she did not take any pain medication.\nThe neurological examination showed no motor deficits. There was no clear deficit in sensory testing, but a slight decrease in vital sensibility in her arms and legs was suspected. Tendon reflexes were normal. Plantar reflexes were normal on both sides. The pain could not be provoked by manipulation of the spine. As the pain continued at night and no good explanation could be found, imaging of the spine was ordered. However, the a priori chance of finding a tumor was thought to be very low. An MRI scan of the thoracic spine showed an intramedullary, partly cystic/necrotic, partly solid tumor at levels C5–Th1. The solid part of the tumor was 3 cm long. It showed eccentric growth and was surrounded by edema. Using gadolinium, the solid part of the tumor showed enhancement, indicating a disruption of the blood-brain barrier (Fig. ). The patient was referred to a neurosurgeon, who performed a debulking of the tumor. Histopathological examination showed tissue of high cellularity and pseudorosettes. There were hardly any mitoses seen, no necrosis, and some calcification. These findings are consistent with a WHO grade II ependymoma.\nAt follow-up, the patient had made a full recovery. Repeated MRI scans showed that the debulking was total, and there were no signs of recurrence. |
A 32-year-old female was admitted to a specialized inpatient rehabilitation program utilizing a comprehensive rehab team focused on assessing patients with severe traumatic brain injury with the goal of providing accurate diagnosis, family training, and intensive therapy to promote best outcomes. The team included a physician, neuropsychologist, physical therapist, cognitive therapist, speech therapist, occupational therapist, and nurse. This multidisciplinary team collaborated towards the final diagnosis described here and together established a personalized plan of care and discharge recommendations.\nAcute care records showed patient had undergone CT of the brain revealing right frontal parenchymal contusion and a diffuse area of subarachnoid blood. No midline shift, herniation, or mass effect was identified. Other acute comorbidities included right subcondylar mandible fracture requiring her jaw to be wired shut, further complicating assessment during her inpatient stay. No reports regarding MRI or angiography were received from the acute care setting which may have expedited diagnostics prior to admission to inpatient rehabilitation.\nInitial team evaluation in the specialized program focuses on identifying and differentiating purposeful and generalized responses to stimuli using a combination of testing components derived from the Western, CRS-R, and Glasgow []. Observations of purposeful activity during initial evaluation were not observed due to lack of any spontaneous movement of the patient; however, the patient appeared generally awake based on observation of open eyes and spontaneous visual tracking. Ocular bobbing, which is characterized by a fast down beat of the eyes and slow return to baseline, was observed in addition to a distinct sustained and direction-changing nystagmus []. The functional independence measure (FIM) was used to capture the patient's disability and how much assistance the patient required to perform activities of daily living. Refer to for further examination findings and for FIM scoring.\nBased on the patient's wakefulness and consistent meaningful and purposeful interactions with the environment through eye gaze communication, a disorder of consciousness was ruled out. Further, understanding of the anatomy of the described reflexes and presentation guided the team towards isolation of a ventral pons lesion location and the suspected diagnosis of LIS, with need for further work-up to confirm. |
A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan (Figs. and ) of the liver was performed, and the patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments and extensive regions of necrosis. Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated to attempt radical resection. During the exploration, a voluminous tumor was found attached to the peritoneum. Intraoperative ultrasound was performed and revealed a tumor originating from the gallbladder bed area and reaching up to the area of the hepatic hilum and extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes. The tumor was classified as inoperable due to this finding. But during the exploration, however, a rupture of the fragile tumor occurred with massive eruption of the necrotic mass and the gallbladder content into the abdominal cavity, accompanied by bleeding of the liver parenchyma. We decided that the condition could only be managed by attempting modified resection. We performed cholecystectomy and non-anatomical resection of hepatic segments S5 and S6 and partial resection of S4 without lymphadenectomy as a debulking operation (Fig. ). The course of hospitalization was uncomplicated, and the patient was discharged to home care on postoperative day 9. Histologically, the tumor was confirmed as MINEN of gallbladder (Figs. , , and ), and its non-neuroendocrine component had the character of moderately differentiated tubular gall bladder adenocarcinoma, while the neuroendocrine component had the appearance of small cell carcinoma and was dominant, accounting for more than 65% of the viable tumor. The neuroendocrine component contained extensive necrosis, with mitotic index 64/10 HPF and a proliferation index of 70% (Fig. ). It was therefore obvious that the prognosis and the subsequent biological behavior would be influenced in particular by the neuroendocrine carcinoma component. Six weeks after the discharge, the patient underwent a follow-up CT scan prior to the initiation of systemic therapy, which revealed a large recurrence of the disease at the resection surface of the liver accompanied by hilar lymphadenopathy. The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues with very good radiological effect. We use this regimen as a standard in patients with MINEN of gastrointestinal tract with dominant neuroendocrine component, even with no somatostatin receptors staining available. Now the patient is almost a year after being diagnosed with a tumor, after completion of 6 cycles of adjuvant chemotherapy (carboplatin + etoposide) in combination with biological therapy, the long-acting somatostatin analogues. The patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases, with a solitary metastasis in Th9. The condition was evaluated as disease progression stage according to RECIST criteria, the patient remains in the follow-up care, and it is now 13 months after surgery (Figs. , , and ). |
A two-week-old female was brought in with an initial complaint of multiple masses that failed to regress since birth. She was born from a nonconsanguineous union and the mother’s pregnancy was uneventful. The baby was delivered vaginally at 37 weeks of gestation and multiples masses were found over the body. The treating physician advised follow-ups on discharge. However, the parents decided to seek more medical help for the child and she was admitted for more investigations.\nOn physical exam, the child was alert and active. She was not jaundiced and no pallor was noted on the extremities. Her vitals were all within the normal range and the birth weight and changes in weight corresponded properly. Two masses measuring 26 mm by 19 mm and 19 mm by 17 mm were observed on the forehead and the scalp (Figures -). One smaller mass was seen on the abdomen, measuring 11 mm by 10 mm (Figure ). All three masses were red and non-hemorrhagic. The parents reported that the size of the masses did not change since birth. No similar family history was found and both parents were healthy. Any hepatosplenomegaly was not observed on palpation nor were any other cutaneous lesions detected. She did not present with any other systemic abnormalities. An ultrasound was performed, and it revealed a normal liver, spleen, and kidneys with no masses or lesions. A Doppler examination also showed a fast-flow vascular lesion, as reported by many other articles []. The full blood count showed normal levels of white blood cells, platelets, hematocrit, and red blood cells.\nThe diagnosis of congenital hemangioma was confirmed and the family was properly educated about the condition as well as possible complications. A wait and watch approach was adopted and the child was scheduled for regular visits at three months. The family was asked to properly monitor the size of the masses and informed that appropriate surgical treatment would be provided if the masses fail to regress or if they continue to grow. |
A 68-year-old right-handed man with an educational background of a high school diploma had visited the hospital due to weakness in the bilateral upper limbs and lower limbs, decreased sensation of lower extremities and dysuria occurred 5 days ago as main complaints. Due to decreased vision of the left eye, which had occurred seven years ago, and decreased vision of the right eye occurring 2 months before visiting the hospital, he was diagnosed as optic neuritis and received a steroid treatment from other hospital. He had discontinued the medication and was under prognostic observation. The vision in both of his eyes at the time of visiting the hospital were decreased but still he was able to distinguish shapes or colors of all objects.\nHis consciousness was clear, and eye movements, facial symmetry and sensory functions were normal other than the existing sight disorder. The muscular strength of extremities showed MRC grade III in the right upper limb, grade IV in the left upper limb, and grade IV in both lower limbs. When conducting the sensory test, there were slightly degraded pain senses, vibration senses, tactile senses and location senses below T4 skin fragments. He showed a positive response to Lhermitte's sign where the patient has sensations of electrical current flowing through his bilateral arms when suddenly flexing his head forward. The deep tendon reflexes of extremities were all normal, and both sides showed negative responses to the Babinski reflex. As abdominal distention was observed, 1000 cc of urine was drained after insertion of a urinary catheter.\nDuring the spinal magnetic resonance imaging (spine MRI), a high intensity signal of T2 was shown from C1-T8 spine () and the findings from the brain MRI were normal. The number of cells, the chemical values and IgG index were normal in the cerebrospinal fluid tests, whereas the oligoclonal band was negative also.\nThe visual evoked potential test showed poor waveforms from both sides, whereas the left posterior tibial nerve sensory evoked a potential test among the somatosensory evoked potential test showing an abnormality reasonable for central nerve conduction disorder, and the auditory evoked potential test results were normal. Basic blood tests, urinalysis, vasculitis test and thyroid function tests were all normal and from the autoimmune antibody test, it showed positive response to the AQP4 antibody.\nAs the guardian commented that the patient is gradually speaking less, has a reduction of interest in hobby activities, and has character and behavioral changes such as being unable to control his appetite and becoming furious to insignificant matter, we conducted the Seoul Neuropsychological Screening Battery for additional evaluation. The patient's education level was graduation from high school; his score on the Korean Version of the Mini-Mental State Examination was 22 points whereas the clinical dementia rating was 1 point (). In the case of this patient, the profile of frontal lobe dysfunctions was prominent compared to other cognitive domains.\nThe patient was diagnosed as NMO and treated with methylprednisolone 1g via IV administration once daily for 5 days. After the treatment, the muscle power of the bilateral upper limbs was observed as MRC grade IV, and the muscle power of his lower limbs was the same as measured at the time of admission. Since the patient had no large scale change in the conditions, he is under prognostic observation as being treated with prednisolone and azathioprine from the out-patient department currently without recurrence for about 1 year. After 1 year of time lapse, we conducted the Neuropsychological Screening Battery (NSB) again for cognitive function evaluation, and frontal lobe functions showing an improving trend but there were no large changes in other domains compared to the conditions before NSB (). |
A 59-year-old Asian male presented to the gastroenterology office for a follow-up of a previously found duodenal lesion. He had an EGD at an outside facility 2 years earlier for evaluation of abdominal pain which showed a 1.2 cm duodenal polypoid lesion in the second portion of the duodenum. Pathology of the polyp revealed heterotopic gastric mucosa with benign lobules of gastric glands. He also was found to have chronically active H. pylori gastritis with numerous Helicobacter organisms and atrophic gastritis with patchy areas of intestinal metaplasia. At that time, he was instructed to follow up for a repeat endoscopy for surveillance in two years. As recommended, two years later he presented to our office for surveillance of his duodenal lesion. Due to his history of atrophic gastritis and a large duodenal lesion, we performed an upper endoscopy that showed atrophic gastritis, duodenitis, and a single 10 mm polyp in the second portion of the duodenum. The duodenal polyp was biopsied. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypia including nuclear enlargement, stratification, nucleoli, and few mitoses. The patient was referred for endoscopic ultrasound to further characterize the lesion and complete resection. Several weeks later he underwent an endoscopic ultrasound that revealed a 13-mm pedunculated and sessile polyp on the lateral wall opposite to the major papilla in the second portion of the duodenum (). The polyp was removed en bloc using a hot snare following a 4-mL saline lift. Two endoclips were placed for hemostasis. Pathology revealed a pyloric gland adenoma (Figures , , and ) with predominantly low grade dysplasia (Figures and ) and some small areas of focal high grade dysplasia. The slides were read by the in-house pathologist and were also reviewed by a GI expert pathologist at the University of Michigan. The patient was recommended to follow up for surveillance upper endoscopy in 6 months due to the areas of high grade dysplasia found on pathology. He was lost to follow-up for over one year. Fifteen months after the PGA was removed, the patient did follow-up for a surveillance upper endoscopy. A duodenal scar was found at the site of the PGA and a biopsy was taken from the site. There was no evidence of residual pyloric gland adenoma. The patient was then recommended to follow up for surveillance endoscopy in 5 years in accordance with the ASGE guidelines for surveillance of gastric adenomatous polyps. |
Patient 4 is a 43-year-old female who presented to our clinic with a left chronically infected native hip and ipsilateral infected native knee. She had undergone 2 irrigation debridements at an outside hospital prior to referral for her to our clinic. She had a past medical history of poorly controlled type 1 diabetes (hemoglobin A1c of 9.7 on presentation), treated lumbar osteomyelitis, hypertension, and hyperlipidemia. She was initially treated with standard articulating hip and static knee antibiotic spacers () along with IV antibiotics. She continued to show drainage from the incisions and was found to have osteomyelitis of the femur in between the 2 spacers. We elected to treat her with an MAAS () that extended to the tibia. This case is unique to the previous cases as it begins as infections in native joints as well as the entire femur was removed. The modular body was still cemented into the femoral nail, which was locked distally into the tibia. Intraoperative cultures during placement of the MAAS were negative. However, given previous positive cultures and drainage from wounds, our infectious disease colleagues recommended continuing broad-spectrum antibiotics. After 6 weeks of IV vancomycin and by mouth ciprofloxacin, the patient was reimplanted with a total femur implant () 20.5 weeks after placement of the MAAS. Attempts were made to improve her glucose levels by medicine with only mild improvement in the patient’s hemoglobin A1c. Due to the amount of bone loss from her tibia, tibial stem and metaphyseal cone were used in addition to the total femur. This resulted in a cortical breach while placing the tibial stem. This was treated with a prophylactic plate. Patient was made touch down weight bearing in the postoperative period due to this cortical breach. She was taken to the operating room for open reduction of posterior hip dislocation with placement of constrained liner at 5 weeks postoperatively. She then developed a recurrence of PJI and underwent irrigation and debridement with polyethylene exchange 1 month after the open reduction. Her infection persisted; however, she underwent hip disarticulation 3 months after placement of the total femur. At last clinical follow-up, the patient did have significant phantom pain but had healed her amputation incision with no signs of infection. |
A 49 year old woman complained of abdominal pain in November of 2015 with diagnosis of large uterine fibroid, a myomectomy from within the uterus was performed. No malignancy was associated with the specimens recovered. In December of 2016, the abdominal pain persisted and a mass was palpable on physical examination in the mid-abdomen on the right. Colonoscopy was performed and biopsy showed a moderately differentiated adenocarcinoma of the caecum.\nCT was performed in December of 2016 and the primary right colon malignancy along with bilateral ovarian metastases were imaged. Percutaneous biopsy of the right ovarian mass showed well differentiated adenocarcinoma consistent with a colonic primary. From December of 2016 through December of 2017, the patient was maintained on chemotherapy. Initially, she was treated with FOLFOX. After four cycles, because of neuropathy, the oxaliplatin was stopped. The patient was maintained on 5-fluorouracil and bevacizumab.\nIn December of 2017, a CT documented marked regression of the primary tumor. It was not visible by CT. However, multiple lymph nodes within the mesentery of the distal small bowel were enlarged. Also by CT a pelvic mass showed that the right ovary had increased in size to 15 cm in greatest diameter despite the fact that the primary caecal malignancy was no longer visible by CT.\nOver approximately one month the patient became rapidly more symptomatic with abdominal distention from ascites and an expanding right ovarian mass. On February 1, 2018 the patient underwent cytoreductive surgery and HIPEC in a specialized center for management of peritoneal metastases. At the time of surgery she underwent a greater omentectomy, hysterectomy, bilateral salpingo-oophorectomy, complete pelvic peritonectomy, right colon resection, and small bowel resection. She received HIPEC with mitomycin C and doxorubicin with systemic fluorouracil. In order to determine if the multiple enlarged lymph nodes within the small bowel mesentery were involved by cancer, individual lymph nodes were removed and subjected to histopathologic study by permanent sections at a later time. A portion of each of these lymph nodes was sent for pharmacologic analysis for doxorubicin content. shows the pharmacokinetics of intraperitoneal doxorubicin in peritoneal fluid, mesenteric lymph nodes, and plasma. Clearly, the lymph nodes have taken up large amounts of doxorubicin nearly equal to that which was seen within the peritoneal fluid. The increased amounts of doxorubicin within lymph nodes as compared to the plasma can be measured by the area under the curve ratio. The ratio of lymph nodal tissue concentration times time to plasma concentration times time was 40. The area under the curve ratio (AUC ratio) of peritoneal fluid to plasma was 80.\nAfter the HIPEC chemotherapy and biopsies, an end-to-side coloenteric anastomosis was performed. The patient required a 3-week hospitalization and was discharged eating well and having normal bladder and bowel function. Pathology showed cancer in the right ovary and small amounts of cancer remaining at the primary site. No cancer was present in the mesenteric lymph nodes. |
This 35 year old woman began noticing increasing fatigue in 2014. The fatigue and left lower quadrant pain became increasingly severe so that she went an emergency room. On 19 February 2018, a CT scan was performed that showed an infiltrate into the greater omentum and multiple nodules associated with small bowel mesentery. There was no ascites. Masses were present on both the right and left ovaries. On 14 March 2018, she was taken to the operating room where multiple biopsies were taken. Her left ovary and appendix were removed. Pathology showed a mature cystic teratoma and extensive malignant peritoneal mesothelioma. Multiple biopsies from omentum, surface of uterus, peritoneum from the abdominal wall, and peritoneum from the small bowel showed malignant peritoneal mesothelioma.\nRepeat CT on 2 May 2018 showed malignant peritoneal mesothelioma infiltrating the omentum and accumulating as a diffuse mass in the pelvis. The small bowel mesentery showed multiple prominent lymph nodes. For definitive treatment of her malignant peritoneal mesothelioma, the patient was taken back to the operating room on 3 May 2018. At that time she had a greater and lesser omentectomy, cholecystectomy, pelvic peritonectomy with hysterectomy and right oophorectomy along with cytoreductive surgery of the small and large bowel surfaces. HIPEC was performed with cisplatin, doxorubicin, and systemic ifosfamide with Mesna (2-Mercaptoethanesulfonic acid sodium). During the HIPEC procedure Mayo scissor dissection removed a layer tumor from large and small bowel surfaces along with large and small bowel mesenteric surfaces []. In order to rule out disease within the mesenteric lymph nodes, six of these lymph nodes were harvested during the HIPEC chemotherapy []. Portions of the node were sent for histopathologic analysis and other portions were sent for pharmacologic analysis of the intraperitoneal drug, doxorubicin. The results of the doxorubicin within blood, peritoneal fluid, lymph nodes, and tumor are shown in . The area under the curve ratio of lymph node doxorubicin to plasma doxorubicin was 30. The area under the curve ratio of tumor nodules to plasma was 20 and from peritoneal fluid to plasma was 50.\nAgain in this patient the markedly increased levels of doxorubicin in lymph nodes as compared to plasma were documented.\nThe patient was hospitalized for 15 days and was discharged eating well. An intraperitoneal port was placed at the time of the cytoreductive surgery and will be used to deliver long-term intraperitoneal pemetrexed with systemic cisplatin. Six cycles of treatment are planned. Pathology of resected specimens showed malignant peritoneal mesothelioma; the lymph nodes were negative for cancer. |
A 33-year-old Nepalese man presented to our department of neurology in a university hospital for evaluation of an acute-onset flaccid paraplegia in the background of a 10-day history of headache and puffiness of the face.\nTen days prior to his presentation to our hospital, he had sudden onset, unilateral right-sided headache that later became generalized. He developed facial puffiness concomitant with headache that gradually progressed to involve his lower limbs. This was associated with shortness of breath on exertion, but without cough, fever, and decreased urinary output. For these complaints, he was initially evaluated at a local medical center. During his stay at the center, on his eighth day of admission, he developed stiffness of the neck for which he underwent lumbar puncture. The lumbar puncture yielded a bloody tap. He was then referred to our center for further evaluation.\nDuring his transfer from the local medical center to our hospital, he developed a sudden onset weakness of both lower limbs with loss of sensation. He presented with all of these symptoms at our center 10 days after the onset of headache. The loss of sensation gradually spread up to the level of his xiphisternum. He also developed severe back pain in his mid-thoracic region. He gave no history of weakness or any sensory disturbances involving his upper limbs. However, there was a history of both bowel and urinary incontinence. There was no history of loss of consciousness, altered sensorium, or seizures. He did not have any ocular symptoms at presentation. There was no evidence of a recent respiratory or gastrointestinal tract infection prior to the development of lower limb weakness. He had no history of alcohol intake or tobacco smoking. There was also no history of chronic medical illness.\nHis higher mental functions and cranial nerves examination were normal. Visual acuity and fundal examination were also normal. Muscle strength was intact in his upper limbs. Muscle tone was decreased in both lower limbs. Power across all major muscle groups in his lower limbs was 0/5. Deep tendon reflexes were absent in his lower extremities. Bilateral plantar responses were mute. A sensory examination revealed a sensory level at approximately T4/T5.\nBlood investigations showed: hemoglobin 12.1 gm/dl, packed cell volume 36%, white blood cells 17190/mm3 (neutrophil 82%, lymphocytes 16%, eosinophils 1%), and platelets 213,000/mm3. His renal function test was deranged: urea 21 mmol/l and creatinine 185 μmol/l. Urine routine evaluation showed: white blood cells 1 to 2 cells per high power field, red blood cells 8 to 10 cells per high power field, and albumin 3+ without any casts. Tests for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) were negative. Serology was positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antibodies (anti-HBe) while hepatitis B e antigen (HBeAg) and hepatitis B core IgM antibodies (anti-HBc IgM) were negative. His hepatitis B viral load was less than 2000 IU/ml. Venereal Disease Research Laboratory (VDRL) test and rapid plasma reagin test were negative. Serology was negative for cytomegalovirus (CMV), varicella zoster virus (VZV), and herpes simplex virus (HSV). His 24-hour urinary total protein was 3.9 grams per day, suggestive of nephrotic range proteinuria.\nCerebrospinal fluid (CSF) analysis revealed pleocytosis with elevated protein and normal glucose: total count 1300 with 70% polymorphs and 30% monomorphs, protein 380 mg/dl, and sugar 5.3 mmol/l. The red blood cells count in CSF was 12,500/mm3 and the opening pressure was 26 cm of water. Microscopy with gram stain and acid-fast bacilli stain followed by culture did not reveal any organism. CSF VDRL was also negative.\nA computed tomography (CT) scan of his head revealed linear hyperdense areas in his ambient and suprasellar cisterns which was suggestive of SAH (Fig. ). Magnetic resonance imaging (MRI) of his dorsal spine showed diffuse T2 high signal intensity within his spinal cord extending from second to 12th thoracic vertebral level which was suggestive of transverse myelitis (Fig. ). A CT cerebral and spinal angiogram did not reveal any abnormalities. However, an MRI of his brain was not done.\nSerological evaluations for antinuclear antibodies and anti-double stranded-deoxyribonucleic acid antibodies were negative and his serum angiotensin-converting enzyme (ACE) level was normal. Immunofluorescent assay showed perinuclear-ANCA (p-ANCA) within range but cytoplasmic-ANCA (c-ANCA) was positive with end-point titer over 1:20. In the light of positive serological tests for HBV and c-ANCA that pointed toward the vasculitic origin of myelitis, a further test for neuromyelitis optica (NMO) was not carried out.\nThe final impression was that of a SAH with acute transverse myelitis and with nephrotic syndrome in a patient who is a chronic carrier of hepatitis B. He was started on entecavir administered orally for hepatitis B infection. He was treated for myelitis with methylprednisolone administered intravenously (1 gram per day) for 3 days followed by a short course of prednisolone administered orally. During the course of his stay at our hospital, his sensory symptoms improved but his motor symptoms did not improve. Moreover, it was not economically feasible for him to remain in our hospital any longer and, hence, he was discharged after 1 month of hospital stay. He and his family members were counselled about rehabilitative care to prevent secondary complications of prolonged immobility. He came for regular follow-up in our neurology clinic for the next 3 months during which his condition remained the same with no improvement in motor function. After 3 months, he was lost to follow-up. |
A 56-year-old man of Asian origin was in his usual state of health until 4 days prior to presentation in our emergency room (ER); he had complaints of a rapidly progressing weakness of bilateral upper and lower limbs immediately prior to which he had a gastrointestinal upset. The weakness started from his lower limbs and gradually involved bilateral upper limbs in a similar glove and stocking fashion. He, however, did not have any sensory deficits and at the initial presentation in our hospital he had no respiratory and ocular muscle involvement. Consciousness and orientation were intact and he did not have significant hemodynamic instability. There was no significant medical or surgical condition requiring long-term hospitalization or medication use in the past. A government officer by profession, our patient had an active lifestyle and had no history suggestive of substance abuse or accidental or intentional poisoning. He lived with his wife and had two sons; one of his sons was living with him to support him and the elder son lived abroad but had been on good terms with the family. Our patient did not take any regular medications apart from the hypoglycemic agent metformin 500 mg administered orally twice daily. He did not smoke tobacco or consume alcohol regularly. During his initial presentation in our intensive care unit (ICU), he was conscious yet unable to speak properly. His vital signs were blood pressure (BP) 120/65 mmHg with no inotropic support, heart rate (HR) 102/minute regular, respiratory rate (RR) 26/minute regular, and he had no fever on admission.\nOur initial assessment led to a provisional diagnosis of GBS and immediate supportive tests were performed. A nerve conduction velocity test showed findings of motor axonal and demyelination neuropathy. A lumbar puncture done on the sixth day of the development of symptoms showed evidence of albuminocytologic dissociation with total counts (TC) of five cells/cc, which were all lymphocytes and CSF protein of 81 mg/dl (Table ). On the sixth day of the development of symptoms and third day of admission in ICU, he had complaints of difficulty in breathing with gradual decline in saturation with pulse oximeter reading of oxygen saturation (SpO2) to < 85% at fraction of inspired oxygen concentration (FiO2) of > 80%, and hypercapnia with partial pressure of carbon dioxide in arterial blood (PaCO2) of 86 mmHg. He was immediately intubated and kept on mechanical ventilator support.\nDiscussion was held with his relatives regarding available treatment options. A plan to initiate IVIG was made and started at 0.4 mg/kg per day for 5 days. The administration of IVIG was not associated with any significant complications. He did not, however, show major signs of recovery from respiratory weakness and was continuously kept on assist-control mode of ventilation with intermittent spontaneous breathing trials. At this time, he had occasional blood-tinged secretion in the subglottic suction and during intermittent endotracheal suctioning. A detailed coagulation profile did not show significant abnormalities. On the ninth day of admission in ICU, a plan for tracheostomy was made anticipating prolonged need for mechanical ventilation and as a part of routine pre-anesthetic preparation, a unit of group-specific (A +ve) blood was asked to be arranged. However, we were then notified by the blood bank that they had problems with cross-matching of the blood. A repeated blood sample of our patient was sent which also had a similar problem of inability to cross-match the blood. A literature search for the possible causes of such an occurrence was made but we only had a few reports of such problems. With a provisional diagnosis of significant hemolysis leading to cross-matching difficulties, further tests were sent (Table ). An arrangement of O negative blood was made as a reserve and a tracheostomy was performed with no major problems.\nHis stay in ICU was then complicated with hospital-acquired chest infections for which he received antibiotics based on organisms’ susceptibility. Liver function tests (LFTs) which were initially deranged subsequently normalized after gradual stabilization of his condition and de-escalation of drugs. Serological tests which included quantitative HIV, hepatitis B surface antigen (HBsAg), and anti- hepatitis C virus (HCV) antibody were negative. He was subsequently moved out of ICU on the 19th day with tracheostomy in situ and on portable bilevel positive airway pressure (BIPAP) support. Three days after being moved to a ward, he was brought back to ICU for sudden-onset dyspnea and tachypnea. He had coarse crepitations more on the anterior aspect of bilateral chest and slight decrease in breath sounds on bilateral basal regions. He did not, however, have fever or changes in vital signs and his consciousness was intact. He was managed conservatively with chest physiotherapy, deep breathing exercises, regular tracheostomy care, and suctioning of secretions from lungs. He recuperated in 2 days and was moved back to a ward where he slowly recovered from his weakness. No other untoward events occurred during this period of approximately 4 months. He is being planned for discharge to the care of a nursing home and the prognosis of the disease has been well explained to his relatives. |
A 22-year-old female patient reported to the department of conservative dentistry with a chief complaint of pain and discoloration in relation to an upper front tooth. On examination, it was seen that tooth #11 presented with severe discoloration and considerable tooth structure loss on the palatal aspect []. The patient gave a history of prior attempted endodontic treatment a year back, and she could not follow up the treatment with the dentist as she had relocated. The onset of pain prompted her to seek immediate dental treatment.\nClinical examination revealed significant tooth structure loss in a failed attempt to gain access to the root canal resulting in thinning of dentin on the labial and palatal aspect of the crown and subsequent discoloration due to incomplete root canal treatment []. The tooth was mildly tender to percussion, absence of any swelling, and exhibited physiologic mobility. The radiograph revealed the presence of periapical periodontal widening along with dentin loss extending from middle third of the crown till the junction of the cervical and middle third of the root around the root canal [].\nAfter examining the case, the patient was informed regarding the present condition and the treatment plan was explained, with which she complied. The procedure comprised of root canal treatment, followed by restoration of iatrogenic tooth structure loss with a dentin substitute and intracoronal bleaching.\nAt the first appointment, the dentinal floor was explored to locate the root canal orifice, which had been obscured due to lodgment of debris since the access opening was exposed to the oral environment for a considerable time. After the canal orifice was located, a no. #15 K-file was used to scout through the canal to reach the apex. The working length was established at 21 mm using no. 30-K file and confirmed using an apex locator and radiograph. The cleaning and shaping was initiated, and thorough irrigation was achieved using sodium hypochlorite 5.25%. The canal was enlarged to size #50 using K-files only. After irrigation and drying of the canal, calcium hydroxide (UltraCal XS, Ultradent Products, Inc.) intracanal medicament was placed and secured with a cotton pellet and temporary restoration.\nThe subsequent appointment was a week later. There was no tenderness to percussion and patient-reported absence of pain. After removal of the temporary restoration, the canal was further irrigated with sodium hypochlorite 5.25%, normal saline, and final irrigation with chlorhexidine 2%. The canal was dried and prepared for obturation. AH plus sealer and gutta-percha were used for obturation using a lateral condensation method.\nAt the same appointment, the tooth was prepared for restoration of the lost tooth structure using Biodentine. The access cavity was flushed with saline and dried to remove any sealer and particles of gutta-percha. Biodentine was mixed in a triturator as per instructions and placed in the access cavity. Following this is a crucial step, which was carried out using an anterior Schilder plugger size 11 (1 mm diameter). The plugger was inserted into Biodentine projecting exactly above the coronal end of gutta-percha. It was moved in a circumferential motion to create a short groove of approximately 4-mm length uncovering the coronal portion of gutta-percha. The plugger was continuously moved making a circle of 2-mm diameter along with lateral flaring to form a triangular shape to simulate the pulp chamber. This was done to sustain the artificially sculpted orifice until the Biodentine had set (setting time: 12 mins) eventually replacing the lost dentinal structure as well as maintaining the natural canal anatomy [] []. Subsequently, the pulp chamber was sealed with temporary restoration until next visit.\nAfter a week, the patient was scheduled for intracoronal bleaching procedure. The patient was asymptomatic, and the radiograph revealed periapical healing. The procedure included an initial formation of an intraorifice barrier. Glass-ionomer cement (GIC) was mixed and placed in the artificially created orifice to form a 2-mm thick plug over the gutta-percha with a bobsleigh configuration []. Hydrogen peroxide-based powder and liquid bleaching system (Pola Office) were used for bleaching purpose. The powder and liquid were mixed to the consistency of wet sand and packed into the pulp chamber using a plastic instrument []. A cotton pellet was pressed over the bleaching agent, and a 2-mm thick plug of GIC was used to secure these contents into the pulp chamber [].\nThe next visit was scheduled after 2 weeks, at which the tooth bleaching was assessed. The patient was satisfied with the esthetic result of bleaching []. Hence, the bleaching agent was carefully evacuated from the pulp chamber and copiously flushed with water. The final restoration was done with fiber-reinforced composite (EverX Posterior) and final increment of conventional composite (3M ESPE Filtek Z350) [].\nThe patient was asymptomatic when called for a follow-up visit at 2 weeks, 3 months, 6 months and 1 year []. |
A 55-year-old white male was brought to the emergency department after he woke up in the morning with complete blindness. He was unable to appreciate any light in both eyes. He also reported a moderate headache after he woke up that morning. Initial examination revealed elevated blood pressure with the systolic blood pressure more than 200 mm of Hg. The patient has a history of hypertension and has been noncompliant with his antihypertensive medications. Neurological examination revealed complete blindness in both eyes and 5 mm wide pupils that were reacting to light equally to direct and consensual light stimulation. The fundoscopy did not reveal any optic disc edema or retinal hemorrhages. Surprisingly, he was not distressed by his profound blindness and even denied his loss of vision during his examination, occasionally confabulating about things he was seeing during visual field testing. His general somatic sensations revealed no focal deficits, except for a mild loss of vibration sense in both lower extremities. There were no gross motor or cerebellar deficits. A preliminary computerized tomography (CT) scan of his head revealed hyperintense lesions bilaterally in the occipital lobes, consistent with hemorrhage as shown in Figure . There was no subarachnoid extension nor any intraventricular extension.\nHis preliminary lab results, including the coagulation profile, did not reveal any abnormalities. The patient was admitted to the intensive care unit and his blood pressure was monitored with an intra-arterial line, which revealed even higher blood pressures (systolic blood pressure exceeding 250 mm Hg). Magnetic resonance imaging (MRI) of his brain with gradient echo sequences revealed bilateral occipital lobe hemorrhages without any intraventricular or subarachnoid extension as shown in Figure .\nThere was no associated acute infarction. He had a magnetic resonance angiogram (MRA) which did not reveal any occlusion in his posterior circulation. A subsequently done magnetic resonance venogram did not reveal any venous thrombosis. His blood pressure was initially controlled with intravenous labetalol and later switched to a nicardipine drip. He had a prolonged hospital course with improvement in his vision at the time of his discharge. An Institutional Review Board (IRB) approval from the University of Missouri was obtained for the publication of this case report. The IRB approval number for this case is 230320. |
A 70-year-old female with multiple comorbidities presented to the ER from the nursing home with symptoms suggestive of septic shock. At the time of admission, the patient was undergoing active treatment for urinary tract infection in the nursing home. Physical examination of the patient revealed respiratory distress and hypotension, so emergency intubation was done and vasopressors started to maintain blood pressure. Empiric broad spectrum antibiotics were initiated for septic shock. Patient was then transferred to the medical intensive care unit for further management.\nPatient history revealed that the PEG tube was inserted one year prior due to dysphagia from a stroke. Upon abdominal examination, the PEG tube was in place in the epigastric area with signs of edema and erythema on the right lateral side of the abdomen.\nBullae were spread diffusely across the abdomen (), and gastric contents were noted to be leaking around the PEG tube. The patient localized tenderness to palpation, and bowel sounds were normal with no rebound or guarding.\nThe general surgery team was consulted for PEG tube position and abdominal wall erythema and edema.\nLaboratory studies revealed leukocytosis of 18000 cells/cubic mm, hemoglobin of 5.3 g/dl, hematocrit of 15.2%, and an INR greater than 10 as the patient was on regular Coumadin for chronic atrial fibrillation. Computed tomography scan of the abdomen and pelvis was recommended to confirm PEG tube position and to evaluate for retroperitoneal hematoma in view of high INR and low hemoglobin. The nursing staff was subsequently instructed to hold feeding through the PEG tube till its position could be confirmed with the CT scan.\nCT scan of the abdomen showed dislodgement of the internal button of the gastrostomy tube into the abdominal wall and a large collection measuring 10 × 7.5 × 20 cm. The collection showed equal parts of gas and fluid density in the subcutaneous compartment of the right anterolateral abdominal wall just lateral to the percutaneous gastrostomy tube outside the muscle and peritoneal reflection (Figures and ).\nAfter explaining the benefits and risks of the surgical procedure for drainage in the operating room, the intervention was denied by the patient's next of kin. Aspiration of the subcutaneous collection by the interventional radiologist was scheduled; however, the plan was withheld due to hemodynamic instability and the risk of transport to the radiology suite. A plan was made for bedside incision, drainage, and debridement of the subcutaneous collection. Vitamin K and FFP was administered for increased INR. After explaining the risks and benefits, informed consent was obtained from the patient's next of kin.\nBedside debridement was performed, and over 600 milliliters of foul smelling brownish fluid was aspirated from the wound (Figures and ). The fluid and the PEG tube tip were sent for culture and sensitivity. Wound vacuum was inserted and kept in situ for further drainage (). The aspirated fluid and PEG tube tip culture and sensitivity revealed Klebsiella Pneumonia and Candida Vulgaris. Despite resuscitative efforts, the patient expired 10 days after debridement from septic shock.\nWound vac was inserted after bedside debridement and drainage. Appropriate antibiotics and antifungals were initiated according to the microbial sensitivity. |
The patient, a 32-year-old Caucasian woman, presented to the West Virginia University Hospital Emergency Department via Emergency Medical Services. The patient had been at her usual baseline state of health with no significant past medical history prior to visiting the chiropractor for neck adjustment earlier that day for tension like soreness. The patient underwent neck manipulation after which she immediately complained of neck pain, diaphoresis, and proceeded to experience cardiac and respiratory arrest. Emergency Medical Services was called, and cardiopulmonary resuscitation was performed with one round of epinephrine administered. It was reported that the patient was pulseless and apneic for 3 minutes prior to EMS arrival. The patient was intubated on transport and her Glasgow Coma Scale score was 3T prior to arrival. Mean arterial blood pressure was 80 with palpable femoral pulses at arrival to the emergency department. Upon arrival in the emergency department, a CT stroke protocol was performed which demonstrated bilateral severe distal cervical vertebral artery dissections with acute thrombotic emboli seen in the left cervical vertebral artery ( and ). This was accompanied by complete occlusion of the basilar tip including the proximal posterior cervical arteries.\nThe patient received an initial bolus of intravenous tissue plasminogen activator (IV rtPA) at this time and the decision was made to proceed with endovascular intervention given the recent onset of occlusion. The patient was brought to the neurovascular angiography suite and femoral access obtained. Angiography of the left vertebral artery demonstrated severe dissection involving the distal cervical vertebral artery segments at the C1-C2 level with presence of sub occlusive thrombi. There was an occlusive clot in the left Posterior Inferior Cerebellar Artery (PICA). Intracranial imaging demonstrated occlusion at the basilar apex with absent filling into the right Posterior Cerebral Artery (PCA). There was occlusion of the distal left PCA. Angiography of the right vertebral artery demonstrated severe dissection of the distal cervical vertebral artery at C1-C2 with the presence of trickle-like flow into the vertebrobasilar junction. No filling was observed in the right PICA territory (). At this point, it was decided that the left vertebral artery offered the best access to the basilar trunk.\nSubsequently, distal aspiration was begun with a Penumbra 5 Max ACE distal aspiration catheter which initially demonstrated slow flow through the suction tubing. The 5 Max ACE was withdrawn into the proximal basilar artery until flow was seen within the suction tubing. Repeat angiography at this time demonstrated recanalization of the basilar apex and proximal PCAs. TICI3 perfusion was seen in the right PCA. Occlusive clot remained in the left distal P2 segment. Given the large size of the PCA, timing of events, and patient’s age, the decision was made to attempt clot retrieval of this. At this time, the Trevo ProVue microcatheter was navigated into the left distal PCA distal to the clot. The Trevo 4 mm × 30 mm stent retriever was deployed for approximately 3 minutes. The suction canister was attached, and the stent retriever was pulled with distal aspiration. No significant recanalization was achieved with what amounted to TICI0 perfusion to the left PCA territory. No further attempts were made as it was believed that the left PCA territory had completed its infarction.\nFollowing completion of endovascular therapy, the patient was taken for immediate MRI Brain with and without contrast for assessment of brainstem integrity and cerebrovascular status prior to transport to the intensive care unit. MRI demonstrated extensive areas of restricted diffusion accompanied by perfusion abnormalities consistent with acute infarction of the posterior circulation, specifically within the bilateral cerebellar hemispheres, right medulla, pons bilaterally, midbrain, thalami, and left occipital lobe (). The following day, additional CT Brain imaging was acquired and demonstrated signs of elevation of intracranial pressure with hydrocephalus, worsening of cerebral edema diffusely, hemorrhagic transformation of the left occipital lobe, continued infarct evolution within the posterior circulation, and cerebellar tonsillar herniation. |
The patient is an 80 year old male with a past medical history of atrial fibrillation with sinus block with dual chamber pacemaker placed in November 2006, and a complicated oncologic history including breast cancer in the 1970s treated with left-sided mastectomy and axillary lymph node dissection; prostate cancer treated with intensity modulated radiation therapy (IMRT) in 2001; mucosal melanoma with metastases to small bowel treated with small bowel resection in 2005; and multiple skin cancers. He was treated with a total thyroidectomy for anaplastic thyroid carcinoma in March 2008, followed by post-operative cisplatin-based chemo-radiation therapy to the surgical bed and the draining lymph nodes. A subsequent left lung nodule was treated with thoracotomy and wedge resection in December 2008, with documented metastatic anaplastic thyroid carcinoma on pathology. He also received one cycle of Abraxane and Bevacizumab in February 2009.\nThe patient had been asymptomatic and in his usual state of health until July 2009 when he presented with a 2 month history of decreased exercise tolerance and orthostatic hypotension. Workup revealed a loss of atrial function, leaving the patient dependent on his pacemaker. An outpatient echocardiogram was concerning for "intracavitary irregular densities" in the right ventricle and right atrium. CT Chest with contrast revealed a 5.1 × 4.8 cm right atrial mass, with a broad base of attachment at the right atrial posterior wall and extension into both the inferior and superior vena cava. There was a notable displacement of pacemaker leads. The right ventricle also demonstrated an irregular lobulated 6.8 × 2.5 cm mass attached to the ventricular septum. Retrospective evaluation of a prior PET-CT from June 2009 confirmed increased FDG uptake within the right atrium and right ventricle.\nIn mid-July 2009, the patient was admitted to University of California San Francisco Moffitt Hospital for cardiac telemetry and management of this intracardiac mass. Admission labs showed thrombocytopenia with platelets ranging between 20 and 35. The differential diagnosis for right heart masses included metastases from anaplastic thyroid carcinoma or melanoma, a new primary cardiac malignancy, or a thrombus.\nA Fibrinogen level was within normal limits, and hematology smears were negative for schistocytes. A bone marrow biopsy demonstrated a normocellular marrow for the patient's age with mixed trilineage hematopoesis and no evidence of lymphoma or thrombus. A trial of dexamethasone for suspected idiopathic thrombocytic purpura (ITP) did not impact the thrombocytopenia. The differential diagnosis for the thrombocytopenia therefore remained a consumptive coagulopathy secondary to tumor, versus tumor-associated immune thrombocytopenia.\nAfter careful consideration at a multi-institutional tumor board, it was decided to treat these intracardiac metastases with radiation therapy. A pre-treatment electrophysiologic interrogation showed intermittent loss of capture by the pacemaker, most likely secondary to growth of the intracardiac mass. Therefore, a new pacemaker with epicardial leads was emergently placed. During this procedure, biopsy of the intracardiac mass was performed, confirming metastatic anaplastic thyroid carcinoma.\nRadiation therapy to the right atrium and part of the right ventricle was initiated at 2.5 Gy per fraction for 15 fractions to a total dose of 37.5 Gy, with an intended maximum dose in the tumor areas just exceeding 40 Gy (see below) (Figure ). Paclitaxel (50 mg/m2) was administered concurrently on days 1 and 8 of radiation treatment.\nDuring the course of his radiation treatment, the pacemaker demonstrated full capture. A single episode of ventricular undersensing with pacing stimuli during T-waves was successfully addressed by the reprogramming of the device. Transcutaneous pacer was available during treatment should failure of the primary pacing device occur. Echocardiograms during radiation treatment showed that the intracardiac mass had not increased in size. The patient required platelet transfusions approximately every 48 hours, and his platelet count held steadily around 18 to 20. Given his leukopenia and sepsis, Abraxane was withheld after two courses.\nAfter discharge, the patient participated in regular activities of daily living, including work-related meetings and exercise on the treadmill, but experienced persistent dyspnea on exertion. His pacemaker continued to demonstrate full capture without evidence of dysfunction.\nIn late August 2009, less than one month after completion of treatment, a PET-CT showed decreased FDG uptake right atrium (maximum SUV decreased from 27.9 to 7.8) and stable FDG uptake within the right ventricle (Figure ). There was some questionable uptake in the interventricular septum, representing normal physiologic uptake or residual disease. Unfortunately, multiple pulmonary and chest wall metastases were subsequently detected.\nThe patient completed one additional course of palliative radiation therapy to a symptomatic left chest wall metastasis. He died in his home two months after completion of radiation therapy. |
A 78-year-old white caucasian lady presented to her local hospital with rapid loss of vision in her right eye over 12 hours. She had been suffering from non-specific joint pains for several months for which she had been receiving acupuncture. Ten days prior to her admission a rheumatologist had diagnosed polymyalgia rheumatica based on her symptomatology and scalp tenderness, but she had not been started on steroid treatment. She had had an anterior resection for adenocarcinoma of the bowel in 2001 and a computed tomography scan six months previously showed no evidence of tumour recurrence. There was a past medical history of melanoma (resected from her right foot) in 1983, and a transient ischaemic attack but had no history of diabetes, ocular trauma or sinusitis. There had been no recent hospital admissions or medical procedures.\nInitial examination revealed a reduction in her visual acuity on the right to hand movements only, there was also tenderness over the right temporal artery. The left eye vision was normal. The right fundus seen with a direct ophthalmoscope showed an elevated, yellow, sub retinal macular lesion with associated retinal haemorrhages and cotton wool spots. There was no evidence of uveitis. The physical examination was otherwise normal. At this time her erythrocyte sedimentation rate was 58 mm/hr, her C reactive protein 1 mg/L, total white cell count of 11.9 × 109/L. Giant cell arteritis was suspected to be the cause of her pain and she was commenced on 80 mg of prednisolone daily. After five days the pain worsened and became more localised to the right eye and she developed panuveitis with 1 mm hypopyon in the anterior chamber. She was transferred to our institute for further management. An ultrasound B scan of the eye showed retinal elevation at the macula, choroidal thickening and subretinal fluid suggesting the diagnosis of endogenous endophthalmitis. A vitreous biopsy was performed which showed the macular lesion to orginate from a subretinal mass accompanied by an area of macular retinitis with intense inflammatory exudate in the posterior vitreous. Intravitreal ceftazidime and vancomycin were administered. The Gram stain of the vitreous biopsy showed moderate numbers of neutrophils, branching septate hyphae and no bacteria (Figure ). Bacterial cultures were negative but culture on Sabouraud's agar revealed a mould identified as Aspergillus fumigatus on the basis of typical colonial and microscopic morphology. The organism was susceptible to voriconazole (MIC 0.25 μg/ml) using the Clinical and Laboratory Standards Institute MS27-A2 method[]. She was commenced on oral voriconazole 400 mg twice a day for 24 hours as a loading dose. The following day she complained of visual hallucinations at night, a well-known side effect of the drug and the agent was discontinued for a day. She subsequently tolerated maintenance treatment at a dose of 200 mg 12 hourly to complete a two-week course. Systemic steroids were tapered and discontinued over two weeks. Six days after commencing voriconazole she underwent a second vitreous biopsy with intravitreal injection of 5 mcg of amphotericin B. Gram stain and culture of this sample were negative. Voriconazole levels were measured in serum and vitreous aspirate, both eight hours after her last 200 mg dose, by means of a bioassay. Both the assay of the serum and the vitreous revealed a concentration of 0.69 μg/ml.\nAn extensive search for a source of her infection (blood cultures, echocardiogram, computed tomography of chest, abdomen and pelvis and magnetic resonance imaging of the brain) was negative. The uveitis improved substantially during the first week of treatment, but there was no improvement in her visual acuity due to the macular involvement. On review two months later the uveitis had settled, but there was persistent pain and low intraocular pressure (4 mmHg) in the right eye indicating the onset of phthisis bulbi. She was blind in the right eye. Therefore enucleation of the right eye was suggested and the patient consented to the procedure. Histological examination of the enucleated eye showed non-specific chronic fibrosing vitritis with no fungal elements seen using special stains. |
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