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A 43-year-old lady presented to emergency department with a 3-week history of intermittent headaches, deteriorating vision, and dizziness with nausea and vomiting. A few days later she started having episodes of generalized tonic-clonic fits. There was no history of fever, weight loss, or recent travel abroad. Her past medical history was significant for an episode of left sided weakness with facial weakness at age 19 which resolved on its own with no residual deficit. A CT scan at that time showed an area of damage in the right hemisphere within the white matter; these appearances were suggestive of an infarct. An MRI scan done at that time did not show any features consistent with multiple sclerosis. CSF analysis was within normal limits. Visual evoked potentials were also normal. The exact cause for this episode was not found and the patient was discharged with the advice to quit smoking. No further tests were done at that time. Since then, she remained fit and healthy with no further episodes of weakness. She was not on any regular medications. Her family history was unremarkable. Physical examination, including a full neurological examination, was also unremarkable. There was no focal neurology, neck stiffness, or any other signs of meningism.\nRoutine lab tests were all normal. With this presentation, head CT scan was an obvious first choice investigation. It showed an area of low density within the right parietal region measuring about 2.7 cm, with no evidence of enhancement following injection of IV contrast and no mass effect (). A head MRI scan showed mature damage most likely due to an old infarct () but it also revealed leptomeningeal enhancement along several regions of the brain ().\nBased on the findings of the head CT scan and head MRI scan the differentials included diffuse leptomeningeal disease (with an old infarct) as a result of inflammation secondary to sarcoidosis, infection with tuberculosis (TB), and malignancy either primary or as a result of an underlying metastatic process from lung or breast. She then had a chest X-ray and then a CT scan of the chest and abdomen which did not show any evidence of an underlying malignancy. A complete vasculitic screen, including ANCA antibodies, was negative. Serology for syphilis, HIV, HBV, and HCV was all negative. The images were then transferred to a tertiary centre (Walton Neurology Centre in Liverpool) for further review by a specialist neuroradiologist and expert opinion was sought from a neurologist. His opinion was that the top differential could be neurosarcoidosis and he recommended starting her on steroids and doing a lumbar puncture for CSF analysis. The lumbar puncture showed increased opening pressure of 41 cm of H2O. The CSF analysis revealed cellular deposit containing a mixed population of small lymphoid cells with no malignant cells. Also, on the CSF analysis, there was increased protein content of 12,90 g/L. A CSF culture was negative for TB. ACE levels and serum calcium were requested and both came back as normal, but the neurologist suggested continuing with the steroids as the patient reported some improvement of her symptoms. More specifically, she reported some transient improvement in her visual symptoms and there was also a decrease in the CSF opening pressure on a repeated lumbar puncture. In terms of other differentials, lymphoma was low on the probability as there was no history of weight loss, fever, or lymphadenopathy. Serum LDH was also within the normal range. Fundoscopy did not show any evidence of papilloedema. 2-3 weeks after being started on steroids, her vision continued to deteriorate. She became totally blind in the left eye and her vision was reduced to light perception in the right eye. Serial CSF analysis continued to show raised opening pressure with high CSF protein but the neurology multidisciplinary team decided not to do any shunting as the shunt could be blocked by the high CSF protein content. An MRI scan of her spine showed diffuse meningeal enhancement coating the whole of the spinal cord down to the conus and extending to cover the nerve roots of the cauda equina. The cord itself returned a normal signal (Figures and ).\nTo reach the final diagnosis a biopsy was taken from the lower thoracic dura (). The appearances of the biopsy were in keeping with a diagnosis of leptomeningeal gliomatosis. Three previous CSF cytospin preparations did not show any atypical cells. Immunohistochemical staining showed that the cell nests were GFAP and S100 positive. A few scattered proliferating nuclei were present (Ki67). A few scattered LCA positive lymphocytes were seen. The following markers were negative: CAM5.2 and IDH1.\nBy the time final diagnosis was reached the patient's symptoms had already progressed considerably. More specifically her visual impairment progressed to complete blindness over the next few weeks and she also developed weakness in both lower limbs with a motor power of 1-2/5 bilaterally. Sphincter function was also lost. Around the time of her death she had flaccid paralysis and unresponsive plantar reflexes. She did not respond to steroids any more but steroids were continued up until a few days before her death. Once the diagnosis was established, along with the prognosis, which happened about one week before her death, the steroids were stopped as they were not making any difference. After consultation with her family, it was decided to treat her palliatively. She was referred to the palliative care team and unfortunately she passed away in the next few days, after a total of 4 months since she first presented. The cause of death was due to aspiration pneumonia and a postmortem examination was not performed. |
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. |
The patient is a 56-year-old male in very good health. He exercises regularly, primarily walking, running, and bicycling, and has an excellent cardiovascular profile with a body mass index of 23. He is educated at the doctoral level and is medically literate. As reported previously [], he was diagnosed with major depressive disorder at age 42 and was treated with fluoxetine, omega-3 fatty acids and psychotherapy which were eventually effective, with the depression going into a yet-continuing remission starting at age 53. The patient had discontinued the fluoxetine more than 6 months after the depression had gone into remission. Of note, he had not experienced significant anxiety symptoms until age 54, which at that time were associated with the use of EPA-enriched fish oil supplements. The patient had taken the same refined fish oil supplements for over 5 years and he partially attributes the remission of his depression to them, but they gradually began causing the anxiety and insomnia symptoms, which became noticeable by age 54 and abated when he temporarily stopped taking the fish oil supplements. A subsequent challenge with the fish oil triggered the symptoms again, so the patient stopped taking them altogether after which the anxiety and insomnia symptoms were largely eliminated []. He was prescribed lorazepam for the anxiety symptoms, which by agreement was restricted to no more than 12 1 mg tabs per 6 months to prevent dependence.\nDuring a recent annual physical exam, his primary care practitioner suggested montelukast for his mild chronic asthma. Two to three weeks after initiating montelukast at 10 mg/day he noticed gradually worsening generalized anxiety and began waking suddenly after several hours of sleep. During his awakenings, he often experienced strong sympathetic activation, with increased heart rate, flushing and a loosening sensation in his viscera. These panic symptoms were associated with ruminative thoughts in which routine life concerns led to the imagination of catastrophic outcomes for himself, his family and society at large. He described one night in which he experienced nasal congestion and had persistent, intrusive fears of suffocation should his mouth somehow be forced shut. He is experienced in somatic quieting and cognitive self-soothing [] but found these difficult to execute in these night-time panic episodes. Instead, he chose to get out of bed and read until he was calm enough to resume sleep. On a few occasions he took 0.25–0.5 mg of lorazepam, often with a glass of wine. The only other medications the patient used were fluticasone 100 mcg-salmeterol 50 mcg inhalation powder (Advair®, GlaxoSmithKline) and albuterol HFA, both for occasional asthma exacerbations. The anxiety symptoms occurred virtually every night by the fourth week of taking montelukast.\nThe patient reported that in the daytime he was also frequently overcome by morbid fears of such things as aging in loneliness, his children failing at life or worldwide economic collapse. At other times he would suddenly feel extreme anxiety about expectations of him at his workplace, in which he experienced a wave of sympathetic arousal, mainly felt as flushing and an increased heart rate. Because of the night-time awakenings he was chronically sleep-deprived during this period, to which, based on experience, he attributed the fact that he felt restless and ‘jittery,’ and had a pounding heart throughout much of the day. The patient recognized that the current symptoms were very similar to those associated with fish oil supplements, but he considered them significantly more intense than the previous episode.\nThe patient did not associate his anxiety symptoms with the new medication until it was time to refill his prescription. He researched the adverse events associated with montelukast and immediately decided to discontinue the drug after ~1 month of daily use. The panic symptoms during night-time awakenings abated within a few days, while the awakenings themselves and the general anxiety took a few weeks to largely resolve. Several months after the discontinuation of montelukast the patient reported that he felt a ‘normal’ mild degree of daytime anxiety and experienced mild maintenance insomnia less than once a week with no panic symptoms. |
A 43-year-old female presented with a history of VP shunt placed at birth. She had multiple revisions throughout her lifetime. She presented to our service with abdominal pain, severe headaches, mild nausea, but no vomiting, and was found to have worsening hydrocephalus secondary to abdominal pseudocyst []. The cyst was determined to be infectious and was drained percutaneously; however, fluid from the pseudocyst and CSF grew Streptococcus Group D. Her shunt was externalized and eventually revised to the right side. One month later, she had a recurrent infection with the same organism. Shunt was externalized again and replaced after Infectious Disease consultation, and separate CSF cultures showed that the infection was cleared. She tolerated the procedure well and was discharged home in stable condition with alleviation of her symptoms.\nSix years later, she was admitted to the hospital with sepsis, which was likely secondary to cellulitis as well as poorly controlled diabetes mellitus (A1C = 13.4%). She complained of pain on her abdominal wall, but otherwise had no neurological signs or symptoms. It was noted on admission that she had cellulitis along the tract of her distal shunt catheter. She was also noted to have pockets of underlying abscess in the soft tissue of her abdominal wall on a contrast CT abdomen. ESR on admission was 113; CRP was 22.05. Given the cellulitis secondary to the distal catheter, she underwent bedside externalization of the distal portion of her VP shunt. The culture from the wound, CSF, and catheter tip culture grew Beta Streptococcus Group A, necessitating an Infectious Disease consultation. An endoscopic third ventriculostomy was attempted, however, it could not be safely performed due to diffuse thickening of the floor of her third ventricle. After resolution of the soft tissue infection of her abdominal wall and infectious disease clearance, a new VP shunt was placed on the opposite side. A revision surgery was performed on the left side with the assistance of the general surgery service in laparoscopic placement of the distal catheter. |
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. |
Our patient was a 65-year-old Caucasian man with an 18-month history of ALS, who presents with progressive dyspnea and palpitations. A previous evaluation of his dyspnea attributed the cause to neuromuscular weakness and he underwent a pulmonary evaluation. A chest X-ray demonstrated clear lung fields. His arterial blood gas revealed a pH 7.4, carbon dioxide partial pressure 62, oxygen partial pressure 117, on fraction of inspired oxygen 40% and concomitant blood chemistry demonstrated elevated serum bicarbonate, both consistent with chronic carbon dioxide retention. Pulmonary function testing indicated a forced expiratory volume in 1 second (FEV1) of 79% and FEV1/forced vital capacity of >80%. These pulmonary function tests did not represent a significant decrement from baseline.An electrocardiogram (ECG ) was obtained which demonstrated hemodynamically stable new third degree atrioventricular (AV) block with a junctional escape rate of 50 beats per minute (Figure ). A previously obtained ECG indicated normal sinus rhythm. On further review, he was not prescribed medications with AV nodal blocking properties while at home or during his hospitalization. On echocardiogram, a structurally normal heart was observed with normal left ventricular dimensions and function without significant valvular disease. He was offered a permanent dual chamber pacemaker for definitive treatment, however, he declined.\nWe believe that his symptoms were probably attributable to his AV block. The original symptoms of dyspnea with palpitations were initially attributed to ALS neuromuscular weakness during periods of exertion. The narrow complex escape rhythm suggested the block occurred at or above the level of the AV node, an area innervated by the autonomic nervous system. The role of ALS as the etiology for the development of AV block has not been previously reported. However, given the association of autonomic dysfunction with ALS, conduction abnormalities might be expected.\nDetermining associations of disease can be difficult and often requires large data sets to generate conclusions. The Explorys platform is a system that aggregates standardized and normalized electronic health record data currently from 13 healthcare systems around the USA and thousands of providers’ systems representing 15 million patients. We conducted a query using the Explorys Explore tool of patients with ALS and any degree of heart block (1st, 2nd, and 3rd degree) using International Classification of Diseases, Ninth Revision, diagnosis codes for both conditions (ALS = 335.20, Heart block = 426.0, 426.11, 426.12, 426.13). We sought to determine the difference between the prevalence of heart block in the general population and in those with ALS.\nIn Explorys, there was a base of 14,092,470 patients of which 3470 had ALS. Heart block was present in 73,801 patients without ALS and in 30 patients with ALS. The prevalence in the diagnosis of heart block in the general population was 0.52%. In ALS the prevalence of the diagnosis of heart block was 0.86%. The difference in prevalence of heart block was therefore estimated to be 25% higher in patients with ALS (P-value 0.01; confidence interval 0.002 to 0.100). |
A 64-year-old man presented with medial osteoarthritis of both knees. He underwent Oxford UKA on each knee on the same day. The surgery on both sides was performed by the same experienced senior surgeon. Post-operative radiographs of his left knee showed that the femoral and tibial implants were placed properly, and there were no loose cement fragments. Post-operative course was good, and the patient was discharged at 3 weeks walking alone. He was able to work without pain for 1 year after surgery. At that time, pain developed on the anterior knee surface of the left knee, and at two and a half years after surgery; the pain became localized around the medial margin of the patella of the left knee. In addition, the pain intensified at the same site with twisting movements. The symptoms led to suspicion of soft-tissue-mediated pain, and a local anesthesia injection temporarily achieved complete pain relief. However, the patient’s symptoms subsequently persisted, and an additional surgery was scheduled. Pre-operative range of motion of the left knee was 0-140°, and there was no marked swelling of that joint. There was pain and tenderness at the medial margin of the patella, pain when standing from a bending position, and pain during twisting movement. The radiolucent line was verified beneath the tibial components in both knees 1 year after surgery on plain radiographs, and we diagnosed it as physiological radiolucency [] because it was no more than 2 mm thick and was surrounded by sclerotic margin. No enlargement of the radiolucent line was evident before additional surgery (). The arthroscopic operation was performed two and a half years after primary UKA. The surgical findings showed that scar tissue extending from the intercondylar area to the posterior part of the infrapatella fat pad covered the anterior surface of the femoral implant to the anterior groove of the implant, and we were able to confirm that the scar tissue was in contact with the femoral implant (). While surgically removing the scar tissue, a 3 mm diameter cement fragment was identified in the scar tissue and this was removed along with all of the scar tissue ( and ). After arthroscopic surgery, the symptom disappeared immediately, and at present, 2 years after the additional surgery, there has been no recurrence of symptoms and the pain has disappeared.\nThe patient was informed that his data would be submitted for publication, and he gave his consent for the same. |
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. |
The patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().\nThe patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.\nShe underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.\nAfter identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.\nAfter a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014 guidewire was placed into the proximal portion of the neck.\nA 21 gauge needle was used to cannulate the proximal portion of the neck percutaneously from the right groin. The previously placed guidewire was used as a landmark to place the tip of the 21 gauge needle into the pseudoaneurysm. After blood return was noticed from the needle, a 0.018 guidewire was placed into the lumen of the right common femoral artery. A 6 French access sheath was placed over the guidewire. Fluoroscopy was then used to visualize the deployment of a vessel closure device (VASCADE 6 French). This was done without difficulty, and the collagen patch was positioned outside the vessel wall in the area of the pseudoaneurysm neck. Interval angiogram revealed partial occlusion of the pseudoaneurysm neck ().\nIt was then decided to place an occlusive 8 mm balloon into the lumen of the right common femoral artery to facilitate pseudoaneurysm thrombosis. The balloon was insufflated up to 8 ATM for 600 seconds. This was done twice in total. Interval angiogram then revealed complete occlusion of the pseudoaneurysm blood flow (Figures and ).\nAll wires and catheters were removed at this point, and a left common femoral artery access sheath was kept in overnight. Postoperatively, the patient had no complications, and formal ultrasound confirmed complete thrombosis of the pseudoaneurysm. The access sheath was then removed without issue. There were no ischemic complications due to balloon occlusion in the immediate postoperative period. |
A 28-year-old female visited our institute because of headache for a month. The consciousness level was alert and motor grades of the extremities were normal. However, she had repeated vomiting for several days. This symptom was likely due to increased intracranial pressure, and therefore brain imaging was performed. The brain CT scan showed abnormal low density on the right frontal lobe and bony thinning on the right frontal bone (). Brain MRIs revealed cystic and enhancing mass on the right frontal lobe (). Dural enhancement suspected to be the dural tail sign was identified (). Conventional angiography was performed and sunburst appearance through the right middle meningeal artery was confirmed (). These radiographic findings suggested a diagnosis of a cystic meningioma.\nA surgical excision was performed. Intraoperatively, the dura was intact and there was no abnormal findings at the craniotomy eroded bone site. The mass had a well-defined arachnoid plane. Also, there was no dural attachment or adhesions (). A biopsy was taken and sent to the pathologist for intraoperative diagnosis, and the result of the frozen biopsy was a glioma. After cyst fenestration, the mass was totally removed. The final pathology findings described a proliferation of piloid glial cell with Rosenthal fibers and eosinophilic granular bodies (). Biphasic pattern was also identified. The Ki-67 was 1%. However, some scattered mitotic figures were identified. A maximum of 3 mitoses per 10 high power field showed that it was difficult to diagnose the patient as an anaplastic astrocytoma. Also, slightly increased cellularity was also shown, but there was no necrotic tissue. Therefore, the histologic findings confirmed a diagnosis of pilocytic astrocytoma with transformation to a more cellular and mitotically active lesion.\nPostoperatively, enhanced CT scans revealed that the tumor was totally removed. The symptoms improved and there were no abnormal neurologic signs. Additional treatment such as radiation was not performed because pilocytic astrocytoma are known to be benign. There were no specific symptoms during follow-up. However, CT scans after nine months for routine follow-up showed a mass-like lesion. An MRI with gadolinium was performed, and the tumor recurrence was identified (). The recurrent mass was removed surgically. Pathologic diagnosis was an anaplastic astrocytoma (). Postoperative radiation therapy of 60 Gy was performed. After radiation, there was no tumor recurrence for 3 years. |
A 31-year-old woman suffered from sudden onset pharyngeal pain after she had eta fish during a dinner party. At that time, she tried to swallow rice and vegetable roll in order to dislodge the fish bone when she felt the pain of the foreign body, but it was not effective. Subsequently, she underwent fiberoptic laryngoscopy because of the sensation of foreign body in the pharynx. But the result of examination showed that no foreign body and no abnormalities were detected. The uncomfortable symptoms were alleviated after a week and therefore no further diagnosis and treatment were done.\nShe occasionally suffered from the foreign body sensation and tingly sensation on the left neck area when turning her head within two months after onset of symptoms. She came to our hospital for further examination. Except for mild tenderness at the left neck, there are no other pathognomonic signs from the physical examination which are specifically related to a residual foreign body in the neck.\nAfter neck ultrasonography had been performed, the report revealed the presence of abnormal echo structure which was approximately 2.43 cm hyperechoic linear image embedded in the left part of the thyroid lobe and surrounded by a thin hypoechoic area (). Other routine examination showed no abnormalities, including blood examinations and thyroid function tests. Combined with medical history, the diagnosis was residual fish bone in the thyroid.\nIn order to remove the foreign body, the patient underwent an exploratory surgery. After isolating and cutting the left middle thyroid vein, a sharp object piercing the surface of the dorsal thyroid membrane was found. We held the tip of the object with a mosquito forceps and pulled it out gently. The sharp object was a fish bone about 2.45 cm in length (). Confirming that the esophagus, vascular, and nerve had not been damaged, left thyroid lobectomy had been performed. A drain was left for 24 hours. The postoperative course was uneventful, and the patient was discharged after 3 days. The pathological results showed that a well-defined region composed of macrophages and inflammatory cells around the hemorrhage cavity in accordance with classic foreign body granulomatous inflammation (). |
A 12-year-old male presented with inability to walk even a few steps due to buckling of knee and striking of both knees while taking a few steps, which was present since the child learnt walking after birth. The child preferred not to walk for these reasons. His mother noticed deformity immediately after birth. She, being illiterate, could not describe the deformity. There was no history of birth trauma and the child was born of normal vaginal delivery. He was the first sibling of three brothers. The parents were apparently healthy and there was no family history of congenital, metabolic, or neurological disorders. The child developed his milestones normally. There was no evidence of any other congenital anomaly and the child was advised about the need for surgery at the age of 5 or 6 years by a village doctor. At the age of 6 years, the patient underwent surgery at the level of lower thigh, presumably bilateral supracondylar femoral osteotomy. The child continued to have inability to walk even after surgery. He consulted this institute at the age of 12 years.\nGeneral physical examination revealed stunted growth with no joint laxity. There were no other associated congenital anomalies; local examination revealed a fixed flexion deformity of 30° with further range of flexion of 15° on the right side and a fixed flexion deformity of 45° on the left side with further range of flexion of 20°. There was prominence anteriorly confounding to tibial plateau bilaterally. There was a surgical scar of around 8 cm on the lateral aspect of both thighs at the level of the upper two-third and lower one-third junction. The popliteal area was full and the contours of femoral condyles were palpable in this area. There was wasting of quadriceps muscles.\nPlain radiograph showed hypoplastic femoral condyles displaced posteriorly in relation to upper end of tibial. The upper tibial surfaces were convex. The patellae were hypoplastic, located above and anterior to femoral condyles [Figure , ]. Magnetic resonance imaging (MRI) of both knees revealed medial bowed femur, trumpet shaped metaphysis and small epiphysis, posterior subluxation of knee, splayed capsule and attenuated ACL and posterior cruciate ligament (PCL) [Figure , ].\nAn informed consent was obtained from the parents of the patient for publication of the data. The surgical correction was planned in stages. First we applied Ilizarov ring fixators in order to distract the soft tissue around knee joints to avoid surgical shortening of femur. The construct consisted of one full and one half rings in femur and two full rings in tibia with hinges at knee joint. The distraction of 1 mm/day was performed till the overlap of tibia and femur was corrected which took 3 weeks. The deformity on the right side was corrected from 30° to 25°, whereas on the left side was corrected from 45° to 30°. The surgery was performed by the senior surgeon (AKJ) []. In the second stage, open reduction of both femoral and tibial condyles was performed. Both the tibial condyles were convex. The ACL and PCL were markedly attenuated and elongated. The menisci were attenuated, but shaped like tibial condyles. The open reduction could be achieved easily and was stabilized by two cross K-wires []. The limbs were immobilized with above knee plaster-of-Paris (POP) cast for 6 weeks. The K-wires were removed at 6 weeks and knee mobilization was started. The patient started walking at 6 months postoperatively with bilateral knee ankle foot orthosis (KAFO) and axillary crutches. He continued to walk for the next 1 year. At 1 year followup, the patient had 45° fixed flexion deformity on the right side with further range of motion till 100° and 25° fixed flexion deformity on the left side with further flexion range of motion till 90°. On followup X-rays at 1 year, the convex surfaces of upper end of tibia remolded to concavity []. The patient was upright, doing his activities of daily living with brace.\nA bilateral supracondylar femoral osteotomy (extension osteotomy) was done after 18 months of previous surgery to change the arc of motion (third stage) [Figure , ]. The arc of motion was improved from 5° to 100° on the right side and from 5° to 80° on the left side. At 4 years followup visit, the patient had range of motion of 5°–100° on the right and 5°–80° on the left. More or less, the knees were found to be stable [Figures and ]. The patient was able to walk with a KAFO. His activity of daily living had improved and was able to drive bicycle. He gained in height also. |
The patient was a 30-year-old Japanese woman. This was her first pregnancy. She had a pelvic neuroblastoma in the front of her sacrum at 1 month of age. She had undergone surgical resection, and the pathology revealed rosette-forming neuroblastoma. She received adjuvant chemotherapy with vincristine and cyclophosphamide (the James method) postoperatively up to the age of 2 years. She also received pelvic irradiation with a total dose of 18 Gy. By age of 3 years, there was no evidence of disease, and she was considered cured.\nShe visited out hospital for prenatal care at 6 weeks of gestation. At 15 weeks and 5 days of gestation, she complained of abdominal pain due to frequent uterine contractions and was diagnosed with threatened abortion or incompetent cervix by transvaginal ultrasound. She was admitted at 16 weeks of gestation and ritodrine tocolytic therapy was initiated to control her frequent uterine contractions. At 20 weeks and 2 days of gestation, she developed acute abdominal pain. Ultrasound and magnetic resonance imaging (MRI) revealed intra-abdominal bleeding of unknown etiology (). The patient and her husband chose to continue the pregnancy even after we explained to them the risks involved in doing so and after we suggested termination of pregnancy. She received 4 units of red blood cells but did not require any surgical intervention. At 23 weeks of gestation, she prematurely delivered a 510 g female infant due to sudden onset of labor pain. There were no signs of chorioamnionitis. The infant was admitted to the NICU and was discharged in good condition 110 days after birth.\nThe patient presented with massive vaginal bleeding 14 days postpartum. Medical and surgical therapy was performed. Uterine curettage revealed a retained placenta. Despite these treatments, the patient experienced continuous slow vaginal bleeding. However, because her bleeding was light, she waited to see if the bleeding would stop naturally. An MRI was conducted at 46 days postpartum, and the scan revealed a placental polyp (). Heavy vaginal bleeding occurred at 49 days postpartum. Uterine artery embolization (UAE) was considered, but the patient was noted to shed the placental polyp spontaneously with full recovery. |
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 37-year-old female presented with a history of epigastric pain of 8 weeks duration. The pain had an intensity of 7/10 and was a burning type of pain with no reference or radiation. She stated that for the previous 2 weeks her pain was aggravated by food intake. She denied any alarming symptoms in the form of loss of appetite and weight loss. There was no history of vomiting or melena. Her clinical examination was normal and on evaluation, her hemoglobin levels were 14 g/dl. She had a normal leukocyte count, and liver function and renal function were normal. Serum lipase and amylase levels were not elevated. An ultrasound of her abdomen did not indicate the presence of gallstones and all other organs were normal. She underwent upper gastrointestinal (GI) endoscopy to rule out a gastric ulcer due to the pain being aggravated by food. An upper gastroscopic examination revealed normal esophagus. There was 5 cm × 4 cm bulge in the antral portion of her stomach, and the overlying mucosa was erythematosus []. The fundus and body of the stomach were normal. There was no evidence of duodenal ulcer or growth. A biopsy from the antral portion revealed chronic gastritis, but there was no evidence of Helicobacter pylori. She underwent endoscopic ultrasound (EUS) due to the nodular lesion. The EUS showed a round intramural (subepithelial) lesion in the antrum of the stomach. The lesion was hypoechoic and seemed to appear from the submucosa and measured 30 mm in diameter. The outer endoscopic borders were well-defined. The EUS did not show any lymph nodes in the vicinity, and the liver was normal. The differential diagnosis of gastrointestinal tumor (GIST) was considered and fine needle aspiration was performed after color Doppler imaging ruled out the presence of vascular structures along the needle track. However, the microscopic examination [] showed no evidence of malignancy and immune cytochemistry for K-ras was negative for GIST. Abdominal computerized tomography confirmed that apart from a submucosal lesion in the pylorus of the stomach all other organs were normal on imaging.\nAs a result of the mass lesion in the stomach, the patient underwent partial gastrectomy to determine the nature of this gastric lesion as fine needle aspiration had not clearly identified the lesion. The microscopic examination of the resected portion identified islands of pancreatic acini and ducts in the muscularis propria of the stomach. Several dilated ducts were seen extending through all the layers of the muscularis propria. There was evidence of fibrotic reaction and scant mixed inflammatory infiltrate was observed in the area. There was no evidence of malignancy and the immunocytochemistry CA19-9 was positive in the tissue while CK20 chromogranin was negative in the specimen. The overall microscopic features were consistent with pancreatic rest and GIST was ruled out. [] The patient had an uneventful postoperative course and was discharged home after 6 days of hospitalization. She was prescribed oral proton pump inhibitors 20 mg once daily for 1-month duration only. The patient, who did not take any medication for this complaint after the initial proton pump inhibitors, is now pain-free. She has been followed up by the clinic for the last 18 months. |
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 19-year-old female presented to the dental OPD IMS, BHU, with complaint of nonerupting right central incisor. She had no significant medical history. Intraoral examination revealed a normal tooth with a narrow 3.5 mm space for right central incisor due to an unerupted right central incisor (). On radiographic evaluation, an impacted central incisor was noted. To know the exact position of the impacted tooth, a computed tomography (CT) scan was advised. Computed tomography scan and reconstruction of soft tissues on CT scan showed a strange positioning of the impacted tooth ().\nOrthodontists were consulted and they had denied repositioning of the central incisor in its appropriate space by means of orthodontic movement probably due to the curved root and the possibility of damage to the nasal floor and antrum.\nThe right central incisor space was recreated by means of orthodontic movement (). After acquiring adequate space for the right central incisor, we planned for surgical repositioning or autotransplantation of the impacted central incisor into a fresh surgically prepared socket. Blood investigation reports were within normal limits.\nAfter surgical part preparation with betadine solution, an incision was made from the distal surface of right lateral incisor to the distal surface of left maxillary central incisor. The flap was raised with the help of a periosteal elevator by considering the normal anatomical structure. The raised flap exposed the crown of the impacted central incisor (), which was positioned in an anteriolateral direction with the root tip near the nasal antrum as noted in the CT scan.\nA small groove was made around the neck of the impacted central incisor with the help of a small bone-cutting rotary bur with adequate cooling for a better forceps grip. A gradual small rotary force was applied on the neck of the impacted tooth to prevent fracture of the tooth neck or the root. This technique also helps us to expand the alveolar bone, and the tooth was removed () and placed in sterile normal saline.\nThe tooth socket was prepared with the help of a bone bur with adequate cooling so that bone physiology was not hampered. This step also helps in postoperative healing, since the bony socket was freshly prepared by splitting of the buccal cortical plate along with slight elevation of the cortical plate and a bone bur was used to make a socket in the cancellous bone. Viable periodontal ligaments are required for tooth-bone attachment otherwise the tooth ankyloses with bone and physiological root resorption starts. Diameter of the tooth root was measured and an adequate root angulation was marked.\nRoot surface preparation: Root was fully formed. Since we promote attachment, viable periodontal ligament is significant in the success of autotransplantation.\nEndodontic treatment: Since the root apex was fully formed and curved, we decided to do RCT and cut the curved part of the apex for a smooth socket insertion path and orthograde obturation was done extraorally and the apex was sealed with GIC cement.\nPlacement of the extracted impacted tooth into a fresh prepared bony socket (): The extracted tooth was transplanted into the prepared socket gently within 15 minutes after extraction. Precaution was taken to stimulate bleeding into the socket to receive the transplanted tooth and disocclude the transplanted tooth from occlusion to promote healing.\nSemi-fixed Splint: A splint was made to fix the replanted tooth for 4 weeks and the raised flap was repositioned with 3.0 silk sutures. After 4 weeks, the splint was removed and the tooth was polished () to remove composites (the splinting material). |
A 56-year-old man was admitted on August 30, 2011 with a 6-month history of increasing chest discomfort. He had experienced short duration of chest discomfort once or twice a year for the last several years. The chest discomfort occurred more frequently about six months prior, and he felt repetitive chest discomfort and rapid heartbeat sensation since the day before admission. A chest radiograph revealed dextrocardia (). He said it was firstly detected in 2008 at another institute by chance, but no further evaluation was done. No other remarkable medical history was found.\nA 12-lead electrocardiogram showed a heart rate of 190 bpm and wide QRS complex tachycardia (). Intravenous adenosine was administered initially at 6 mg and then 12 mg in an effort to convert the rhythm. A follow-up electrocardiogram revealed a shortened PR interval (112 ms), a slurring and slow rise of the initial upstroke of the QRS complex (delta wave), and secondary ST segment and T wave changes (). Transthoracic echocardiogram demonstrated no clinically significant abnormalities. A 24-hour Holter revealed baseline sinus rhythm with rare premature ventricular complexes and short-runs of paroxysmal atrial tachycardia. To rule out coronary artery disease and find out other congenital cardiovascular malformations, a computed tomography (CT) angiography was performed. There was no significant intracoronary abnormality except myocardial bridging in a diagonal branch. However, persistent left SVC draining into the right atrium via the coronary sinus was observed (). The PA sling, in which the left PA arose from the right PA, was constricting the distal trachea (). A right tracheal bronchus was also detected (). However, this narrowing of the distal trachea did not cause symptoms and did not significantly affect his pulmonary function. In a few days, wide QRS complex tachycardia with a heart rate of 185 bpm recurred in spite of medical treatment. Because the patient became hypotensive, he underwent urgent synchronized cardioversion with 100 J, which successfully converted his tachyarrhythmia to sinus rhythm. He was diagnosed with WPW syndrome with PSVT, and referred to a cardiac electrophysiology clinic to undergo radiofrequency ablation. The accessory pathway was located in the left lateral wall, and radiofrequency ablation was successfully performed without significant complications. Until now, he has remained stable and comfortable without recurrence of chest discomfort or palpitation. |
We want to report the case of a 48 years old man diagnosed with type 2 diabetes mellitus from the age of 25. His prior medical history included a dilated cardiomyopathy treated with a pacemaker at the age of 42. His mother and maternal grandfather had been diagnosed with type 2 diabetes mellitus, while his father was dead for natural causes and he was not affected by diabetes. In addition, his brother and sister were healthy, with no sign of hyperglycaemia. He also had two children in apparently good health (Fig. ).\nThe patient came for the first time to our clinic in September 2017. He had no diabetic complications (nephropathy, neuropathy, or retinopathy) and did not report any diabetic signs or symptoms. He was following a regular treatment for type 2 diabetes with basal-bolus insulin associated with metformin (Table , Visit 1 and Table , Visit 1), set during a previous visit to another clinic. Unfortunately, no HOMA-IR was available to detect if the patient was affected by insulin resistance. In addition, the insulin dosage required for the calculation would be affected by exogenous insulin therapy. The patient’s clinical features, blood parameters, and therapy at his first medical control are summarized in Tables and , respectively. For easier visualization of the case, look at Fig. .\nDue to the poor glycaemic control, we scheduled a medical examination after a month, asking the patient to monitor capillary blood glucose at home in the morning and before every meal, writing the values in a diary. We also required the detection of beta-cell antibodies to investigate the possibility of an autoimmune etiology of diabetes.\nWhen the patient came back to the outpatient clinic in October 2017, blood test results were not significant for autoimmune diabetes, and the values of capillary blood glucose at home showed an acceptable trend of diabetes (most of them were between 90 and 130 mg/dL in the morning and before meals). Therefore, according to the reasonable glycemic control, we modified the patient’s treatment by removing Lispro insulin before meals and introducing an oral hypoglycemic agent of the SGLT-2 inhibitors group (dapagliflozin) associated with metformin (dapagliflozin/metformin 5/1000 mg 2 tablets per day). However, the patient interrupted the treatment with dapagliflozin/metformin about ten days later due to the appearance of severe abdominal pain that spontaneously resolved at the suspension of the therapy. He, therefore, continued treatment with only metformin (500 mg 3 tablets per day) and insulin glargine, maintaining still excellent values (90–130 mg/dL) despite the reduction of the pharmacological therapy. In March 2018, the glycated hemoglobin had remained high at an updated blood test.\nConsidering the clinical features of the patient, we planned to investigate the possibility of a genetic mutation.\nTargeted Next Generation Sequencing (NGS) of the 14 MODY genes, as well as Wolfram syndrome 1 gene (WFS1) and insulin receptor gene (INSR), was performed by using amplicon-based libraries and Ion Gene Studio System S5, according to the manufacturer’s instructions (Thermo Fisher Scientific Inc.). The variant classification was performed according to the American College of Medical Genetics and Genomics (ACMG) standards by using the VarSomeClinical platform () []. Possible pathogenic variants were confirmed by Sanger sequencing. Large rearrangements in MODY1, 2, 3, and 5 genes were excluded by multiplex ligation-dependent probe amplification (MLPA) (MRC-Holland, Amsterdam, NL).\nIn September 2019, the genetic test showed heterozygosity for the missense variant p.Met114Leu c.340A > C in NEUROD1 (NM_002500.4), linked to MODY6. The variant was not found in GnomAD exomes and genomes and resulted in pathogenic prediction from 10 computational analyses (DEOGEN2, EIGEN, M-CAP, MVP, MutationAssessor, MutationTaster, PrimateAI, REVEL, PolyPhen-2, and SIFT) versus two benign predictions (DANN and FATHMM-MKL).\nAt the time of the molecular diagnosis, this variant was previously undescribed, and we classified it as a variant of uncertain significance (VUS). Only recently, Bouillet et al.described the same NEUROD1 variant associated with MODY6 in a French family and classified it as a mutation [].\nInternational guidelines report sulphonylureas as the first-line treatment for monogenic diabetes, so we decided to start therapy with gliclazide RM (60 mg) suspending insulin at all (Table , Visit 2).\nUnfortunately, glycaemic values did not benefit from the treatment with sulphonylureas, and at the following medical examination in March 2020, the patient showed inadequate glycaemic control and a very low c-peptide value (Table , Visit 2). We, therefore, restored the therapy with basal insulin, in addition to gliclazide and metformin. Metformin was maintained to provide a better insulin sensitivity and because of its cardiovascular protective effect. In October 2020, the glycaemic control was remarkably improved with this kind of scheme therapy (Table , Visit 3 and Table , Visit 3), practicing only one injection a day and without the necessity to measure blood sugar after every meal.\nHe referred us that his quality of life has remarkably improved, although this data was not measured with specific questionnaires. Two and a half years have passed from the first visit to obtaining a glycaemic compensation with stable therapy. During the follow-up, no hypoglycaemia was detected, and the patient did not develop any diabetic complication.\nSince MODY is characterized by autosomal dominant inheritance, the family’s counseling was provided to the patient. His brother and sister did not show hyperglycaemia, either evidence of NEUROD1 mutation at the genetic testing. The patient’s mother had been diagnosed with type 2 diabetes mellitus for many years but, because of her old age and immobility, she refused to come to our outpatient clinic for genetic testing. The patient signed written informed consent for the publication of his laboratory and clinical data. |
The patient was a 14-year-old Asian girl with no abnormal perinatal, medical or surgical history. She presented to the emergency medical centre for outpatients with abdominal pain and vomiting 3 h after being struck in the abdomen by a basketball. She had a slight fever but her other vital signs were stable. Her abdominal examination was revealed spontaneous pain and tenderness in the left upper quadrant. Plain abdominal radiography revealed abdominal intestinal gas and blood examination indicated moderately elevated serum amylase level. Hospitalisation was deemed necessary and she was transferred to our university hospital. She was hospitalised 4 h after injury. Blood tests were repeated () and they indicated an increase in white blood cell count and serum amylase level. However, other blood test results were normal. Free air and the colon cutoff sign were absent on abdominal radiography. However, abnormal bowel gas, which indicates paralytic ileus was observed in the abdomen X-rays. Computed tomography (CT) of the abdomen and pelvis was performed to rule out traumatic intra-abdominal injury (). CT revealed a cystic mass measuring 55 mm at the pancreatic body and tail () with associated heterogeneous internal density and smooth rim enhancement (). We diagnosed the patient with acute pancreatitis complicated by pancreatic pseudocyst, hematoma or tumor. Intravenous administration of urinastatin and gabexate mesilate was initiated and continued till 11 days after the onset of illness, after which oral administration was feasible. MRI was performed at 4 days after the onset of illness (). T2-weighted MRI revealed a mass measuring approximately 50 mm at the pancreatic tail with associated heterogeneous high intensity that indicated an encapsulated solid and cystic mass with areas of hemorrhagic degeneration (). The mass showed minimal contrast enhancement on dynamic contrast-enhanced MRI in the early arterial phase; the contrast enhancement gradually increased in the late phases (). The mass was diagnosed as SPT of the pancreas based on these MRI findings. Profound increases in CEA, CA 19-9, AFP and neuron-specific enolase (NSE) levels were not observed on investigation (). SPT of the pancreas has low-grade malignant potential; therefore, we performed total-body CT to confirm the absence of metastases. The patient underwent central pancreatectomy at 28 days after the onset of illness. Final pathology revealed SPT that was 41 mm in greatest dimension. Tissue sections showed extensive hemorrhage, necrosis and granulation tissue. Solid portions of the tumor revealed sheets of uniform round or oval nuclei and a vacuolated cytoplasm. The tissue in the cystic region of the tumor assumed a pseudo-papillary appearance projecting into the space filled with hemorrhagic and necrotic debris. The patient recovered from surgery and was discharged with no reports of hepatic dysfunction. |
A 45-year-old Japanese man was referred to our hospital by his local dentist; he had constant pain in the head and neck region, particularly on the right side. The dentist had initially suspected temporomandibular disease, but owing to atypical symptoms, he was eventually referred to our hospital for further examination. He had various symptoms, including dysphagia, foreign body sensation, and headache. Our patient had been treated by several specialists including an otolaryngologist, a neurologist, and another dentist, during the past few years with no relief or signs of improvement. At first presentation, he complained of constant neck pain and odynophagia; however, palpation of the tonsils did not worsen the pain. Our patient had no history of a trauma, surgical treatment, or neurological or infectious foci. After clinical examination and basic radiological diagnostics, an elongated SP was suspected as the cause of his problems. Computed tomography (CT) images showed a longer and thicker right SP when compared with the left side. Our patient was diagnosed with Eagle’s syndrome in view of the neck pain and radiographic images (Fig. ). Analgesics (daily doses of meloxicam 10 mg) were administered to our patient; the condition was explained to him and operative treatment was recommended. Our patient declined the strong percutaneous approach; therefore, we decided to use the transoral approach. To minimize the risk of damage to the surrounding healthy tissue and difficulty in locating the SP, preoperative digital planning was performed for computed navigation.\nAn investigation of the cervical blood vessels on the right side demonstrated that the SP and the branches of the internal and external carotid arteries were located in proximity to each other. Therefore, accurate preoperative planning was essential. Furthermore, since the transoral approach was being employed, it was necessary to reproduce the same mouth opening conditions during the taking of preoperative images as that required during surgery. This is because the position of the SP and the blood vessels may change depending on the position of the mandible during the mouth opening. As it is difficult to implement the locational findings from the preoperative imaging data while performing the surgery owing to the mobile nature of the mandible, we used a custom interocclusal splint for repeated maximum opening in the same mandibular position while enabling surgical access. As part of the CT imaging preparation for navigation, a custom interocclusal splint was fabricated by pressing acrylic resin into a dental mold obtained during the first visit. First, the created bimaxillary upper and lower jaw splints were adhered with resin at the maximum mandibular opening position. Because there was the possibility of distortion with fixation of only the molar portion, we added a supplementary small strut to the anterior region without hindering the surgical approach (Fig. ). Maxillofacial CT and magnetic resonance imaging (MRI) were obtained using the customized interocclusal splint to maintain the mandible in the same position during repeated movements; this was vital to maintain accuracy during the transoral approach.\nThe imaging data were obtained in Digital Imaging and Communication in Medicine format and transferred to a Medtronic StealthStation S7 workstation using the Synergy Fusion Cranial 2.2.6 software (Medtronic Navigation Inc., Louisville, CO, USA). Our patient was taken to the operating room where the custom interocclusal splint was reinserted. A Patient Tracker EM, which acted as a reference array to track the navigation probe, was affixed on to our patient’s forehead. To perform patient to CT and MRI data registration, the instrumentation navigation probe was used to trace the reference array and soft tissue landmarks of the face (Fig. ). After data registration was complete, continuous three-dimensional (3D) tracking of the navigation probe was available to the surgeon in real time. This was possible because of the maximum mandibular opening position during CT and MRI and in the operating room following the use of the interocclusal splint. In this case, as the splint was not in direct contact with the surgical site, it was not sterilized but was chemically disinfected with benzalkonium chloride.\nUsing the navigation pointer, the tip of the elongated SP was detected based on the navigation image on the screen and easily located through the oral mucosa (Fig. ). The incision in the oral mucosa was designed closest to the tip of the SP to enable easy access with minimal injury. An oral lingual incision (20 mm) was made in the mucosa posterolateral to the pharyngopalatine arch and superior to the tonsillar bed, without tonsillectomy. The blood vessels surrounding the SP were also visible on the navigation monitor, and therefore, we could treat them with care. The navigation pointer was inserted into the wound and moved along the SP until it reached the intended resection spot (Fig. ). After the resection spot was confirmed, the SP was pinched off using bone-holding forceps while the thicker portion was cut down by piezoelectric surgery (Fig. ). The resected SP was then taken out (Fig. ), and a prophylactic drain was left in place before closing the wound on the next day of surgery. The operation time was 37 minutes. The amount of bleeding was very small and it was difficult to measure. Follow-up examination showed an uneventful recovery with no complications. He noticed complete relief of the symptoms on his right side, and he stated after surgery that his quality of life has improved. |
A 62-year old male presented to the oncology center for evaluation of a painless, superficial nodular lesion over his left lower eyelid that had slowly grown over the course of approximately 18 months, to measure 4.0 × 2.0 cm. Patient gave history of a similar swelling at the same site which had appeared in July 2005 and after a similar slow, painless progressive increase in size, it had been excised in February 2006. The histopathology report from the previous surgery was not available for review. The swelling recurred within six months and displayed a painless, gradual, progressive increase in size till he presented at our center. On examination, he had a well-defined, irregularly marginated nodular lesion over the left lower eyelid []. The overlying skin was normal in appearance and freely mobile over the underlying nodular lesion except for an area of 1 × 1 cm at the lateral end, where the scar of the previous surgery was tethered to the mass. There was no regional lymphadenopathy. The lesion appeared free from the underlying orbital ridge. Fine needle aspiration cytology from this lesion reported a benign adenexal tumor. The lesion was excised with 5 mm margins under general anesthesia. The resultant defect involved the entire lower eyelid and was reconstructed by a Mustarde's cheek rotation flap. This was a large skin flap which was rotated from the cheek. Incision began at the lateral canthal angle, extending upward onto the temple, and swinging posteriorly just anterior to the ear and then inferiorly across the mandible []. Eight weeks postoperatively, there was marginal ectropion and lateral tissue sag []. Gross pathology revealed a subcutaneous nodule of tan, gelatinous tissue measuring 4 × 2 × 1.0 cm. Microscopic examination revealed a dermal tumor composed of epithelial cell islands surrounded by lakes of mucin consistent with the diagnosis of mucinous carcinoma []. The lateral margins were tumor cell-free but the deep resected margin was involved. A thorough search for other possible sources of mucinous adenocarcinoma was made. Upper and lower gastrointestinal study, contrast enhanced computer tomography study of the chest and abdomen, as well as a whole body Positron Emission Tomography scan were negative for any other primary. |
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 67-year old Caucasian male of German descent presented to the emergency department of an external hospital at December 8th 2006 due to severe upper back pain. His past medical history was unremarkable. He had no history of previous TB or TB exposure. His complaints had emerged over the past six month and were accompanied by slight night sweats and a moderate weight loss. Physical examination and routine laboratory studies on admission including hemoglobin, white blood count and C-reactive protein (CRP) were within normal range. Conventional radiographs of the chest and the thoracic spine revealed a compression fracture of the third thoracic vertebra (Th3) and a solitary pulmonary nodule of the left upper lobe (Figure ). On the basis of this coincidence, a pathological vertebral fracture secondary to metastatic lung cancer was suspected. The further work-up included a computed tomography (CT) scan of the chest and of the spine, which confirmed the thoracic vertebral compression fracture. Moreover, it revealed lytic destructions of the posterior margins of both adjacent vertebral bodies and showed an intraspinal soft tissue mass expanding between Th2 and Th5. Additionally, a tumorous lesion of the ventral left upper lobe was observed. Apparent mediastinal lymphadenopathy was interpreted as metastatic disease of the mediastinal lymph nodes (Figure ). Bone scintigraphy was not suggestive of malignancy and detected only minor degenerative alterations of the upper spine. Both repeated transbronchial biopsies, which had been obtained by flexible bronchoscopy, and repeated CT-guided transthoracic needle biopsies of the pulmonary nodule failed to establish a specific histological diagnosis, and were read as "necrosis compatible with necrotic tumor tissue".\nGiven the progressive back pain and supposed spinal instability, the patient was referred to another external hospital, where a palliative irradiation of the upper thoracic spine was initiated and a cumulative dose of 36 Gy was applied over three consecutive weeks. However, the patient's condition deteriorated and he soon developed paresthesia and paralysis of both lower limbs. At this point, magnetic resonance imaging (MRI) of the spine revealed an extensive intraspinal abscess, which resulted in compression of the upper thoracic spinal cord. Hence, the patient was immediately referred to the neurotraumatological service of our university hospital for surgical treatment.\nUpon arrival at our institution on January 10th 2007 the patient presented with incomplete paraplegia at the level of Th3. Promptly, spinal decompression surgery including laminectomy of Th2 to Th4, revision of vertebra Th3, and thoracic spondylodesis from Th1 to Th6 was performed. The histology of the removed intraspinal soft tissue mass was read as an unspecific chronic inflammatory and granulating process. No malignancy or specificity was evident. Routine cerebrospinal fluid (CSF) cultures were sterile. No further CSF analyses were performed. Soon, after an initial post-operative improvement, the patient deteriorated again and developed a persistent dorsal swelling, reddening, and fluid collection that was suggestive of a paravertebral abscess (Figure ). Thus, surgical revision was repeated. Again, routine CSF cultures grew no microorganisms and no further CSF analyses were prompted. Nevertheless, temperatures >38.0°C persisted despite the use of various antimicrobial regimes. Repeated routine blood cultures remained sterile and infectious endocarditis was ruled out by transesophageal echocardiography. A CT scan of the brain, which was performed due to persistent headaches, showed no abnormalities, while a follow-up CT scan of the chest showed multiple novel opacities with tree-in-bud sign (Figure ).\nWhen the patient was finally referred to the pulmonary department for further evaluation of the initially suspected metastatic lung cancer on February 28th 2007, he had developed a new brachiofacially accentuated, right-sided hemiparalysis and aphasia. Now, MRI of the brain revealed multiple fresh ischemic bihemispheric and pontine lesions. Again, infectious endocarditis was ruled out.\nThe patient was febrile with a temperature of 39.3°C despite an antimicrobial regime consisting of Imipeneme/Cilastatin, Vancomycin, Ciprofloxacin, and Metronidazole, which had been administered for the past two weeks. At this time, the major findings on physical examination included cachexia, signs of respiratory distress (a respiratory rate of 25/min, productive cough, but insufficiently coughing up), moderate fluid overload (bilateral basal pulmonary rales, peripheral edema), and a dorsal paravertebral reddish and fluctuating swelling at the site of prior surgery, but no meningeal signs. Furthermore, we observed oral candidiasis and a unilateral segmental herpes zoster rash at the lower back that both indicated relevant immunosuppression. Now, routine laboratory studies showed markedly increased inflammatory activity (CRP 22 mg/dL), but a normal white blood count of 4,900/μL. HIV serology was negative. Remarkably, the interferon-γ release assay QuantiFERON®-TB Gold In-Tube was negative (IFN 0.189 IU/mL).\nHowever, complicated and disseminated TB with bone, soft tissue, CNS, and pulmonary involvement was suspected by thoroughly reviewing the patient's previous history and medical course. We immediately prompted retrospective polymerase chain reaction (PCR) analysis of the surgically resected tissue regarding the presence of Mycobacterium-tuberculosis-(MTB)-complex DNA and initiated microbiological sampling for the confirmation of the suspected diagnosis. Aspirates of the dorsal fluid collection suggested an abscess (purulent appearance, low glucose concentration of 0.3 mmol/L), but no CSF fistula (low β-trace-protein of 3.8 mg/L). No microorganisms were detected on gram stain or acid-fast bacilli (AFB) smear. CSF was obtained by lumbar puncture and showed signs of purulent meningitis (800/μL predominantly polymorphonuclear cells, low glucose concentration of 0.8 mmol/L, elevated protein level of 1.5 g/L). CSF microscopy (gram stain and AFB smear), routine cultures, and PCR for MTB-complex DNA were negative. As the patient was suffering from severe respiratory distress, bronchoscopy was considered potentially harmful and therefore abandoned. Instead, repeated morning fasting gastric acid aspirates, which may be considered as swallowed respiratory secretions according to the German authorities [], were obtained for TB cultures in order to evaluate for the dissemination of viable mycobacteria via the respiratory route. AFB smears of repeated gastric acid aspirates were negative. Subsequently, both PCR results of the resected intraspinal tumor tissue and the aspirate of the paravertebral abscess indicated the presence of MTB-complex DNA. After two weeks TB cultures grew MTB from both the abscess and gastric acid aspirates and after six weeks from CSF, too. The MTB isolate was fully susceptible to all first line antimycobacterial drugs. All samples had been negative on AFB smears with both auramine and Ziehl-Neelsen staining (Table ).\nOn March 7th 2007, a total of 57 days after referral to our hospital, and three months after the first presentation to the external hospital, isolation and antimycobacterial treatment with rifampicine, isoniazide, pyrazinamide, and streptomycin were initiated. Due to apparent meningitis, extensive cerebral vasculitis, and suspected arachnoiditis, an adjuvant treatment with oral corticosteroids was administered and tapered after three weeks []. Lumbar puncture was repeated one week after treatment initiation and showed clearly improved findings (290/μL mixed mono- and polymorphonuclear cells, negative AFB smear, negative TB cultures after eight weeks). Within the following weeks the patient's general and neurological condition gradually improved. Isolation was terminated and mobilization into a wheel chair was achieved after four weeks of treatment due to intensive physical therapy (See additional file : Table S1 - Summary of the patient's diagnostic and therapeutic in-hospital course). Unfortunately, at April 12th 2007 the patient died due to a lethal episode of ventricular fibrillation with cardiac arrest. Autopsy confirmed all clinically suspected TB-related diagnoses: spinal TB (Pott's disease) with subsequent tuberculous meningoencephalitis, extensive cerebral vasculitis (Figure ), spinal arachnoiditis, paravertrebral tuberculous abscess, miliary pulmonary TB (Figure ), and a tuberculoma of the ventral left upper lobe (Figure ). Death occurred secondary to CNS dysregulation with elevated intracranial pressure (Figure ). |
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 35-year-old female patient suffering from severe mental retardation and epilepsy since birth was a long-term resident of the mentally incapacitated unit of the hospital. She was bedridden with a small body build of a weight of 32 kg. She had a PEG insertion done 8 years ago and then received regular PEG tube change every 3 months by the nurses and maintained well on the gastrostomy bolus milk feeding. Her body weight was static over the past years and there was no sign or symptoms of malnutrition or diarrhea.\nShe presented to our gastroenterology unit for failure to deflate the PEG balloon during a regular PEG exchange due to blockage of the inflation/deflation catheter. Upon admission, the physical examination of the abdomen was normal with active bowel sound and negative for any distension or tenderness. The routine blood tests including complete blood picture, electrolytes, and liver and renal function tests did not review any abnormality. An oesophagogastroduodenoscopy (OGD) was arranged with an attempt to examine and deflate the balloon in the stomach endoscopically. An OGD examination failed to identify any gastrostomy tube in the upper gastrointestinal (GI) lumen with the scope passed down to the second part of the duodenum. An urgent computer tomography (CT) of the abdomen revealed the distal end of the PEG tube was likely situated at the proximal jejunum distal to the duodenojejunal junction with a normal fill-filled balloon intraluminally. There was no radiological feature of pneumoperitoneum (). The PEG inflated balloon was finally identified endoscopically in the jejunum at 160 cm of the upper GI tract by a push enteroscopy and it was then punctured with an endoscopic needle knife. The PEG tube was successfully removed after the release of the internal bumper.\nA nasogastric tube was inserted and used as a temporary measure for nutritional support and the fistula was allowed to heal spontaneously. A laparoscopic gastrostomy insertion was arranged for the patient. Intraoperatively, the previous PEG site at the jejunum was found to be adhered to the antrum of the stomach and the anterior abdominal wall. Another new gastrostomy tube was inserted by the operation and the patient tolerated gastrostomy feeding well afterwards. |
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. |
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. |
A 31-year-old woman from Uzbekistan presented with an inflammatory and ulcerative mass in her right breast that had been there since 2011. The mass had grown rapidly over the past 3 months and it was extremely painful with a huge ulcerative wound (). Breast ultrasonography and a core needle biopsy were performed initially in an outside breast clinic and the biopsy result was a diagnosis of invasive carcinoma of no specific type. She was referred to Korea University Medical Center, Ansan in January 2016, 2 weeks after being diagnosed.\nAdditional imaging workup was performed to check the primary breast mass and metastatic lesion, including a MRI of the breast; a CT scan of the chest and abdomen; a bone scan; and a PET scan. Breast MRI revealed an irregular necrotic 120-mm mass in the right upper outer quadrant that had invaded the skin and pectoralis major muscle. Several lymph node (LN) metastases at the right axillary level I were suggested on the CT and PET scans, but there was no evidence of distant metastasis.\nShe underwent neoadjuvant chemotherapy with doxorubicin and cyclophosphamide for reduction of the mass and systemic therapy. After the first cycle of neoadjuvant chemotherapy, a core needle biopsy was performed again in our hospital, since our pathologist had suggested the possibility of a phyllodes tumor through review of the outside slides. The rebiopsy result was a diagnosis of phyllodes tumor, and a right modified radical mastectomy (MRM) and transverse rectus abdominis myocutaneous (TRAM) flap were performed (). The right breast mass weighed 2,212 g at the time of excision.\nThe final pathology confirmed a malignant phyllodes tumor measuring 125 mm × 120 mm. The tumor showed brisk stromal overgrowth with lymph and vascular tumor emboli, and the mitotic count was 46 per 10 high power fields. All resection margins were negative and we obtained margins of more than 10 mm except for the deep resection margin which was less than 1 mm. Immunohistochemical staining for estrogen receptor (ER) and progesterone receptor (PR) were positive, but for human epidermal growth factor receptor 2 was negative. There was no metastasis in the 18 retrieved LNs.\nA month after the initial operation, several mass-like protruding lesions appeared at the superior margin of the TRAM flap (). Breast MRI showed recurrent tumors in the deep margin of the TRAM flap as well as the superior margin. The recurrent tumor in the deep margin measured 84 mm × 48 mm and had invaded the pectoralis minor and intercostal muscles (). A wide excision was performed and a superior negative margin was obtained but a negative deep margin could not be achieved.\nTwo weeks after the second operation, masses appeared again at the inferior margin and a chest CT scan revealed new round opacities in both lung fields that were thought to be metastases (). Despite palliative radiation therapy, bilateral pleural effusion increased gradually and the patient suffered from dyspnea. Six weeks after the second operation, the patient died due to progression of dyspnea and respiratory failure. |
A 28-year-old Burmese pregnant woman was referred to our institute because of complicated pregnancy. Two years previously, she had a history of progressive dyspnea and orthopnea. A thorough investigation was carried out, a large left atrial mass was diagnosed, and she was scheduled for surgery. Due to economic problems and poor communication the patient was lost from the schedule and all attempts to contact her failed. She arrived at the hospital again and was pregnant. The pregnancy was unplanned and she had had no antenatal care. The estimated gestation by ultrasound was 24 weeks. The patient reported constant dyspnea on exertion in NYHA II without any progression in symptoms. On physical examination, vital signs were stable with a pansystolic murmur grade IV at apex. The chest film showed cardiomegaly and the cardio : thoracic ratio was 60%. Electrocardiography showed a normal sinus rhythm with left ventricular hypertrophy by voltage criteria. On echocardiographic examination, as shown in , a large, smooth surface, mobile mass, measuring at least 9 × 4 cm was found in the left atrium. There was no calcification or bleeding in the mass. The stalk of the mass was attached to the interatrial septum. The mass protruded into the mitral valve orifice causing both significant left ventricular inflow obstruction and severe mitral regurgitation with mitral annular dilation. The left ventricle was dilated with a good ejection fraction at 70.1%. Left ventricular systolic and diastolic volumes were 53 mL and 157 mL, respectively. The estimated pulmonary pressure was 75 mmHg which indicated severe pulmonary hypertension.\nThe patient was admitted immediately. A multidisciplinary team was established to deal with this special situation including cardiac surgeons, cardiologists, obstetricians, anesthesiologists, pediatrics, and neonatologists. After extensive discussion, the conclusion was to wait for lung maturity and schedule her for an epidural, painless vaginal delivery with a back-up emergency plan for worst case scenario. At the 32nd week of gestation, corticosteroids were given to promote pulmonary maturity and labor was induced. Intensive fetal and maternal monitoring occurred at every step. A painless vaginal delivery was enabled by epidural anesthesia and only a mild degree of pulmonary edema was detected during labor. The male preterm neonate was considerably healthy for his age, with a weight of 1,900 gm and APGAR scores of 7 and 9 at 1 and 5 minutes. The patient was returned to the cardiac intensive care unit for intensive monitoring. There was no clinical deterioration and she was still in NYHA II.\nTwo weeks after delivery, the patient was scheduled for cardiac surgical correction. All preoperative investigations were within normal limits. The operative procedure was conducted under general anesthesia with single-lumen intubation. A central venous catheter was placed on the left internal jugular vein and a 6 Fr vascular sheath was placed on the right internal jugular vein. Transesophageal echocardiography was set up routinely. The patient was placed in a supine position with an inflatable bag placed beneath her right chest wall elevating the right side of the chest to achieve greater exposure. Standard antiseptic preparation was made. A 3 cm right inguinal incision was made allowing exploration of the common femoral artery and vein. Purse string sutures were placed on both vessels. A right submammary 5 cm incision was made and the pleural cavity was entered via the 4th intercostal space. Skin protector was placed round the incision without using a rib spreader. The patient was full heparinized and peripheral CPB was established from the right groin. The femoral arterial and venous cannulas were size 17 Fr and 20 Fr, respectively. Both cannulations were performed using Seldinger's technique under TEE guidance. An additional venous cannula, number 14 Fr, was placed percutaneously via the right internal jugular vein again using Seldinger's technique. A thoracoscopic port was inserted via the 3rd intercostal space at the midaxillary line. After achieving full bypass, ventilation was stopped and the lungs were collapsed. The pericardium was opened longitudinally from the superior vena cava (SVC) to the inferior vena cava (IVC) and 2 to 3 cm anterior to the right phrenic nerve. Both SVC and IVC were snared with large heavy silk. A cardioplegic cannula was placed in the ascending aorta. A Chitwood aortic clamp was passed from a separate small incision through the 2rd intercostal space at the midclavicular line. An aortic cross clamp was applied and the heart was arrested by the antegrade route with crystalloid Histidine-Tryptophan-Ketoglutarate solution. Both SVC and IVC were fastened to achieve total bypass. The right atrium was opened along the atrioventricular groove. The interatrial septum was incised at the lower border of the fossa ovalis. A hanging stitch was placed and the interatrial septum was excised keeping 0.5 to 1 cm from the stalk of tumor. The tumor was removed easily without any adhesion with the residual atrial wall or mitral valve. The mass was delivered, with some additional rib traction, via submammary thoracotomy incision. The reddish bulky tumor was 8 cm × 5 cm × 6 cm in size and had a smooth and sleek surface with a small dense stalk attached to the limbus of the fossa ovalis as shown in . The left ventricular venting cannula was placed after the mass was removed. Mitral valve analysis was done and revealed a grossly normal valve apart from a significant annular dilation. A saline test also showed a significant regurgitation. A mitral valve annuloplasty was done with Carpentier-Edwards Physio annuloplasty ring (Edwards Lifesciences, Irvine, CA, USA) number 34. The atrial septal defect was closed directly using continuous polypropylene 4/0 running sutures. The right atrial wall was closed. After rewarming and deairing, the aortic cross clamp was removed and the CPB was weaned off and terminated uneventfully. All wounds were closed and one chest drain was placed in the right pleural cavity. Total operative time was 3 hours and 40 minutes; cross clamp time and total bypass time were 105 and 160 minutes, respectively. Intraoperative TEE showed good results; there was no residual atrial defect and a resultant good competent mitral valve. The patient was extubated the next morning 14 hours after the operation; then she had a normal recovery with no significant complications. The chest drain was removed on the 2nd postoperative day and the chest film was normal.\nThe patient was discharged 7 days after surgery. There was a delay of 3 days due to her preterm baby's condition. She was clinically stable in NYHA I. However, early postoperative echocardiography showed severe reduction in ejection fraction of 20% with competent valvular function and no residual tumor. Left ventricular systolic and diastolic volumes were 102 mL and 131 mL, respectively. However, heart size from the chest film gradually decreased on each visit until it became normal size as demonstrated in . She was prescribed heart failure medications and warfarin as the mother could not breast feed due to no lactation occurring. Serial echocardiography 2 months postoperatively showed cardiac function was significantly improved with an ejection fraction of 42% and normal left ventricular size (left ventricular systolic and diastolic volumes were 38 mL and 72 mL, resp.). Pathology report later confirmed the diagnosis of myxoma. |
The patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().\nThe patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.\nShe underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.\nAfter identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.\nAfter a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014 guidewire was placed into the proximal portion of the neck.\nA 21 gauge needle was used to cannulate the proximal portion of the neck percutaneously from the right groin. The previously placed guidewire was used as a landmark to place the tip of the 21 gauge needle into the pseudoaneurysm. After blood return was noticed from the needle, a 0.018 guidewire was placed into the lumen of the right common femoral artery. A 6 French access sheath was placed over the guidewire. Fluoroscopy was then used to visualize the deployment of a vessel closure device (VASCADE 6 French). This was done without difficulty, and the collagen patch was positioned outside the vessel wall in the area of the pseudoaneurysm neck. Interval angiogram revealed partial occlusion of the pseudoaneurysm neck ().\nIt was then decided to place an occlusive 8 mm balloon into the lumen of the right common femoral artery to facilitate pseudoaneurysm thrombosis. The balloon was insufflated up to 8 ATM for 600 seconds. This was done twice in total. Interval angiogram then revealed complete occlusion of the pseudoaneurysm blood flow (Figures and ).\nAll wires and catheters were removed at this point, and a left common femoral artery access sheath was kept in overnight. Postoperatively, the patient had no complications, and formal ultrasound confirmed complete thrombosis of the pseudoaneurysm. The access sheath was then removed without issue. There were no ischemic complications due to balloon occlusion in the immediate postoperative 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. |
The patient was a 67-year-old African American male, who initially presented to the ER with a 2-week history of right upper quadrant pain. At presentation, he reported no fever, no changes in his dialysate, and his abdominal pain was unrelated to his oral intakes. The past medical history was significant for hypertension and end stage renal disease (ESRD) for which he has been undergoing peritoneal dialysis since January 2017. His initial blood pressure was 210/111, and he was admitted to ICU/IMC for 24 h. He was then transferred to a regular medical ward. During his admission on the medical wards, the patient continued experiencing constant gnawing abdominal pain while undergoing his scheduled peritoneal dialysis. It was during these dialysis sessions on the medical floor that the drained dialysate fluid began to take on a cloudy characteristic and the patient developed a low-grade fever. This initially led the team to suspect bacterial peritonitis. The patient was placed on empiric ceftriaxone and vancomycin. Gram staining and fluid analysis of the dialysate showed presence of gram negative rods and peritoneal fluid samples showed a WBC count of 528 cells/µL with 25% neutrophils and 75% lymphocytes. After 4 days of non-improving pain, the patient’s peritoneal dialysis catheter was removed and a hemodialysis catheter was subsequently placed so dialysis could continue. Five days after peritoneal fluids were sent, B. vesicularis was identified by our lab with antibiotic sensitivities still pending. Clinically the patient had greatly improved since the removal of the catheter, with resolution of both the abdominal pain and fevers. This prompted the decision by the treatment team to stop antibiotic treatment at this time. The decision was then made that the patient could be discharged safely due to now normal blood pressure status, resolution of abdominal symptoms, and newly scheduled outpatient hemodialysis. Due to the nature and rare incidence of this organism, the antibiotic sensitivities were not returned until several days after his discharge showing resistance to almost all tested antibiotics except for ciprofloxacin and imipenem/cilastatin.\nNote: The peritoneal fluid cultures were cultured on blood, chocolate, thioglycolate, and CDC anaerobic, and Columbia nutrient agar. Cultures were identified using both the Becton Dickinson Phoenix™ 100 automated identification and susceptibility testing system; and the API R 20 NE system for non-enteric Gram-negative rods. The extensive testing for both species and sensitivities led to the increased time course in obtaining both an identity of the organism and antibiotic susceptibilities. |
The patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().\nThe patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.\nShe underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.\nAfter identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.\nAfter a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014 guidewire was placed into the proximal portion of the neck.\nA 21 gauge needle was used to cannulate the proximal portion of the neck percutaneously from the right groin. The previously placed guidewire was used as a landmark to place the tip of the 21 gauge needle into the pseudoaneurysm. After blood return was noticed from the needle, a 0.018 guidewire was placed into the lumen of the right common femoral artery. A 6 French access sheath was placed over the guidewire. Fluoroscopy was then used to visualize the deployment of a vessel closure device (VASCADE 6 French). This was done without difficulty, and the collagen patch was positioned outside the vessel wall in the area of the pseudoaneurysm neck. Interval angiogram revealed partial occlusion of the pseudoaneurysm neck ().\nIt was then decided to place an occlusive 8 mm balloon into the lumen of the right common femoral artery to facilitate pseudoaneurysm thrombosis. The balloon was insufflated up to 8 ATM for 600 seconds. This was done twice in total. Interval angiogram then revealed complete occlusion of the pseudoaneurysm blood flow (Figures and ).\nAll wires and catheters were removed at this point, and a left common femoral artery access sheath was kept in overnight. Postoperatively, the patient had no complications, and formal ultrasound confirmed complete thrombosis of the pseudoaneurysm. The access sheath was then removed without issue. There were no ischemic complications due to balloon occlusion in the immediate postoperative period. |
The patient was a 75-year-old male with a history of coronary atherosclerosis, hypertension, and hyperlipidemia. He reported a prior history of sequential knee replacements with infections in each knee as well as a family history of immunoglobin deficiencies, which made him a very high risk for post-implantation infection. Initial implantation of a dual-chamber pacemaker was performed due to sick sinus syndrome. The device was placed in the left pectoral region without the utilization of a biological ECM pouch. At the initial two-week post-procedure wound check, erythema was observed at the incision with tenderness. Three weeks of oral antibiotics were administered, and the infection cleared without the removal of the device. A few years later, the patient developed congestive heart failure along with chronic right ventricular pacing, and the patient needed an upgrade of his dual-chamber pacemaker to a cardiac resynchronization therapy (CRT) system. This device was implanted using a biological ECM pouch due to the patient's history of prior infection.\nSix weeks after the implantation of the CRT pacemaker, the patient was admitted to the hospital for a moderately sized hematoma and suspected infection of the device pocket and incision. Laser lead extraction of the complete device system was performed, and cultures obtained from the leads were determined to be acid-fast bacilli along with gram-negative rods. After a six-week regimen of broad-spectrum intravenous antibiotics, the patient underwent device reimplantation on the contralateral side. Due to concern regarding the patient's high risk of CIED infection within the pocket as well as at the incision site, a 10 cm by 1 cm strip of biological ECM, commonly used for vascular reconstruction, was utilized in addition to a biological ECM pouch enclosing the device. Both the strip and the pouch were hydrated in a gentamicin solution to further enhance the antimicrobial effects of the ECM, as described in the literature []. Instead of placing the additional biological ECM strip within the pocket, the strip was sewn directly into the incision site, where prior infections were observed (Video ). Upon two-week, six-week, and six-month follow-up wound care visits, no erythema was observed. The patient report no fever, pain, or swelling at the incision site, and normal drainage was observed. We propose that, in this case, the utilization of biological ECM at the incision site in combination with a biological ECM pouch played a significant role in preventing infection in a patient with a high risk of infection. |
A 4-year-old boy with trisomy 21 came to the Dental Hospital-University service with his parents, following a fall at the family home four days before. The child did not show any loss of consciousness after the trauma and was up to date with his vaccines. He had already seen a general practitioner and was referred in emergency to a specialist for oral care. His parents described bleeding and crying when the fall occurred and serious difficulties with eating since it happened. The clinical examination was complicated by the poor cooperation of the child. No lesion of the exobuccal integuments was found, but an enamel fracture of the 51 (upper right incisor) and a complex coronal fracture of the 61 (upper left incisor) with pulp exposure and intrusion were noticed. The swollen aspect of the vestibular gingiva with a necrotic appearance led to the decision to extract the 61 under local anesthesia and nitrous oxide sedation. It had not been possible to obtain a correct X-ray. Despite the use of equimolar oxygen nitrous oxide mix, the patient was very restless. Due to a sudden head movement by the child just after the extraction, the tooth slipped out of the forceps, fell on the tongue, and disappeared into the pharynx. The child performed a swallowing movement without any sign of choking or coughing and thereafter presented normal postoperative behavior while playing in the waiting room. As no obvious signs of respiratory distress were shown by the young boy, it was thought that he had swallowed the tooth. He was discharged with supervisory advice.\nThree weeks later, the patient was admitted to the Emergency Department because of a regular cough and fever that had lasted for several days despite three different antibiotic therapies. The cardiopulmonary auscultation was normal. A chest radiograph confirmed the presence of a foreign body inside the left lung (). It had caused a lung infection of the left lower pulmonary lobe, which was treated by antibiotics (clavulanic acid and penicillin) and anti-inflammatories (prednisolone), before surgery. Two endoscopies under general anesthesia were necessary to recover the tooth. The first one failed due to the presence of purulent secretions and a bleeding granuloma in contact with the tooth that made it difficult to remove. The parents had been informed that, in case of a second failure, more invasive surgery with thoracotomy would be necessary. After the success of the second endoscopy, the child recovered fully. One-year follow-up showed there was no longer any sign of lung infection. This adverse event was discussed at the morbidity and mortality conference of the Dental Hospital service. |
A 14-year-old female patient reported to the Department of Oral Pathology with a chief complaint of swelling on the left side of the face since 4 months. She had a previous history of a similar lesion at the same site 9 months back, which was excised by a private practitioner and was histopathologically reported as neurofibroma. The swelling appeared again after 5 months, which was initially small and gradually increased in size over a period of 4 months. There was evidence of rapid growth in the past 1 month. The patient took non-conventional medicine for the same, but the swelling kept on increasing in size. It was associated with mild and intermittent pain, the intensity of which increased with time. The patient’s medical, family, and habit history were unremarkable. On extraoral examination, diffuse swelling was present on the left side of the face extending from midline to 4 cm posteriorly toward the outer canthus of eye and from corner of mouth to 4.5 cm superiorly toward the inferior orbital margin and was causing deviation of the nasal septum to the right side (). The swelling was firm and tender with normal color and texture of the overlying skin. The mouth opening was found to be normal and lymph nodes were not palpable.\nIntra-oral examination revealed a well-defined soft tissue swelling of size 3 cm × 3.5 cm in the maxillary anterior region extending from distal aspect of 11 to distal aspect of 24 with erythematous overlying labial mucosa that was fixed to the swelling. It was firm in consistency and tender on palpation causing palatal displacement of 11, 21, 22, and 23. Grade I mobility was observed in these teeth ().\nOrthopantomogram showed no bony changes, except displacement of teeth 21 and 22. Contrast-enhanced computed tomography (CECT) revealed heterogeneously enhancing mass measuring 4 cm × 4.5 cm × 5 cm in size anterior to the left maxillary sinus with destruction of its anterior and medial wall. The lesion was extending into the left maxillary sinus. It was indenting over the left inferior turbinate and extending into the left anterior nasal cavity ().\nThe histopathologic examination of the incisional biopsy taken from the lesion revealed highly cellular tumor tissue composed of intersecting fascicles of spindle-shaped cells. Cells in cross section showed vesicular nuclei with vacuolar degeneration of the cytoplasm (). Few hyperchromatic nuclei and mild nuclear pleomorphism were also observed. Increased and abnormal mitotic activity was observed throughout the lesion. The nuclei varied from ovoid to blunt-ended with spherical nuclei also observed at places. The minimal supporting stroma was fibro collagenous with variable vascularity. The tumor tissue was separated from overlying parakeratinized stratified squamous epithelium by fibrous tissue. Tumor cells were diffusely positive for pan-cytokeratin (AE1/3) and vimentin and negative for S100, smooth muscle actin (SMA), Desmin, bcl-2, and CD99 ( to ). Absence of osteoid with these findings pointed toward the diagnosis of monophasic variant of synovial sarcoma.\nThe patient underwent segmental resection of the left maxilla. On histopathologic examination of the resected tissue, hypercellular, and hypocellular areas were noted. The hypercellular areas were composed of spindled to plump fibroblasts. At areas, these cells showed Herring bone pattern intersecting at right angles with scarce cytoplasm, vesiculated nuclei, and exhibiting cellular and nuclear pleomorphism and nuclear hyperchromasia. Two to four abnormal mitotic figures were observed per 10 high power fields (). Malignant osteoid formation was seen only at foci ( and ). A few tumor giant cells were seen in close approximation with the tumor osteoid.\nThe remaining connective tissue stroma was hypocellular, showing loosely arranged collagen fibers in whorled pattern. Mild diffuse infiltration of chronic inflammatory cells was seen throughout the connective tissue. Peripheral area showed degenerated muscle fibers exhibiting fragmentation and loss of striation. The lesional tissue was moderately vascular with deeper area comprising intact muscle tissue and many neurovascular bundles. All surgical margins were negative for tumor tissue. The tumor cells were positive for vimentin and pan-cytokeratin and negative for EMA (, , and ). A differential histopathologic diagnosis of monophasic synovial sarcoma and fibroblastic OS was considered. Furthermore, the tissue was subjected to fluorescent in situ hybridization (FISH), which was negative for SYT gene translocation. Hence, the final diagnosis was signed out as fibroblastic variant of OS. The patient was referred to an oncology center for further treatment involving chemotherapy. |
A 33-year-old male patient reported to us with the chief complaint of a painless swelling involving right half of the palate for 5 years from the date of reporting. The swelling initially appeared as a small mass in the central palatal region and then grew over time to involve the entire right half of the hard palate []. The patient gave a history of being treated for RS which had manifested as a nasal swelling associated with chronic rhinitis 3 years back and reported a similar lesion at the same site 6 months back which was suggestive of recurrence.\nGeneral examination did not reveal any deviation from the routine findings. Upon extraoral examination, slight facial asymmetry was noticed owing to the nasal swelling on the right side which resulted in obliteration of nasolacrimal fold.\nIntraorally, the lesion presented as an ovoid swelling involving the right side extending from the palatal area corresponding to right canine up to approximately 1 cm beyond the third molar and transversely from the gingival margins of the teeth till midline of the palate. The swelling was grossly 4 cm × 2 cm in size with regular, well-demarcated margins, and the overlying surface was smooth and of the same color as the adjacent palatal mucosa. On palpation, the swelling was nontender and soft to firm in consistency.\nBased on the history and clinical findings, a provisional diagnosis of palatal extension of RS was made.\nMinor salivary gland tumor, radicular cyst, and periapical abscess were considered in differential diagnosis. Subsequently, radicular cyst and periapical abscess were ruled out the due absence of any dental involvement.\nPulp vitality test – The teeth were tested vital during the electric pulp testing.\nRadiographic investigations – The patient was subjected to radiographic investigations, wherein the panoramic radiograph was deemed insufficient to comment on the lesion and the patient was further advised cone-beam computed tomography (CBCT). CBCT revealed a palatal swelling appeared as an isodense mass on the right side of the palate measuring 37.4 mm × 20.6 mm in size. In the coronal section, radiopaque structures suggestive of the stents placed to correct the nasal obstruction were present bilaterally, around which soft-tissue masses appeared to grow. On sagittal view, areas of bone erosion were apparent in the posterior palate and floor of the nose indicating continuity in nasal and palatal lesion [].\nOn hematological examination, the patient was found to have hypochromic microcytic anemia. Preanesthetic evaluation was conducted to rule out other systemic malfunctions such as diabetes mellitus and immunosuppressive diseases.\nCytopathology – Cytological evaluation of the aspirate revealed clumps of red blood cells and few inflammatory cells.\nMicrobial colony culture – No microbial colonies were observed after 48 h of incubation on MacConkey's agar.\nIncisional biopsy of the lesion gave the impression of a chronic granulomatous inflammation. Haematoxylin and eosin stained section exhibited fibrocellular connective tissue with severe degree of chronic inflammatory cell infiltrate with lymphoplasmacytic predominance and moderate degree of vascularity. Scattered at places were several large macrophages (foamy histiocytes) having a central nucleus and vacuolated cytoplasm with rod-shaped bacilli at places resembling the Miculicz cells (MCs). Also evident were hyalinized plasma cells which were seen either discretely (Russell bodies) or in clusters (Mott cells) [].\nHistopathology was consistent with the clinical diagnosis and further confirmation was done using special staining techniques to demonstrate the microorganisms. Gram staining showed the presence of Gram-negative rod-shaped bacilli. Periodic acid-Schiff (PAS) and Giemsa stain were also employed for demonstration of the Klebsiella spp. The organisms were stained magenta with PAS and light blue with Giemsa stain [].\nBased on the histopathological findings, the diagnosis was given in favor of RS.\nThe patient was referred to the department of Ear–Nose–Throat surgery for further treatment. The lesion was surgically excised and antibiotic therapy with tetracycline one gram twice a day along with Ciprofloxacin 500 mg/day for 1 month was started and continued as deemed fit by the physician. No recurrence has been observed up to the 6-month follow-up. The patient is kept under regular observation to monitor any incidence of recurrence. |
This 68-year-old male underwent pelvic exenteration, right lower quadrant ileal conduit creation, and left lower quadrant colostomy for the treatment of rectal carcinoma. Four years after these surgical procedures, the patient presented with vague lower abdominal and perineal pain and decreased ileal conduit output for four days. In addition, he related that he was experiencing persistent drainage of cloudy, yellow fluid from the perineum for four weeks.\nOn physical examination, the patient was found to have a wet perineum with a visible draining sinus in the ventral aspect of the anal scar.\nRenal ultrasound was performed and revealed normal kidneys with no evidence of hydronephrosis. A nuclear medicine bone scan was negative for metastatic disease, but it was evident that the ileal conduit was leaking urine into the deep pelvis (). A retrograde ileal conduit examination, with water soluble contrast, revealed contrast flowed promptly from an open end of the conduit intoa pelvic fluid collection. Neither ureter could be visualized as the contrast preferentially flowed into the pelvis (). The findings were considered to be consistent with a proximal ileal conduit dehiscence and extravasation of contrast into a pelvic cavity.\nUrology consulted interventional radiology to discuss placement of bilateral nephrostomy catheters, followed by antegrade ureteric stents, in an attempt to divert urine away from the conduit dehiscence.\nIn the absence of hydronephrosis, nephrostomy insertion was deemed to be too technically difficult and would require multiple needle punctures of the kidneys while attempting to gain access to the collecting system. In addition, the collapsed collecting systems would present a very confined space in which to attempt to maneuver needles, guide wires, and catheters. Because of the probability of procedure technical failure, and heightened concerns about procedural complications, another treatment option was felt to be necessary. It was decided that attempting retrograde ureteric stent placement in the interventional radiology suite was the most appropriate solution.\nThe conduit ostomy bag was removed and the ileal conduit was catheterized retrograde with a 5F Kumpe angiographic catheter (Cook Canada, Inc.). Under fluoroscopic guidance the Kumpe catheter was used to probe for the ureteric anastomoses within the ileal conduit. The left ureter was initially catheterized with the Kumpe catheter. With the assistance of a “0.035”, 15 mm, guide wire (Cook Canada, Inc.) it was possible to implant an Inlay Optima 8F, double J, ureteric stent (Bard, Inc.) in a retrograde fashion. The proximal J of the stent was deployed in the renal pelvis, and the distal J was deployed just external to the skin surface of the ileal conduit. An 8F, double J, InLay ureteric stent was also implanted on the right side, in the same manner. The patient tolerated the procedure without difficulty or complication. The results of the stent procedure are shown in .\nThe patient was discharged the next day for outpatient management. It was hoped that the stents would divert urine away from the conduit reservoir and allow the conduit dehiscence to heal. However, despite this conservative therapy and the presence of the ureteric stents the patient required nephrostomy tubes. The ureteric stents were utilized for this procedure as they were injected retrograde to opacify and dilate the renal collecting systems bilaterally for nephrostomy insertion. |
A 51 year old previously healthy male presented to the emergency room with complaints of dyspnea, chest pain and palpitations while playing tennis. This was the second time over the last month that he experienced some palpitations and dyspnea with exertion. Previously, the patient was ruled out for a myocardial infarction and had a stress echocardiogram which showed mild/moderate pulmonic stenosis, normal right ventricle, and thickened pulmonic valve with doming, but otherwise normal stress test. He was sent home from the emergency room with follow-up with his primary care physician and cardiologist. His cardiologist ordered a cardiac MRI to further evaluate the pulmonic valve. The MRI revealed a large mass starting near the pulmonic valve and extending into the main pulmonary artery and 4 cm into the right pulmonary artery and 3 cm into the left pulmonary artery (Fig ). The MRI findings were suspicious for a pulmonary artery sarcoma. The patient was admitted into the hospital for further evaluation of the mass. Although the patient's vital signs were stable with normal oxygen saturation he was started on heparin due to suspicion of a thromboembolism. CT scan of the chest was done which showed the large pulmonary artery mass and 2 small 9 mm nodular densities of the right lung without lymphadenopathy (Fig ). PET-FDG showed uptake in the pulmonary artery trunk, but the 2 nodules did not show abnormal FDG uptake. Cardiothoracic surgery was consulted and the pulmonary artery mass and 2 lung wedge resections were completely excised. Frozen section evaluation was consistent with sarcoma.\nGross pathology showed a large intimal sarcoma filling the pulmonary artery (Fig ). It infiltrated the arterial media without extension into the adventitia. The neoplasm consisted of spindled and stellate-shaped cells deposited in variably myxoid stroma (Fig ). The 2 lung wedges were positive for metastatic sarcoma.\nThe patient tolerated the surgery well and was discharged with oncology follow-up as an outpatient. Adjuvant chemotherapy with doxorubicin and ifosfamide was initiated soon thereafter. Eighteen months later and after 7 cycles of chemotherapy, he continues to remain disease free by imaging. |
A 29-year old female diagnosed with SLE for 4 years complicated with grade II lupus nephritis presented with status epilepticus. She denied a history of fever on admission, but was treated with cyclophosphamide 1 month prior for an episode of cerebral lupus. She had noticed a papule over the left deltoid region which progressed to an ulcer over 1 week. Fever was noted following several days of hospital admission and the ulcer site became painful. She had worked in paddy fields several months prior to the admission when she was in good health. However, she could not recall any precipitating injury at the affected site during working. She is a mother of two and both pregnancies were uncomplicated. She denied history of alcohol abuse or smoking.\nOn examination she was emaciated and had a GCS score of 15/15 following recovery of status epilepticus. There was no obvious lymphadenopathy. At presentation, the size of the ulcer was about a 3 cm lesion and it gradually developed in to an ulcer with a necrotic center with surrounding erythema. A tentative diagnosis of pyoderma gangrenosum was made with the appearance of the ulcer (Figure ). It gradually advanced into the underlying muscle over 3 weeks of onset despite the antibiotic treatment. Examination of the cardiovascular, respiratory systems, and the abdomen was normal.\nHer full blood count, blood picture, and other supportive investigations showed evidence of microangiopathic hemolytic anaemia, which was suggestive of thrombotic thrombocytopenic purpura which resolved following plasmapheresis. Her ESR was persistently normal. Renal functions were stable during hospital stay, so were the liver profile. Chest radiography revealed evidence of bilateral mild pleural effusions and echocardiography revealed a thin rim of pericardial effusion and good cardiac function. MRI, MRA brain showed evidence of Posterior Reversible Encephalopathy Syndrome. Repeat imaging showed resolved changes.\nA punch biopsy of the skin was done from the lesion and sent for fungal studies and histopathological studies. The direct microscopy examination revealed wide and irregular ribbon-like nonseptate hyphae with right-angle branching suggestive for Mucormycete fungi. Culture was done on Sabouraud dextrose agar with chloramphenicol (at 26°C and 37°C) yielded a white aerial mold, which covered the entire surface of the agar and came up to the lid of the culture bottles after 4 days of incubation (Figure ).\nThe lactophenol cotton blue mount of the growth revealed broad, nonseptate hyaline sterile hyphae. The slide culture test has been attempted with the hope of sporulation, however it was not successful. They only resulted in broad, nonseptate hyaline sterile hyphae without spores. Then the isolate was subcultured on to potato dextrose agar (PDA) and Rose Bengal (RB) agar for induction of sporulation. However, they yielded only sterile mycelia.\nThe isolate was inoculated on nutritionally deficient medium, tap water agar and incubated for 14 days at 37°C. It provided a hazy view of flask shaped sporangium with rhizoids in lactophenol cotton blue mount. Then floating agar method was used and it yielded characteristic flask-shaped sporangium in short sporangeophore with rhizoids after 10 days of incubation (Figure ).The sporangia had a long neck and the apex of the neck closed with a mucilaginous plug. The sporangiospores were cylindrical, with rounded ends. Those morphological features were suggestive for S. vasiformis and the isolate was identified as S. vasiformis.\nThe histopathology of the punch biopsy of the skin also reveled broad aseptate hyphae suggestive of Mucormycetes group of fungi.\nBased on the histopathological evidence of broad aseptate hyphae, suggestive of Mucormycete fungi, the patient was started on IV amphotericin B deoxycholate. Repeated surgical debridement was done and samples were sent for fungal studies. However, local application of antifungals was not included in the management. Her second tissue biopsy, which was taken during debridement after 5 days of IV amphotericin B also had similar direct microscopy findings and yielded S. vasiformis. However third tissue sample which was obtained after 10 days after IV amphotericine B deoxycholate became negative for fungal studies. Following the confirmation of sterile cultures from the subcutaneous biopsies, superficial skin grafting was done which was completely accepted from the wound site. She was treated with intravenous conventional amphotericin B for 28 days and she was asymptomatic when she was discharged from the ward. |
A 29-year-old young male law graduate, morbidly obese since adolescence, has been symptomatic since the last 7 years with fatigue, generalized weakness, and fluctuating jaundice. He was 160 kg at the time of presentation with a BMI of 55.36 kg/m2. He was diagnosed to have cirrhosis with persistently high bilirubin which fluctuated between 2 and 5 mg/dL. His Child's score at presentation was B9 with a MELD score of 14. Extensive evaluation for the etiology of liver disease including viral markers and autoimmune markers and iron and copper studies were all negative. There was no history of alcohol intake; hence, in view of morbid obesity and dyslipidemia, the diagnosis of nonalcoholic steatohepatitis for cirrhosis was considered. His gastroduodenoscopy showed small varices with portal hypertensive gastropathy, and a triple-phase CT scan of the abdomen showed a shrunken liver with splenomegaly, multiple portosystemic collaterals, and no ascites. He was listed for deceased donor liver transplantation and advised weight reduction with dietary and behavioral measures. However, he did not show any significant improvement over the next three months. Since he was morbidly obese and had failed medical therapy for weight reduction, he was planned for bariatric surgery after counseling for worsening of liver disease in the postoperative period and a possible requirement for immediate liver transplantation in that eventuality. A prospective living donor was identified in the family and completely worked up in case the patient showed signs of worsening liver disease following bariatric surgery. He underwent laparoscopic sleeve gastrectomy and had a smooth postoperative course. Following bariatric surgery, he had a significant reduction of weight from 160 kg to 102 kg in six-month period. However he developed worsening of his liver disease in the form of progressive jaundice, ascites, and recurrent episodes of hepatic encephalopathy. His Child's score worsened from B9 to C12, and MELD score increased to 24 over the next six months. In the absence of availability of cadaveric donor, living donor liver transplantation was considered as his weight had now decreased substantially. He underwent a modified right-lobe LDLT from his sister-in-law as the donor with a graft weight of 837 grams and an acceptable GRBWR of 0.81. The postoperative period was smooth except for basal atelectasis, which required intense physiotherapy and intermittent BIPAP for a few days. |
This report involves a 49-year-old Caucasian male with no significant past medical history who presented to the emergency department (ED) complaining of pain and coldness in the right foot with some tingling for the past few hours. The pain was described as vague and had a progressive onset. The patient has a history of smoking one pack per day for the last 30 years, and he works as a general contractor. At the time of presentation, the patient was able to move his toes and foot without much difficulty. The right foot examination revealed diminished dorsalis pedis pulse, mild sensory loss, and no muscle weakness. The right foot was cold and displayed pallor with no distinct demarcation. The patient had a CTA done, which revealed an acute occlusion involving the proximal anterior tibial artery and the tibioperoneal trunk with reconstitution distally. Given the poor reconstitution, no evidence of atherosclerotic disease in either extremity and no evidence of vasculitis the occlusions were likely acute and embolic in etiology. The patient was admitted to the intensive care unit (ICU), a tissue plasminogen activator (TPA) was infused directly into the affected peripheral vessel, and a heparin drip was started.\nThe patient did not have any history of cardiac arrhythmias or myocardial infarction. An echocardiogram revealed a patent foramen ovale which was only evident by a bubble study. Due to the foramen ovale not being large enough to explain the current arterial occlusion, a transesophageal echocardiogram and a closure device were not recommended. Interventional radiology was consulted, and the patient underwent four attempts of thrombolysis, resulting in improved clot burden by the end of each procedure. However, the patient continued to have repeated episodes of thrombosis. Angioplasty of the anterior tibial and posterior tibial arteries was also performed. Unfortunately, recanalization of these vessels was unsuccessful. Despite four days of TPA thrombolysis therapy and multiple attempts at angioplasty and thrombectomy of all three tibial vessels, they remained occluded. The patient's right lower extremity angiogram demonstrated persistent occlusion of all three tibial vessels below the knee in concurrent images (Figure ). There was also rethrombosis of the peroneal artery and anterior tibial artery.\nHypercoagulable workup was negative for factor V Leiden, lupus, antiphospholipid syndrome, and vasculitis. Furthermore, the activity of protein C, protein S, and anti-thrombin III was normal. Seven days after the patient's initial presentation, he had worsening discoloration, advancing pain, and a cold avascular foot, ankle, and calf. The patient's foot was insensate, with the inability to move toes, severe mottling, and darkening of the skin below the ankle. There was also mottling of the distal third of the leg. A right below-knee amputation was planned to prevent infectious gangrene. At the time of amputation, the patient was noted to have avascular gangrene of the distal half of his right lower extremity, especially lateral and anterior compartments, with non-contractile muscle. Complete occlusion of all arterial portions of the vascular tree was found during amputation, with a gelatinous clot. Pathology reports stated findings of an embolic clot with some atherosclerotic changes in the posterior tibial vessels.\nPostoperative D-dimer was elevated at 12,021 ng/mL FEU and platelets dropped from 253,002 to 26,000 in two days. HIT was suspected which is a clinicopathologic diagnosis that requires combined evaluation of clinical examination and laboratory test results. The 4Ts scoring system was used to support the need for laboratory testing (Table ). This case resulted in a score of at least 6 which is correlated with a high probability of HIT. Heparin was held, and HIT testing with a serotonin release assay was positive. Therefore, he was started on an argatroban drip and coumadin. The argatroban drip was stopped once his INR was therapeutic.\nCOVID-19 IgG and IgM antibody tests were positive even though testing at the time of admission via nasal swab, reverse transcription-polymerase chain reaction, and nucleic acid amplification were negative. This raised a concern that the clotting was possibly a complication of a previous COVID-19 infection, although the patient denied any history of COVID-19 infection and showed no other symptoms.\nOnce stabilized, the patient was discharged on 6 milligrams of warfarin and low-dose aspirin daily. After discharge, the patient was lost to follow up and was brought to the ED 13 days later by ambulance complaining of severe headache and altered mental status. When the patient arrived at the ED, he was minimally responsive and appeared lethargic with no apparent trauma. The patient was not responding to painful stimuli, no posturing was noted, and his pupils were reactive to light and measured at 4 millimeters. CT of his head showed massive intraparenchymal and intraventricular hemorrhages with extension into the third ventricle and a rightward shift consistent with subfalcian herniation as well as downward herniation (Figure ).\nThe patient decompensated, his respiratory efforts became closer to agonal, and the patient was intubated. The patient's INR was 7.2. He was given fresh frozen plasma, vitamin K, and Kcentra. The patient was transferred to another hospital better equipped to handle critical patients but could not survive. |
A 62-year-old woman was hospitalized for the further evaluation of her progressive chest discomfort for 10 days. The patient had undergone total thyroidectomy 20 years earlier, and she has been managed for hypothyroidism since then. Seven years prior to admission, she was diagnosed with and managed for angina pectoris, but was not evaluated properly. A month before presentation, she had experienced worsening chest pain with dyspnea on exertion despite medication. She was diagnosed with severe mitral regurgitation by echocardiography at our cardiovascular clinic. When she was hospitalized, she complained that her chest pain and dyspnea had been aggravated with time. Two weeks of medicinal management did not control the symptoms. After dobutamine stress echocardiography, it was determined that the patient should undergo open heart surgery. Mitral valve replacement was performed under extracorporeal circulation. Immediately after surgery, the patient's general condition and laboratory data were found to be stable except for mild thrombocytopenia. Platelet concentrates were transfused to increase the platelet number and prevent unexpected bleeding. A postoperative echocardiogram showed good mitral valve function without para-valvular regurgitation. Since postoperative day 4, she had a fever over 38℃ and the laboratory data showed signs of disseminated intravascular coagulopathy (DIC). Acinetobacter baumannii was cultured in the blood. She was treated with broad spectrum antibiotics for sepsis as well as plasma and platelet transfusion for pulmonary hemorrhage, which occurred on postoperative day 6. Since the thrombocytopenia did not respond to transfusion, intravenous immunoglobulin G was infused and methylprednisolone was administrated intravenously at a dose of 15 mg three times a day. In spite of vigorous treatment, the platelet count did not increase, and even worse, it decreased to a lower count. The lowest platelet count occurred at postoperative day 9. To identify the reason for the refractory response to platelet transfusion, a study for antibody to platelet and additional immune workup were performed on postoperative days 9 and 10. The findings included hemolytic anemia with thrombocytopenia (hemoglobin=7.6 g/dL, platelet=15,000/µL, schistocytosis(+) in a peripheral blood smear), negative direct and indirect Coombs tests, decreased haptoglobin (3 mg/dL), normal ranges of an international normalized ratio (INR 1.13), activated partial thromboplastin time (38.2 seconds) and fibrinogen (287 mg/dL), slightly elevated D-dimer (3.3 µg/mL), hyperbilirubinemia (total bilirubin 3.28 mg/dL, direct bilirubin 1.9 mg/dL), increased lactate dehydrogenase (580 mg/dL), normal serum alanine aminotransferase (10 IU/L) and aspartate aminotransferase (15 IU/L), increased blood urea nitrogen (51 mg/dL), normal creatinine (0.8 mg/dL), microscopic hematuria (red blood cell >30/HPF), negative human immunodeficiency virus antibody, and positive hepatitis B surface antibody. The immune workup results showed decreased complement 3 and 4 levels (lower-most to 51.5/6.9 mg/dL; normal range, 90-180/10-40 mg/dL) and strong positivity in an autoimmune target test (autoimmune cytoplasmic antibody level 4). Antiplatelet antibody was negative. Since postoperative thrombotic thrombocytopenic purpura (TTP) needed to be ruled out at that moment, platelet transfusion was discontinued and the dosage of methylprednisolone was increased to 75 mg/day. Treated with the increased dosage of methylprednisolone, the platelet count steadily increased and maintained within a stable range. The increase in the platelet count and associated dosage of methylprednisolone can be seen in .\nSince the patient's general condition was stable without thrombocytopenia, or pulmonary bleeding or bleeding from other sites as of postoperative day 18, the tapering of the dosage of methylprednisolone was begun and close observation for bleeding or thrombotic events was maintained. The patient was not given heparin or any other anticoagulation agent until postoperative day 36 due to the above history, but warfarin was given as an anticoagulant since the patient clearly had no risk of bleeding tendency. The patient was discharged on postoperative day 51 after a long period of not only antibiotics treatment for sepsis due to Acinetobacter baumannii but also management and monitoring for ventricular tachycardia. The patient has not complained since of the symptoms of congestive heart failure and has had a normal platelet count for 28 months of follow-up. |
A 62-year-old male patient visited our hospital with dyspnea and mild dysphagia that began approximately 4 months prior to the visit as the main symptoms. Gentle exercise, such as steps, caused difficulty of inspiration 1 month ago, but it had become worse around the time of his visit, he appeared at rest and accompanied by dysphonia. Dysphagia emerged as foreign body sensation and intermittent aspiration during a solid meal, but he did not have history of weight loss or aspiration pneumonia. Various physicians, from a pulmonologist to an otorhinolaryngologist, failed to make an accurate diagnosis and the symptoms of the patient continued to progressively deteriorate.\nThe patient did not have any particular past internal or surgical medical history other than being a smoker for the last 20 years. The patient had clear consciousness without cognitive dysfunction at the time of his visit to our hospital. In physical examination, stridor was auscultated during inhalation. There was no abnormality of the tongue and no atrophy of the body muscles. The sensory tests displayed normal findings, and normal muscular strength was observed in all muscles of the upper and lower limbs on both sides in the manual muscular strength tests along with normal findings in the deep tendon reflex tests. Fibrillation was not observed in neurological examinations, and masticatory function and gag reflex were normal without observation of particular findings, such as dysarthria in linguistic assessments. Brain magnetic resonance imaging (MRI) for intracranial pathology did not show any abnormalities. There were no abnormal findings in the electrodiagnostic studies that were screened for neuromuscular diseases such as progressive bulbar paralysis. In addition, all the enzymes related to muscular diseases, such as creatine kinase, lactate dehydrogenase, and so on, were in the normal range of the laboratory test. Pulmonary function test was performed to find the cause of dyspnea, but normal pulmonary function was observed without abnormal findings, such as obstructive or restrictive pulmonary patterns. A VFSS showed that osteophytes were severely protruding at the anterior portion of the 5th to 7th cervical spine and translocated the lower pharynx and the upper esophagus anterosuperiorly. In the oral phase, there was no abnormality except for premature bolus loss. In the pharyngeal phase, although laryngeal elevation and epiglottic closures were normal and aspiration was not observed, a lowering of food took a circuitous route around the osteophytes and the pharyngeal transit time of the solid food was delayed by 1.4 seconds. X-ray and computerized tomography (CT) scan of the cervical vertebrae were performed to verify these anterior cervical osteophytes and revealed that the formation of large osteophytes was caused by overgrowth of cortical bones of the 5th to 7th cervical vertebrae. Osteophyte in the 5th cervical spine was the most prominent and protruded 8 mm outside of the vertebral body. C-spine MRI showed anterior herniation of the intervertebral disc accompanied with a ruptured anterior longitudinal ligament, with fluid collection in the retropharyngeal space. A T2-weighted image showed high signal intensity with irregular enhancement caused by retropharyngeal irritation and inflammatory changes due to the large cervical osteophytes (). Anatomical deformities or mass-like lesions on the oropharynx and laryngopharynx were not observed in the larynx endoscopic examination. However, the paradoxical vocal cord motion, adducted vocal cords during the time of inhalation, was observed.\nBecause we did not find any possible etiology of these symptoms other than the anterior cervical osteophytes and the patient displayed a tendency of gradually aggravating dyspnea with severe anxiety and sleep disturbances, we decided to perform surgical treatments. Surgery was conducted through the anterior approach method. Removal of the anterior osteophytes and 5th to 6th cervical herniated disc were performed and interbody fixation with a bone graft was executed.\nDysphagia disappeared immediately due to relief of mechanical pressure on the larynx, but dyspnea and paradoxical vocal cord motion still remained. Accordingly, for correcting the abnormal vocal cords motion, the patient performed the breathing exercises, such as relaxation technique and diaphragmatic breathing method. Finally, the respiratory difficulties and dysphonia were gradually improved after 3 months of continuous self-treatments. |
A 78-year-old right hand-dominant woman suffered a fall on her right side in a bicycle accident, and presented at our institution on the same day with severe arm pain. Her medical history included internal fixation for a glenoid fracture 7 years ago, and also hemiarthroplasty (bipolar humeral head type) for a proximal humeral fracture 5 years back. She had also undergone coracoid tip transfer to the glenoid rim for atraumatic postoperative dislocation. All the previous operations had been performed at other hospital. Upon initial presentation, the patient had severe pain in the right arm without vascular or neurological abnormalities, and the right arm was swollen, with deformity. She was not aware of any pain around the shoulder. She stated that although her range of motion in the arm had been limited before the accident, she had been able to live without assistance. Standard radiographs of the humerus revealed a periprosthetic fracture, which was centered at the tip of the prosthesis stem with minimal proximal extension, chronic anterior dislocation, proximal medial side osteolysis, and a thin cortex with osteopenia ( and ) We considered that surgery might have a considerable risk of complication because of the patient’s advanced age, poor bone condition, and history of multiple operations on the shoulder. Therefore, we decided to follow her up conservatively using functional bracing with routine periodic X-ray examinations. Her arm was immobilized using a plaster U-slab in a sling, to rest the arm and allow the swelling to subside for 2 weeks after the injury. After the swelling had improved, we modeled a functional brace. At 2 weeks after injury, the functional brace was applied without a sling, and physiotherapy was started, with very good patient compliance. The arm pain gradually resolved on a daily basis, but after 3 weeks, radiography showed that the fracture gap had widened. Therefore, we treated this fracture using a sling to prevent any traction force on the fracture site until sufficient callus formation had been achieved. The presence of a callus was confirmed on radiographs after 5 weeks, and use of the sling was continued until 7 weeks after injury. The patient was able to live an almost normal daily life with a functional brace by 10 weeks. Complete radiographic union was confirmed at 17 weeks, and the bracing was then removed. At the final follow-up at 33 months after injury, three- dimensional computed tomography showed anterior angulation of 27 degrees and valgus deformity of 3 degrees (), and radiographs showed no change in alignment at the end of bracing (). The range of motion of the right shoulder was forward flexion to 90°, external rotation at the trunk to 30°, abduction to 90°, and internal rotation to level L2. The patient was relieved of the arm pain, and her level of daily living activity was the same as that before injury. |
A 24-year-old previously asymptomatic male presented to his primary care physician with a complaint of focal penile irritation related to sexual intercourse. The irritation originates from a lesion along the midline on the dorsum of his penile glans. He was referred to a urologist for further evaluation.\nThe patient reported noticing a small dimple along the midline on the dorsum of his glans for as long as he could remember. The lesion had not previously caused him any discomfort, nor did he report a history of discharge, including urine, semen, blood or pus from the orifice. In recent months, the patient has become more sexually active and he has become aware that during and after intercourse the site is painful and inflamed for a short period of time. The patient wants to make sure there is not something wrong with his anatomy and seeks a solution.\nThe patient had no significant past medical history. There is no family medical history of relevance, specifically no one has reported any genital malformation. Physical examination by a urologist demonstrated a well-developed adult male. A small midline opening was present on the dorsum of the penile glans. There was no focal erythema or discharge present at the time of examination. Manipulation of the opening demonstrated a thin lumen that appeared to continue proximally along the dorsum of the penile shaft. The most likely aetiology was determined to be urethral duplication. Imaging was necessary for confirmation and to delineate the particular anatomic presentation in order to plan treatment. Demonstration of communication with the urethra or bladder would require more extensive surgical intervention to eliminate the sequelae of discharge accumulation in the lumen causing infection, cyst formation or recanalisation of the accessory orifice. The patient was referred to radiology for urethrography.\nSince no urine, semen or other discharge had ever been noted to exude from the accessory urethra, a retrograde urethrogram (RUG) was performed (). A 5F paediatric catheter was advanced 3 cm through the dorsal accessory meatus. Simultaneously, a 6F Foley catheter was inserted into the orthotopic urethral meatus and the retention balloon inflated in the fossa navicularis. Cystografin contrast was manually instilled into both catheters. Opacification of the accessory meatus demonstrated a hypoplastic urethra traversing the dorsum of the penis and terminating blindly at the level of the levator musculature. No contrast was visualized refluxing into either the orthotopic urethra or the bladder. Contrast injected into the orthotopic urethra demonstrated a normal appearing urethra terminating at the sphincteric musculature. There was 2 mm of distance separating the terminal blind end of the accessory urethra and the orthotopic urethra. Based on the radiographic evidence a Type 1-A urethral duplication was diagnosed.\nAfter confirming a Type 1-A urethral duplication the patient was offered and consented to operative reconstruction. A short rigid ureteroscope was used to inspect the main urethra and bladder demonstrating the appearance of normal verumontanum and sphincteric mechanisms confirming the ventral urethra as the functional urethra. The ureteroscope was then used to evaluate the accessory urethra and passed through to the blind-end. The accessory urethra was cauterized as the ureteroscope was withdrawn.\nThe patient tolerated the procedure well without any reported postoperative complications. At follow-up the patient did not report recurrent irritation during sexual intercourse and was pleased with the cosmetic result. |
A 77 year old female patient was referred to the vascular surgery clinic for further evaluation of a possible vascular malformation at the right lower thigh region. She was a diabetic patient and had a history of rheumatic mitral valve stenosis. She had undergone mitral valve replacement in 2005 and since then was on warfarin. In 2010 she noted abnormal, dilated veins over the right lower thigh region, but as they were asymptomatic, she chose not to seek medical attention. When the right leg developed progressive swelling with some discomfort she brought the matter to the attention of doctors in 2019. At the first contact surgical clinic, a duplex scan was done to exclude deep vein thrombosis. Suspecting a vascular anomaly they next arranged a contrast CT of the lower limb, which failed to demonstrate an arteriovenous malformation (AVM) or a vascular tumor.\nWhen we saw her at our clinic, the first striking feature we noted was the abnormal distribution pattern of VV (, ). There was a bunch of dilated tortuous veins at the medial aspect of the mid-thigh as well as the posterior aspect of the lower thigh of the right lower limb. The veins over the medial thigh communicated with the dilated proximal greater saphenous vein (GSV), which was pulsatile. A bruit was audible over the saphenofemoral junction (SFJ). When the limb was elevated the veins failed to empty completely. Pedal pulses were present and there was pitting ankle edema. On the contralateral lower limb, a few varicosities were noted and there was no associated edema. Auscultation of the precordium revealed a pansystolic murmur best heard at the left lower sternal edge. The neck veins were dilated (). The abdomen was mildly distended. We could not demonstrate a pulsatile, enlarged liver.\nA venous duplex scan of her right lower limb revealed arterial type pulsatile flow in the proximal GSV () and the common femoral vein (). The abnormal VV also had a pulsatile flow pattern. There was saphenofemoral incompetency with reflux in the GSV and the abnormal superficial veins.\nGiven the clinical features and the history of rheumatic fever, we suspected she may have tricuspid regurgitation (TR). The 2D echocardiogram confirmed severe TR with moderate pulmonary hypertension. The pressure gradient across the tricuspid valve (TV) was 40mmHg. Considering the age of the patient and the prior history of open heart surgery, a joint decision was taken by the cardiologists and the vascular surgeons to manage the tricuspid incompetence and the VV conservatively. Presently she is doing well, with the use of Class II below-knee compression stockings. |
A 79-year-old man who was a current smoker was admitted to our hospital for hemoptysis in July 2011 (day 0). Before admission, pulmonary emphysema and multiple pulmonary bullae were detected on a chest computed tomography (CT) scan, and we also discovered that the patient had hypertension. He had a history of lobectomy of the left lower lobe for lung cancer in 1993, with no recurrence; two episodes of bacterial pneumonia; gastrectomy for gastric cancer in August 2010; right spontaneous pneumothorax that required tube drainage in November 2010; and hospitalization for dyspnea in February 2011, at which time chest radiographs showed left lung opacity and a chest CT scan showed consolidation with pleural effusion in the left lung. Several bacterial antibiotics failed to improve the opacity on chest radiographs. A sputum culture was negative for Aspergillus. The lack of efficacy of bacterial antibiotics and the presence of multiple bullae and precipitating antibody to Aspergillus in the serum (day -163) led to a presumptive diagnosis of chronic necrotizing pulmonary aspergillosis. Voriconazole with a loading dose of 800 mg a day followed by a maintenance dose of 400 mg a day was started on day -155. A switch from intravenous to oral administration of voriconazole at a dose of 400 mg a day was made on day -106. With administration of voriconazole, the opacity on chest radiographs had significantly improved by June 2011. The patient underwent transurethral resection of bladder cancer in March 2011. Oral voriconazole was continued at our outpatient clinic until his admission for hemoptysis. He had no hematologic neoplasm.\nOn admission, a chest radiograph (a) showed consolidation in the upper field of the left lung and an infiltration shadow in the middle and lower fields of the left lung. A chest CT scan (b) showed consolidation in the pulmonary bullae adjacent to the aortic arch. These shadows were considered to be due to hemorrhage. Bronchoscopy revealed slight bleeding from left B1+2 without evidence of a tumor. Laboratory tests showed a normal count of polymorphonuclear leukocytes. Serological human immunodeficiency virus (HIV) testing was not performed, but the patient had no obvious risk factors for HIV infection. Serum precipitating antibody to Aspergillus was positive on day 2. The amount of expectorated blood decreased with rest, but massive hemoptysis occurred on day 16. Despite bronchial artery embolization, a second massive hemoptysis occurred and the patient died on day 21. The final day of voriconazole administration was day 20.\nAt autopsy, the pulmonary bullae were filled with blood. A macroscopic examination showed a hole in the aortic wall into the bullae (). This hole was unlikely to have been a consequence of the autopsy procedure because a microscopic examination of the tissue around the hole showed extensive accumulation of inflammatory cells (a–c). This microscopic examination also revealed small fungal lesions in the pulmonary bullae adjacent to the aortic wall (a–c). The diameters of these lesions were approximately 4 mm. The fungal hyphae were 5-10 μm in width, with septae and a dichotomous pattern of branching at 45°. These features are consistent with those of Aspergillus species. Microscopically, extensive necrotic lesions with Aspergillus hyphae were found in the media of the aortic wall (a and b). Immunohistochemical analysis with an anti-Aspergillus antibody (rabbit polyclonal antibody, anti-Aspergillus antibody ab20419; Abcam plc, Cambridge, UK) identified Aspergillus hyphae in lesions in pulmonary bullae (a and b) and in the necrotic media of the aortic wall (a and b). This established the diagnosis of aspergillosis. There was no other histopathologic evidence for aspergillosis elsewhere in the body, but we note that autopsy was not performed on the brain. There was no histopathological evidence for recurrence of gastric cancer, lung cancer, or bladder cancer. Prostate cancer was also found at autopsy. |
Case 2 is a 32 years old male with a histopathology of anaplastic oligodendroglioma (grade III) reported in previous literature . The whole simulation of this case can be observed in the File Case S2 video submitted as a supporting information file. compares simulations of this case at different times made with two distinct mathematical models: left column corresponds to simulations obtained with the present model, right column corresponds to simulations derived from our implementation of a model previously described in the literature (this model does not include differential migration based on topological brain structures). This figure should be compared with from that shows the real MRI images from this patient. Real tumor dimensions correspond well with those predicted by the present model. At diagnosis, real and simulated tumor mass radii are 8.9 and 8.7 mm; while tumor infiltration radii are 28.4 and 28.9 mm, respectively (compare from with axial view from ). Eighteen days after diagnosis, real and simulated tumor mass radii are 11.4 and 10.6 mm; and tumor infiltration radii are 33.1 and 31.2 mm, respectively (compare from with axial view from ). Simulations made with a previous model ( and 6(d)) also reach tumor dimensions similar to real ones.\nHowever, if we analyze tumor spreading the situation is different. Our model seems to be more accurate regarding tumor spreading than previous ones and these differences between models become significant 18 days after diagnosis. Real images show that tumor invasion through the corpus callosum is significantly augmented at that time ( from ). They also evidence a mass-effect that compresses the lateral ventricles. Although this kind of mathematical models do not include the mass-effect, this type of spreading through the corpus callosum can be observed in simulations made with our model (see axial view form ) but not in those derived from previous ones (axial view from ).\nThis consideration is extremely important, as its consequences worsen with time: differences between both models become more evident 100 days after diagnosis, as it can be evidenced in and 6(f). At this time point, simulations made with the present model predicts a larger spreading of the tumor through the corpus callosum with tumor cells reaching the contralateral hemisphere and anterior zones of the brain. Simulations with previous models, on the contrary, do not evidence this type of spreading. Though this time stage does not have real images to correlate with, it evidences the natural evolution of the previous tumor status. |
A 77-year-old man with past medical history significant for esophageal adenocarcinoma as well as testicular seminoma that was treated with conventional external bean radiation therapy (EBRT) almost 40 years back presented with three months of left hip and buttock pain in addition to left foot weakness. He had no history or clinical stigmata of neurofibromatosis.\nA magnetic resonance imaging (MRI) of the lumbar spine with and without gadolinium demonstrated a homogenously enhancing, well demarcated intradural extramedullary neoplasm (). An initial MRI of the cervical and thoracic spine with and without gadolinium was negative for additional lesions. While a diagnosis of benign nerve sheath tumor was suspected given typical radiological appearance, a metastatic lesion was also considered in the differential because of prior history of cancer. A metastatic work up performed to look for any additional lesions was negative.\nA partial L2 and complete L3 laminectomy was performed and a midline durotomy was made. A greyish mass was found in the intradural space arising from the left L3 nerve root with obvious enlargement and involvement of the nerve root. A frozen specimen was sent early for pathological evaluation that was diagnosed as MPNST. The nerve root of interest was clearly identified both proximally and distally, which on stimulation resulted in robust electrophysiological response suggestive of origin from a motor nerve root. No obvious plane was found between the tumor and the nerve root. Given the risk of motor deficit, the nerve root was preserved with partial resection of the tumor. Final pathology confirmed the diagnosis of MPNST ().\nGiven the initial pathologic diagnosis on frozen section, subsequent management including reoperation with extensive resection was discussed. Given his preoperative status, the patient, and family elected to observe in the short term with consideration of further treatment options following final pathology. The patient did well initially and was discharged to a skilled nursing facility. Two weeks post-operatively, however, the patient was readmitted with encephalopathy. An MRI brain with and without gadolinium demonstrated leptomeningeal metastasis () with cerebral spinal fluid (CSF) cytology positive for malignant cells. Given the extent of disseminated disease and his progressive worsening mental status, the family elected to pursue palliative care, and the patient died two months after his initial surgery. |
A 51-year-old male was admitted to our hospital on August 28, 2013 after a motorcycle accident. The patient complained of pain, swelling and bleeding in the left upper limb for 2 h.\nThe patient had a motorcycle accident on August 28, 2013. The left little finger landed first, then the left wrist flexed and landed and the dorsal skin of the left forearm was punctured by ulna and radius fractures causing pain, swelling and bleeding of the left upper limb. The skin of the left hand felt normal after the trauma, and finger activity was normal. He was sent to our hospital for emergency treatment for debridement, and his left arm was fixed with long arm plaster. The X-ray radiography showed fractures of the left distal ulna, radius and little finger as well as wrist joint dislocation (Figure ). The injury occurred only in the left upper limb, and no other organs or tissues were injured.\nThe patient was hospitalized for further surgical treatment. External fixation and Kirschner wire were used to stabilize the left distal ulna, radius and little finger (Figure ). The patient walked every day after the operation. The swelling of the left forearm was reduced 12 d after the first surgery. Open reduction and internal fixation were performed under general anesthesia to stabilize the left distal ulna and radius. Because some of the bone in the distal radius was lost due to compression, we took about 10 g of bone from the left ilium to fill (Figure ). The operation continued for 4 h. Broad-spectrum antibiotic was used to prevent infection, and drugs were used to promote blood flow and microcirculation. After the anesthesia recovery period, the patient told us that he suffered severe pain and could hear the noise from the electric drill during the operation, but he was unable to communicate this during the operation. This led to psychological trauma. The patient became very sensitive to pain and remained in bed until the third postoperative day.\nOn the third postoperative morning, when he got out of bed and was going to the toilet, he was unable to stand, owing to double lower limb weakness and pain. The double lower limbs were not tumid, and the skin color was normal. When he received a shot for the intravenous infusion, he was very nervous and suddenly felt chest pain and asthma and had breathing difficulty. Additionally, his double lung breaths sounded thick and had a large number of dry and wet rales. The partial pressure of arterious blood oxygen was 7.2 kPa (normal range 11-13 kPa), arterial oxygen saturation was 88.8% (normal range 91.9%-99.0%), and central venous pressure was 11 cmH2O (normal range 5-10 cmH2O). After oxygen therapy, peripheral capillary hemoglobin oxygen saturation was 92%, blood pressure was 158/110 mmHg, heart rate was 110 bpm, and respiratory rate was 30 bpm. The brain natriuretic peptide troponin I was negative. The serum D-dimer level was 17.48 μg/mL. The bedside electrocardiograph showed sinus tachycardia. Wells and revised Geneva scores were 9 and 11, respectively. The patient was diagnosed with high clinical probability of PTE based on these Wells and revised Geneva scoring systems[,]. We first considered PTE.\nThe patient had no previous surgery or medical problems or family history of blood clotting disorders. Previously, the patient had no respiratory or circulatory problems.\nThe patient was a 51-year-old male, weighed 90 kg and was 175 cm tall. His body mass index (BMI) was 29.4 kg/m2. He started drinking heavily around age 17 (about 500 mL of wine a day). He did not smoke. None of his family has suffered from VTE.\nLeft forearm dorsal skin was pricked by ulna and radius fracture ends, swelling deformity, bleeding, left wrist activity limitations. The skin of the left hand felt normal after the trauma, and finger activity was normal.\nOn the morning of the first day after the motorcycle accident, the serum D-dimer level was 0.80 μg/mL (the reference range < 1.00 μg/mL). When pulmonary embolism occurred, the serum D-dimer level was 17.48 μg/mL. The routine blood and biochemical indicators were not significantly abnormal.\nComputed tomographic pulmonary angiography (CTPA) showed intravascular wirelike, sheet filling defects in both sides of the pulmonary artery trunks and its branches; the large shadow in the right pulmonary trunk was about 56 mm × 16 mm (Figure ). Doppler ultrasonography showed no significant anomalies in the upper extremity deep vein within the bilateral posterior tibial veins of the lower limb thrombus formation. Echocardiography did not show patent foramen ovale and a right to left shunt. |
An otherwise healthy 31-year-old male presented with left hip pain of more than one year duration. The pain was mainly located lateral in the iliac area, with minimal pain in the groin, and was radiating to the thigh. The pain was worse at night and waked the patient up from sleep every night. Physical examination of the affected hip revealed normal extension, and limited flexion at 100°, abduction at 30°, adduction at 10°, external rotation at 30° and internal rotation at 15°. The hip was spontaneously adopting an external rotation and abduction position. Plain radiographs suggested osteopenia and joint space thinning and loss of sphericity of the femoral head, but failed to show any tumor (Fig. ). The CT scan, MRI and bone scan demonstrated findings suggestive of OO of the left acetabular fossa (Fig. ).\nThe patient has tried several NSAIDs before his presentation to our clinic. Nevertheless, all medication trials (including the use of naproxen) failed to relieve his symptoms. Radiofrequency ablation therapy, consisting of three cycles for two minutes at 90 °C with an interval of one minute rest time between each cycle, was performed under CT guidance to treat the lesion. Following the procedure, the patient started to complain of severe pain that was limiting his ability to walk and stand normally even with continuation of NSAIDs. The OO appeared to be unchanged on a CT scan of the left hip that was done 4 months following the RFA. With the possible higher rate of complications of open surgery that requires hip dislocation, the patient agreed for an attempt of arthroscopic excision of the tumor. Based on the CT scans, the tumor was located posterior and superior within the acetabular fossa; therefore, hip arthroscopy was performed using the anterior, anterolateral and posterior portals. The region of the tumor was identified with irregularities of the cartilage at the posterior/superior edge of the fovea. Under fluoroscopic and direct guidance, a burr was placed in the identified region of the tumor. This region was burred, and the cavity of the nidus was identified. The burr could not be placed deeper inside the cavity due to its angulation, thus, the radiofrequency chisel was placed in the region and ablation involved the entire cavity. No intra- or post-operative complications were encountered.\nSix weeks after surgery, the patient reported no relief of his pain. A new CT scan of his left hip showed that the OO was still there, while the burned area appeared slightly posterior to the lesion. The patient underwent a second attempt of CT guided RFA of the lesion three weeks later. Improvement of his pain and increased range of motion of the hip were recorded two weeks following that. During the last follow-up visit, 44 months after the last procedure, he reported ignorable mild discomfort during activity. The nocturnal pain was gone, and he regained his ability to walk and stand without any pain. His range of motion improved fully with the exception of adduction at 10° and abduction at 30°. His latest follow-up x-rays showed no progression of the mild degenerative joint changes of the left hip which were noted in the first images (Fig. ). |
In July 2012, our 76-year old male patient underwent aortic arch replacement surgery with a Dacron graft for an aortic aneurysm. This was complicated by a P. aeruginosa mediastinal and aortic graft infection (confirmed by blood and deep wound culture) for which the patient returned to the operating room on multiple occasions for debridement and washout of the infected chest wall (A). The chest wall was eventually closed with omental and bilateral pectoralis major flaps. The patient was admitted again in early 2013 for recurrent P. aeruginosa infection (confirmed by blood and deep wound culture) and a new mediastinal fistula which drained purulent material. The patient was deemed too high risk for surgical replacement of his infected aortic graft after extensive discussions with his treating cardiac surgeon and multiple other consulting surgeons from other institutions. Therefore, the patient was conservatively treated with IV ceftazidime and superficial chest wall debridement. The patient was successfully discharged from the hospital, completed his multi-week course of intravenous ceftazidime (2 g IV q8h), and was switched to oral ciprofloxacin (750 mg q12h) as the isolated P. aeruginosa was susceptible to ciprofloxacin at this time. Over the course of the next year into 2014 the patient was admitted three more times for P. aeruginosa bacteremia (confirmed by cultures) which always began with subjective fevers and increased purulent drainage from his mediastinal fistula. CT imaging during the patient’s admission in October of 2013 showed increased perigraft fluid near the aortic root with surrounding phlegmonous changes in continuation with the mediastinal fistula tract (B). This poorly organized phlegmonous collection was thought to be the source of the mediastinal fistula discharge. However, the collection never became organized enough on subsequent CT scans to attempt drainage. During these admissions, his P. aeruginosa sample showed intermediate resistance to ciprofloxacin; therefore, the patient was treated with several week courses of intravenous ceftazidime that successfully suppressed the infection. Between each admission, attempts were made to restart oral ciprofloxacin after discussions with the infectious disease physician, but the patient eventually became septic after each attempt, necessitating intravenous ceftazidime treatment. The patient stayed abroad for over a year after his last hospital admission in May of 2014 where the patient continued to receive intravenous ceftazidime treatment. The patient presented to our clinic in late 2015 complaining of increased serosanguinous drainage from his mediastinal fistula. While the fistula had intermittently expressed mild serosanguinous drainage, the patient grew troubled because the fluid appeared to have become bloodier in nature. Based on this history, we became concerned that the perigraft, phlegmonous collection could be eroding into the aorta itself. The patient was not a candidate for elective surgical management and the patient, himself, wished to explore options other than indefinite antibacterial treatment. It was deemed at this time that the patient would make an ideal candidate for exploration of phage therapy with phage OMKO1. |
A 37-year-old male patient was admitted to the department of rehabilitation medicine at our hospital with a major complaint for severe abdominal pains. He was affected by flaccid paraplegia in July 2011 due to a SCI at the T10 level in a traffic accident which led to compression fracture of vertebral body T10 with dislocation. After a long hospitalization in the intensive care unit, he developed a stage IV sacral pressure ulcer (length 10 cm, width 10 cm, depth 5 cm) which was steadily worsened due to fecal incontinences despite the intensive dressings three times a day. Plastic surgeons, therefore, recommended a colostomy to provide a clean environment for healing the pressure ulcer. He also suffered from intermittent abdominal pain 1 month after the injury. The pain was mainly localized in the periumbilical area and did not appear in a radiating pattern. The initial pain scale was 60 mm on visual analog scale (VAS). Physical examination demonstrated no tenderness or distension to palpation of the abdomen. Peripheral blood tests showed elevated erythrocyte sedimentation rates with 69 mm/hr and C-reactive protein was elevated to 3.77 mg/dL. His past medical history included antibiotics therapy for acute cholecystitis a month ago. Computerized tomography (CT) on abdomen showed mild nonspecific gallbladder wall thickening (). Chronic cholecystitis was diagnosed and the patient was referred to the general surgery department for a colostomy and cholecystectomy. Laparoscopic cholecystectomy and sigmoid colon loop colostomy were performed on November 2011, but the abdominal pain around umbilicus persisted and became even more severe. The pain intensity scored 80 mm on VAS. The pain was not associated with food intakes or defecations. No other possible causes of visceral pain such as constipation, paralytic ileus or abdominal distension were identified. Laboratory findings on the peripheral blood tests were nonspecific and follow-up CT images of abdomen showed no abnormalities. The pain was not aggravated by positions, activities, movement and not associated with somatic tenderness, thus, we can rule out the possibility of musculoskeletal origin, such as mechanical instability, muscle spasm, overused syndromes. A magnetic resonance imaging scan of the thoracolumbar spine revealed no evidence for compression of the nerve root in the foramen by bone or disc that are correlated with the location of the pain. The nature of pain was either burning, pricking, electric shock-like, painful cold, tingling or an itching pain, which would fit the diagnostic criteria for neuropathic pain based on the Douleur Neuropathique 4 (DN4) questionnaire [] and had a correlation with the dermatomal pattern within the level of injury. Thus, we concluded the pain as neuropathic at 5 months after the injury and exercised a medication according to guidelines []. We administrated amitriptyline 10 mg twice a day, pregabalin 150 mg four times a day, and oxycodone 5 mg twice a day, after which the pain slightly subsided from 80 to 65 mm on VAS. However, he still suffered from insomnia and could not tolerate rehabilitation programs. He was then referred to the department of anesthesiology for intrathecal injections, with 12 mL of 0.4% lidocaine and 3 mL of 10 mg/mL triamcinolone. The pain level was reduced from 80 to 40 mm on VAS. The effect was not long-term and intrathecal lidocaine injection was scheduled more frequently, once a week for 3 consecutive weeks, keeping the oral medications. A repeated injection resulted in a remarkable decrease in pain level up to 30 mm on VAS for at least 2 months. |
A 34 year-old female, gravida 1 para 0, at 35 weeks was admitted to the hospital in preterm labor. She had been followed throughout her pregnancy by a perinatologist with concerns of preterm delivery secondary to a prominent septate uterus ().\nShe was started on penicillin for GBS prophylaxis. During the second stage of labor she had nonreassuring fetal heart tones. The 5-pound-0-ounce infant was delivered by outlet forceps-assisted vaginal delivery with apgars of 4 at 1 minute and 7 at 5 minutes. A second degree midline perineal laceration was repaired in standard fashion. This was done after 10 minutes of waiting on placenta delivery and to prevent any excess bleeding from the laceration site.\nAfter forty minutes of cord traction, uterine massage, IV pitocin (20 units in 500 mL normal saline at 125 mL/hr), and attempted manual extraction with IV stadol 2 mg for pain, we were unable to deliver the placenta. She was taken to the operating room for manual extraction after spinal anesthesia was placed. Multiple attempts were made at manual removal under direct ultrasound visualization. We were unable to reach the placenta as the septum and the contraction of the lower uterine segment blocked our ability to reach it at its fundal location in the right horn. A sharp uterine currettage was performed, again without success, as the curette barely reached the edge of the placenta. It was clear at this point that the placenta was trapped and not accessible for delivery without general anesthesia.\nConsent was obtained after discussion with the patient and her husband to proceed with general anesthesia and one last attempt for manual removal and possible curettage; however, if unsuccessful, we would proceed with a laparotomy and hysterotomy with possible hysterectomy if there was evidence of myometrial invasion of the placenta. We understood their desire for uterine preservation for future fertility. After general anesthesia was obtained, there was appropriate uterine relaxation but we were unable to remove the placenta via manual attempt and currettage. The placenta remained trapped in the right uterine horn, and the septum continued to block appropriate access. A low transverse uterine incision was then made and we were still unable to reach the placenta that was trapped in the right uterine horn. Thus, a reversed “J-” shaped uterine incision was extended up to the fundus on the right side. The placenta was then identified and manually removed. The placenta was removed entirely intact, and there was no evidence of abnormal invasive placentation. The uterus was closed in a three-layer closure. The estimated blood loss was 1,000 mL. Her preoperative hemoglobin was 13.6 and postoperative day 1 hemoglobin was 9.8. She did not require blood product transfusion. The remainder of her postpartum course was unremarkable, and she was discharged home in stable condition on postoperative day 4. Upon discharge, she was appropriately counseled on the need for a repeat cesarean delivery given her uterine incision. We also recommended her to have an outpatient consultation by a reproductive infertility specialist regarding a metroplasty to decrease her risk of preterm delivery and recurrent retained placenta in future pregnancies. |
A 65-year-old male patient reported with the chief complaint of difficulty in chewing due to missing teeth in upper and lower arches and impaired speech due to partial resection of the tongue along the left lateral border following the surgery. The patient had been diagnosed with squamous cell carcinoma involving the left lateral border of the tongue 2 years back.\nThe patient had type II diabetes since last 20 years and was under medication. General examination indicated there was collapse of lip and cheek on the left side of the face, due to lack of support of the musculature.\nIntraorally, completely edentulous well-formed maxillary and severely resorbed mandibular residual alveolar ridges were intact []. The lingual sulcus was almost completely lost on the resected side. The floor of the mouth was also compromised with musculature partially covering the mandibular residual alveolar ridge on the left posterior region.\nThe tongue was compromised with resected left lateral border, flaccid, with altered posture, and restricted movements. The patient had a complaint of excessive pooling and drooling of saliva from the left corner of the mouth.\nThe patient wore an old denture, fabricated 1.5 years back. The tissue surface of the denture showed signs of frequent chair side relining and use of denture adhesive. The prosthesis lacked the required stability, retention, and esthetics. There was a loss in the vertical dimension, accentuated by collapsed bite [].\nThe treatment plan included maxillary and mandibular complete dentures, using a special impression technique for mandibular arch and modified occlusal scheme.\nThe patient was instructed to discontinue the use of old dentures and report back after 3 days. A modified impression technique was used for the mandibular arch. The mandibular metal stock tray was beaded using impression compound and was extended properly for recording the residual alveolar ridge and associated tissues, and then tray was loaded with an admix of impression compound and tracing compound in ratio of 3:7 []. The casts were poured with type III dental stone (Kaldent, Kalabhai). Custom tray was fabricated using self-cure resin. Peripheral tracing was done, and the secondary impression was made using zinc oxide eugenol impression paste.\nThe master cast was poured with type IV die stone. Jaw relation was recorded, decreasing the vertical dimension of occlusion slightly by reducing the height of the occlusal plane on the mandibular denture, to allow the residual tongue to more conveniently place the food bolus on the occlusal table.[] Posterior teeth with reduced buccolingual width and reduced cuspal angle (semi-anatomic) were selected. These would aid in providing the stability to the mandibular denture as well as reduce the stress transmitted on to the underlying ridge, hence slow down the further resorption of the bone. The teeth arrangement was done with the anterior teeth arranged closed to prevent the escape of air between them and posterior in lingualized occlusion. Try-in was done to verify the retention, stability, and esthetics of the prosthesis, the denture was cured, finished, and polished [].\nThe maxillary denture was modified after acrylization by palatal augmentation. Functional palatal impression technique was followed, whereby modeling compound was softened and added to the palatal aspect of the denture on the left side. The patient was instructed to functionally manipulate the modeling compound with the tongue by repeating the lingual alveolar sounds /k/and/g/for the posterior palatal tracing, and the lingual alveolar sounds/t/and/d/for the anterior palatal tracing.[] This enabled the tongue to make palatal articulations. Additional compound was added to the anterior palatal region, allowing the mandibular anterior teeth to indent into the compound. This resulted in a significant improvement for the fricative and affricative (hard) palatal lingual sounds /s/,/sh/,/z/,/zh/ []. For tracing the swallowing patterns, patient was asked to swallow blenderized, soft diet. A proper balance was made between speech and swallowing tracings, making sure that none of them is restricted.[] The patient was able to communicate and swallow effectively. The entire traced area is processed with heat cure acrylic resin [].\nThe denture was delivered to the patient and follow-up was done after 24 h and 1 week. After 3 weeks, speech therapy and oral exercises were initiated to improve the efficiency of the prosthesis.\nThe average speech session lasted for 30 min, following which patient was asked to repeat the exercises 3 times daily.[]\nIn producing alveolar plosives/t/,/d/, which requires tongue articulation, modified gesture similar to the production of labial plosives/b/,/p/with the lips coming to each other In producing the alveolar fricatives/s/,/z/, the speakers blew the air through closed teeth instead In producing stop consonants, different degree of labial protrusion and retraction was followed.\nThe patient was instructed that all exercises are five repetitions daily, 5 times a day.[]\nOpen the mouth as wide as possible for stimulation of tongue base With a tongue depressor; push nonaffected side of tongue against depressor for the count of three and relax With the help of tongue, attempt to lick alveolar ridge, left to right, then right to left With the help of tongue, attempt to lick lip, left to right, then right to left With the help of tongue, attempt to push nonaffected cheek out and hold for the count of three With teeth together and lips closed, attempt to push tongue forward and hold for count of three For prevention of saliva pooling and drooling, pucker lips and do a strong suck-back and swallow.\nThe patient regularly underwent the speech therapy and oral exercises. After insertion of a denture, follow-up was done after 24 h, 1 week, 1 month, and periodically after every 6 months. The patient expressed satisfaction and gratitude for the rehabilitation efforts. |
A 68-year-old male patient was referred to our department from neurosurgery due to the occurrence of diplopia 10 days after a head surgery that was performed following a pedestrian traffic accident. On the day of the initial trauma, the patient was admitted to the intensive care unit after neurosurgical evaluation, because of a compound comminuted depressed fracture of the right temporal bone. In the initial ophthalmologic examination, there were no ocular symptoms. On day 4 after trauma, an open reduction and internal fixation were performed on the temporal bone fracture by the neurosurgeon. On day 2 after neurosurgery, the patient complained of diplopia and orbital computed tomography (CT) revealed bilateral orbital superior wall fractures. In contrast to the fact that a herniation of the brain parenchyma was unclear on the initial facial CT scan (Fig. a), the fracture fragment and the brain parenchyma were downwardly moved into the orbit, observed on CT scans taken when diplopia occurred (Fig. b). Upon physical examination at the time of admission to the department of oral and maxillofacial surgery, right eye movement limitation and right eye protrusion were observed (Fig. a, c). The surgical plan was to reconstruct the bilateral medial orbital wall using a titanium mesh via coronal approach. For better fitness of the titanium mesh, the mesh was contoured preoperatively on a model of the patient’s skull that included the orbital wall defect. The defect on the model was restored using a plate wax (Fig. ); following pre-operative manipulations, the mesh was sterilized.\nThe reconstruction of the orbital wall was performed 1 month after trauma. A bicoronal approach was attempted in order to easily access the tissue on the right orbital wall. Due to severe tissue adhesion, a craniotomy was performed on the frontal bone to approach the anterior cranial base, even though this is a more invasive approach. Despite utilizing this approach through the anterior cranial base, sufficient tissue dissection was not achieved due to severe adhesion. We thus decided to remove the superior orbital rim in order to secure the operating field, which was successful. Before the osteotomy of the superior orbital rim, a miniplate for fixation of the bony fragment was prepared to reposition the fragment in its original position. After osteotomy, strong adhesions between the brain parenchyma and orbital contents were found (Fig. a). Further forcible dissection of the adherent tissue was expected to cause damage to the meninges and parenchyma, so after a neurosurgery consultation, neurosurgical procedures were performed in order to dissect the adherent tissue, remove the fractured fragment and necrotic brain tissue, and repair the damaged meninges (Fig. b). After the adhered tissue was dissected, the superior orbital wall was reconstructed with a pre-prepared titanium mesh, and the superior orbital rim bone fragment was placed in the original position with a miniplate (Fig. c).\nIn the left superior orbital wall fracture where the tissue adhesion was not severe, tissue dissection was completed without an osteotomy of the superior orbital wall rim. The titanium mesh was placed and fixed through conventional methods. After fixation of the fracture fragment, which had been obtained from the craniotomy site, the surgical site was closed.\nWe could confirm the improvement of the exophthalmos immediately following surgery (Fig. d) as the CT scan taken immediately after the operation showed that the brain parenchyma that had been protruding into the orbit returned to its normal position (Fig. c). Postoperative diplopia and exophthalmos were improved, and the patient was discharged without complications. At 3 months after surgery, further improvements in diplopia and exophthalmos with no limitation of ocular motility were found (Fig. b, d). |
Case 6 was a 59 years old non-smoking woman who presented with a tumour in the right lower lobe, confirmed as an adenocarcinoma with a bronchial biopsy. Pyrosequencing did not show any EGFR mutation (any further analyses were not performed as the patient was planned for surgery). An additional suspicious area in the right upper lobe was detected on a CT scan before surgery, and the patient underwent a lobectomy of the lower lobe and a wedge resection of the upper right lobe. The upper lobe lesion was also an adenocarcinoma. Both tumours were non-mucinous, 4.0 cm (lower lobe) and 1.1 cm in size respectively. They were regarded similar in appearance and the upper lobe tumour was considered an intrapulmonary metastasis (pT4). No lymph node metastases were found and adjuvant chemotherapy was initiated.\nAfter four months additional mutational analysis on the existing material was performed in order to investigate additional lines of treatment as there was radiological suspicion of more extensive tumour growth in the upper lobe than initially suspected. Pyrosequencing showed an EGFR mutation in the previously resected upper lobe tumour, while FISH for ALK gene rearrangements was negative (a later IHC staining for ALK was also negative). It was assumed that the EGFR mutation was also present in the lower lobe tumour, and that the first pyrosequencing analysis on the pre-surgical biopsy had failed to detect it, being a newly introduced method at the time. As the disease progressed, TKI was given for four months but with continued progression with spreading also to the left lower lobe. A core needle biopsy was taken from the latter to investigate if an EGFR resistance mutation had developed, but unexpectedly targeted NGS did not detect any EGFR mutation. See Table for full NGS data.\nIn light of this, the tumours were again reviewed. The tumour in the right lower lobe had 75% micropapillary, 15% acinary, 5% papillary and 5% lepidic growth pattern and had a <5% mucinous component. The tumour in the right upper lobe had 100% acinary growth (<5% solid). Both were positive for TTF-1 and napsin A. The adenocarcinoma in the left lower lobe had predominant acinary but also micropapillary and lepidic growth on biopsy. See Fig. .\nTargeted NGS did not detect any mutations in the tumours of the right lower lobe or the left lower lobe, while the right upper lobe tumour exhibited the previously known EGFR mutation and a TP53 mutation. Based on the morphology and genetic profiles, it was concluded that the right upper and lower lobe tumours were synchronous adenocarcinomas and the left lower lobe tumour a contralateral metastasis from the EGFR negative right lower lobe tumour (explaining the lack of effect of TKI treatment). The patient was again put back on chemotherapy. However, after two months, the oncologist asked for PD-L1 analysis and noted that ALK analysis was missing from both the right lower lobe tumour and its left lower lobe metastasis. IHC staining for ALK proved to be positive in both tumours – see Fig. – why treatment with a TKI for ALK was started. |
A 68-year-old male patient was referred to our department from neurosurgery due to the occurrence of diplopia 10 days after a head surgery that was performed following a pedestrian traffic accident. On the day of the initial trauma, the patient was admitted to the intensive care unit after neurosurgical evaluation, because of a compound comminuted depressed fracture of the right temporal bone. In the initial ophthalmologic examination, there were no ocular symptoms. On day 4 after trauma, an open reduction and internal fixation were performed on the temporal bone fracture by the neurosurgeon. On day 2 after neurosurgery, the patient complained of diplopia and orbital computed tomography (CT) revealed bilateral orbital superior wall fractures. In contrast to the fact that a herniation of the brain parenchyma was unclear on the initial facial CT scan (Fig. a), the fracture fragment and the brain parenchyma were downwardly moved into the orbit, observed on CT scans taken when diplopia occurred (Fig. b). Upon physical examination at the time of admission to the department of oral and maxillofacial surgery, right eye movement limitation and right eye protrusion were observed (Fig. a, c). The surgical plan was to reconstruct the bilateral medial orbital wall using a titanium mesh via coronal approach. For better fitness of the titanium mesh, the mesh was contoured preoperatively on a model of the patient’s skull that included the orbital wall defect. The defect on the model was restored using a plate wax (Fig. ); following pre-operative manipulations, the mesh was sterilized.\nThe reconstruction of the orbital wall was performed 1 month after trauma. A bicoronal approach was attempted in order to easily access the tissue on the right orbital wall. Due to severe tissue adhesion, a craniotomy was performed on the frontal bone to approach the anterior cranial base, even though this is a more invasive approach. Despite utilizing this approach through the anterior cranial base, sufficient tissue dissection was not achieved due to severe adhesion. We thus decided to remove the superior orbital rim in order to secure the operating field, which was successful. Before the osteotomy of the superior orbital rim, a miniplate for fixation of the bony fragment was prepared to reposition the fragment in its original position. After osteotomy, strong adhesions between the brain parenchyma and orbital contents were found (Fig. a). Further forcible dissection of the adherent tissue was expected to cause damage to the meninges and parenchyma, so after a neurosurgery consultation, neurosurgical procedures were performed in order to dissect the adherent tissue, remove the fractured fragment and necrotic brain tissue, and repair the damaged meninges (Fig. b). After the adhered tissue was dissected, the superior orbital wall was reconstructed with a pre-prepared titanium mesh, and the superior orbital rim bone fragment was placed in the original position with a miniplate (Fig. c).\nIn the left superior orbital wall fracture where the tissue adhesion was not severe, tissue dissection was completed without an osteotomy of the superior orbital wall rim. The titanium mesh was placed and fixed through conventional methods. After fixation of the fracture fragment, which had been obtained from the craniotomy site, the surgical site was closed.\nWe could confirm the improvement of the exophthalmos immediately following surgery (Fig. d) as the CT scan taken immediately after the operation showed that the brain parenchyma that had been protruding into the orbit returned to its normal position (Fig. c). Postoperative diplopia and exophthalmos were improved, and the patient was discharged without complications. At 3 months after surgery, further improvements in diplopia and exophthalmos with no limitation of ocular motility were found (Fig. b, d). |
A 50-year-old woman attended the surgical outpatient clinic with a foreign body in the anterior abdominal wall. She was referred by the physician who had initially admitted her to the medical ward with deliberate self-poisoning in 2005. She denied ingesting foreign body apart from her usual medications. Her past medical history includes deliberate self-harm, taking overdose of medications, bulimia nervosa, anxiety and alcohol excess. She has no past surgical history of note apart from tonsillectomy.\nOn further questioning, she denied ingesting or inserting any foreign object into her abdomen. She alleged that she was raped anally once prior to 2005 but denied that the assailant had inserted any foreign object into her anal canal. She also denied swallowing any foreign object in the past. She has no pain or other symptoms referable to this object. On examination, there was no scar visible in the abdominal wall. A foreign body is easily palpable in the right upper quadrant of the abdominal wall.\nA plain abdominal X-ray confirmed the presence of a diamond shaped foreign body in the right upper quadrant of the abdomen (). Computed tomography (CT) scan of the abdomen was performed to assess the foreign object. The CT showed a radio-dense foreign body measuring 65 × 14 × 4 mm deep to subcutaneous fat of anterior abdominal wall on the right side, lying just outside rectus abdominis. The CT also confirmed no component of foreign body is seen to enter the peritoneum.\nShe was asymptomatic in relation to this foreign body. She was then follow-up in the surgical outpatient clinic for consideration of removal of the foreign body if it causes any symptoms. However, she failed to attend the surgical outpatient on several occasions. She was referred back to the surgical outpatient clinic 2 years later by her general practitioner as the foreign body is causing her discomfort.\nAn ultrasonography was arranged to further evaluate the foreign body. The ultrasonography confirmed the presence of foreign body as described in the previous CT scan, which lies in the subcutaneous tissue in the right hypochondrium, approximately 2.5 cm below the skin surface. She was keen to have this removed.\nShe was admitted electively and taken to theatre for removal of the foreign body under general anaesthesia. The foreign body was found underneath the subcutaneous tissue of the abdominal wall. This foreign body turned out to be an arrow shaped glass (). Patient made an uneventful recovery and was discharged home with no further follow-up. |
A 34-year-old male patient who was previously healthy suffered 20% total body surface area mechanical burns and crush injuries to his bilateral upper extremities and right lower extremity, after being caught in a cucumber stripping machine. He was initially treated for his traumatic injuries at the regional trauma center and was noted to have rhabdomyolysis associated with traumatic muscle injury. The patient was fluid resuscitated, ruled out for any additional traumatic injuries and subsequently transferred to a burn center for care of his thermal injuries.\nWorthy of note is that on examination the patient was unable to extend his left hand and fingers. In addition, he was found to have necrosis and cellulitis involving the burned areas of his left upper extremity, which appeared to be rapidly progressing. He was therefore taken to the operating room for debridement of the wound (). At that time, both upper extremity wounds as well as the wound to his right lower extremity were excised of devitalized tissue. The necrotic area was excised down to the fascia, and necrotic muscle tissue was removed wherever possible.\nPostoperatively the patient's myoglobin and creatinine kinase normalized with intravenous hydration. He was started on empiric antibiotic therapy, and his intraoperative wound cultures eventually grew several pansensitive organisms including Pseudomonas aeruginosa, Aeromonas hydrophila, Enterococcus faecalis, Enterobacter cloacae, and Proteus vulgaris, all of which were amenable to treatment with oral gatifloxacin, for which he was eventually switched too.\nThe patient returned to the operating room three days after admission for possible further debridement of the wounds as well as exploration of his left radial nerve, at which time additional necrotic areas were noted in the left forearm wound extending proximally. These areas were excised completely, taking care to preserve the neurovascular structures.\nThe left arm wound was extended proximally to expose the length of the biceps and posteriorly to include the elbow. Similarly, on the right arm, the wound was extended and excised. After all necrotic tissue was debrided, each of his wounds was covered with allograft (donor skin) meshed to a ratio of 2 : 1 and dressed. The left hand was then splinted in neutral position. The left elbow was also splinted. On hospital day five, these dressings were removed revealing healthy adherent allograft to the previous wounded areas. Given the patent's left upper extremity palsy, he was referred for electrodiagnostic testing to evaluate for the presence of a radial neuropathy. He was found to have an absent left radial nerve sensory response. This exam was unable, however, to elucidate the etiology of the conduction loss, but given the manner in which this injury was sustained and his presentation with rhabdomyolysis and necrotic muscle, it is likely that the patient had sustained a crush injury in addition to his burns.\nOn hospital day twelve, the patient was discharged with plans to return to the operating room for exploration of the left upper extremity in order to assess nerve damage as well as to place autografts on previously allografted areas.\nHe was readmitted approximately four days after discharge for this planed exploration and autografting. The left forearm and radial nerve were explored at this time revealing no evidence of direct injury to the nerve (). The left forearm was initially explored between the brachioradialis and the extensor carpi radialis longus, where the superficial radial nerve was emerging between the brachioradialis and the extensor carpi radialis longus. The muscles were split to see the superficial radial nerve overlying the supinator and the posterior interosseous nerve extending beneath the supinator itself.\nThe recurrent radial artery and its accompanying veins were divided. The posterior interosseous nerve was then traced in its course and was found to be crushed with abundant scar tissue around it. The scar was carefully divided, and the nerve was followed until it appeared healthy and branched into the extensor muscles of the forearm and thumb.\nDuring the course of his outpatient followup, the patient's left antecubital fossa demonstrated a well granulating wound; however, a contracture over this area limited the range of motion about his elbow to 25 degrees short of full extension. He was then readmitted for release of the burn scar contracture to his left elbow. The left elbow contracture was released via a horizontal incision across the antecubital fossa until the range of motion about the elbow was limited to only approximately two degrees short of full extension. Approximately 200 sq cm of 1 : 1 meshed split thickness skin harvested from his left thigh was placed over the left antecubital fossa wound and anchored into place with skin staples.\nThe patient's postoperative course was uneventful. He will be followed in our clinic on a routine basis for further evaluation of his autografts and left radial nerve palsy. Although the prognosis following posterior interosseous nerve decompression is reported to be unpredictable, we are hopeful that this patient's function will improve. At last report, the patient has had some improvement in function of his left upper extremity. |
A healthy 35-year-old woman with a history of 2 elective cesarean sections and one miscarriage (G4 P2 A1) was accepted as a referred case to our hospital. The patient was admitted for the elective cesarean section at 37 weeks of gestation. She was referred from the rural primary care hospital where routine ultrasonography revealed low-lying placentation. A Doppler ultrasound at 35 weeks showed complete covering of the cervical os which was attached to the scar with incessant hemorrhagic lesions in the inner anterior myometrium, indicative signs of PA (Figure ). She had diagnosed placentation in the lower uterine segment and had given a history of irregular, painless bleeding of the vagina during the fifth and seventh months of gestation. Further, magnetic resonance imaging (MRI) was performed, images still revealed that the placenta was completely covering the cervical os and suspected implantation of placental villi penetrating the full thickness of the myometrium, which further extending posteriorly up to the bladder wall and anteriorly displayed vascular engorgement (Figure ). On the day of surgery, an expert urologic surgeon had been involved along with the interventional cardiology team. During the cesarean, the uterus was opened along the midline in upper segment of uterus, and a baby of the 3 kg was delivered with a good Apgar score. Due to invasive placentation and bleeding, cesarean hysterectomy was proceeded immediately after the birth of the baby. The lower uterine segment was noted to be relatively thin but was covered by a plexus of deep vessels which spread over the bladder near the broad ligament which was covered by peritoneum. The bladder was opened and repaired due to continuous bleeding as the placenta extended to the bladder. Left-sided salpingo-oophorectomy was also performed due to constant bleeding from the left tubo-ovarian ligament. The estimated blood loss was approximately 3500 mL during the procedure. Afterward, three units of whole blood were transfused, and two hemaccel infusions were given. The patient was kept on inotropic support in postoperative ICU for 24 hours. Later, the patient was moved to the surgical ward and discharged from the hospital on the 5th postoperative day. Foley's catheter was retained for 2 weeks, and a smooth postpartum recovery was observed. |
A 22-year-old man presented to us with raised intracranial pressure type of headache with obscuration of vision for about 6 months in duration. The patient complained of gradual loss of vision in the left eye since 3 months prior to presentation. Also, over the last month he has had severe gait ataxia and hence was unable to walk without support. His examination revealed florid papilledema in the right eye with concentric field cuts and in the left eye secondary optic atrophy with no perception of light.\nMRI of the brain revealed a large contrast enhancing heterogeneous lesion that was hypo intense on T1 weighted image and hyperintense on T2 weighted image with areas of necrosis and calcification. The lesion was expanding the fourth ventricle causing obstructive hydrocephalus. It was found extending inferiorly through the foramen magnum into the upper cervical canal till C2 vertebra level displacing the medulla and cervical spinal cord anteriorly and to the right side [].\nThe patient underwent a midline sub-occipital craniotomy, with removal of posterior arch of C1. The lesion was found arising from the trunk of the left spinal accessory nerve at the level of the foramen magnum []. The tumor was variable in consistency, mostly firm and vascular with some areas of cystic degeneration. The lesion was extending from C2 and into the fourth ventricle below the vermis, pushing the upper cervical cord and cervicomedullary junction to the right []. The accessory nerve was thinned out and draped over the lesion and a portion of it was embedded within. The lesion was excised along with the embedded segment of the nerve, preserving the uninvolved portion which was draped over the tumor [].\nThe patient recovered postoperatively with no obvious sternocleidomastoid or trapezius weakness ascribable to the left accessory nerve partial excision at the time of surgery. His post-operative contrast CT scan showed no residual lesion with resolving hydrocephalus []. On last follow up after 5 months no neurological deficit was noted and he was doing well.\nPathology report revealed benign schwannoma with hyper cellular (Antoni Type A pattern) and hypo cellular (Antoni Type B pattern) areas. |
A 16-year-old Japanese girl with no past medical history or previous injuries presented to a nearby clinic complaining of chronic anterior left ankle pain for the past 2 years. She was diagnosed with anterior ankle impingement syndrome by ultrasonographic findings of synovial hyperplasia in the anterior aspect of the ankle joint and referred to our hospital for further treatment. A physical examination revealed tenderness and swelling across the anterior aspect of the left ankle but no local heat or redness of the overlying skin. She played badminton three times a week and complained of increasing pain with sports activities. Careful interviewing revealed that she also had pain at rest which increased with motion in the morning which was strong especially immediately after awakening.\nThe range of motion of the left ankle was normal, and marked pain was observed with forced dorsiflexion. There were no signs of ankle instability. A blood test showed that her white blood cell count, C-reactive protein level, and matrix metalloproteinase-3 level were within normal limits. Rheumatoid factor and anticyclic citrullinated peptide antibody tests were negative. Plain radiographs showed a small exostotic bony bulge on the talar neck which resembled a traction spur and a recess on the talar neck (). Computed tomography (CT) showed an 8 mm radiolucent lesion with marginal sclerosis and central calcification in the talar neck (). Magnetic resonance imaging (MRI) revealed a bone lesion in the talar neck with surrounding bone marrow edema, synovial thickening in front of the bone lesion, and joint effusion ().\nWe initially considered two pathologies as differential diagnoses: one was anterior ankle impingement syndrome considering the bone lesion as a recess, flake, and spur caused by impaction of the distal tibia against the talar neck; and the other was OO in the talar neck considering the bone lesion in CT and MRI as a nidus with secondary synovitis in the ankle joint. Activity modification and daily oral aspirin therapy slightly reduced but did not eliminate her symptoms. An intra-articular steroid injection provided some pain relief; however, the effect lasted only 1 week. Persistent synovitis unresponsive to conservative treatments for several months prompted us to narrow down the differential diagnosis to OO. The patient opted for conservative treatment consisting of oral aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs); however, her symptoms persisted and she finally decided to undergo surgical resection 14 months after the first visit.\nWe performed arthroscopic surgery using anteromedial and anterolateral portals. The patient was placed in the supine position on a radiolucent carbon fiber table with the ankle manually distracted. Arthroscopy revealed capillary hyperemia and synovial hyperplasia in the anterior aspect of the ankle joint (). We performed a thorough synovectomy with a shaver and radiofrequency probe to obtain a clear and larger operative field. The surface of the OO lesion was suspected after exposure because the overlying cortex was irregular and too thin to exhibit evidence of denting under gentle pressure with a probe (). We then used 3D C-arm-based imaging (ARCADIS Orbic 3D, Siemens Medical Solutions, Erlangen, Germany) to verify the lesion's exact location and visualize the exact extent of the nidus without removal of large part of cortex () and used grasping forceps and curettes to remove it. The entire shell of the lesion could not be visualized arthroscopically after thorough resection; therefore, we checked the lesion with another 3D scan. Unexpectedly, a remnant lesion was confirmed in a dead angle of the arthroscope. We resected the residual nidus and marginal sclerotic bone using curettes and a radiofrequency probe. A final 3D scan was performed to confirm that the nidus was completely removed (). The cavity of the excised tumor was left empty without any augmentation. The excised nidus and obtained synovium were sent separately for histopathological examination. The histopathology of the synovium was consistent with inflammatory synovitis, while the excised nidus showed randomly interconnecting trabeculae of the osteoid in a fibrovascular stroma rimmed by osteoblasts which was consistent with OO.\nPostoperatively, the patient reported immediate relief of her ankle pain. She was followed up for 12 months without lesion recurrence. Symptoms of anterior ankle impingement disappeared with no functional disability at the latest follow-up. |
A 40 year-old male patient was treated in the emergency room for a large perineal abscess. Examination revealed that he had an approximately 9 × 9 cm2 tense, tender, fluctuating swelling with the features of acute inflammation in the perineum. The X-ray of the pelvic region showed a large stone in the bulbar urethra []. He underwent incision and drainage of the abscess and removal of the stone (8 × 5 cm2) in the emergency room []. He was postoperatively managed with daily dressing, and antibiotics were continued according to the results of cultures and sensitivity. He was discharged with the catheter in situ after 15 days but in the three months' follow-up visit, he complained of discharge of urine from the perineum. Local examination showed that there was an about 0.5 × 0.5 cm2 sized opening in the perineal region at the level of the bulbar urethra with continuous dribbling of urine. Urine examination showed 8–10 pus cells and growth of Pseudomonas and E. coli sensitive to Amikacin and Ceftriaxone was noted upon culture. He was treated with the above antibiotics until the urine culture became sterile. A fistulogram was taken to examine the fistulous tract, which was seen to be continuous with the bulbar urethra []. Surgical exploration and repair of the fistula were planned. There was healthy and adequate redundant bulbar urethra after excision of the fistulous tract. In contrast to the stricture cases, there was redundant urethral flap secondary to the presence of a large urethral stone in our case. We decided to use the technique of double breasting to repair and reinforce the urethra by utilizing this redundant urethral flap as it would provide an adequate urethral lumen and lax suture line after stripping the urethral mucosa of the redundant flap []. This was further reinforced with reimposition of corpus spongiosa. The wound was closed in layers and healed well. Sutures were removed on the 10th day and the urethral catheter was removed on the 18th day []. The patient was seen to have good force and stream of urine without any leakage. Further investigations to rule out stricture of the urethra did not reveal any abnormalities. The patient is on regular follow-up and doing well three months after surgery. |
A 28-year-old man was brought to our emergency department with severe right hip pain with deformity following a high-velocity motor vehicle accident due to the collision of his car with a truck. He was conscious with Glasgow Coma Scale 15 with stable vital parameters. After an initial assessment of the patient, according to the Advanced Trauma Life Support protocol, a secondary survey revealed his right hip in an abducted and externally rotated position with shortening of the right lower limb. On further examination, the femoral head was palpable in the ipsilateral inguinal region. There was no external bleeding wound and no associated distal neurovascular deficit.\nThe routine imaging investigations and examination ruled out any head, cervical, thoracic or abdominal injury. Plain radiograph of the pelvis with both hips revealed a pubic-type anterior dislocation of the right hip with ipsilateral greater trochanter fracture. A computed tomography (CT) scan of right hip was also ordered to look for any associated acetabular fracture, intra-articular fragment, occult femur neck or intertrochanteric fracture; it ruled out any associated injury and confirmed anterior hip dislocation with ipsilateral greater trochanter fracture (Figure ).\nWe performed a closed reduction of the dislocation under sedation within two hours of the accident in the emergency department. The patient was positioned supine and the reduction involved the collective effort of four persons; the pelvis was stabilized by one resident, another person pushed the femoral head into the acetabulum by direct palm pressure while the other two gave continuous axial traction in the extended position followed by flexion and internal rotation. A snap sound suggesting relocation of the femoral head followed this reduction maneuver. The post-reduction plain radiograph of the pelvis showed a congruent reduction of the hip joint along with a displaced fracture of the greater trochanter. Subsequently, open reduction and internal fixation were planned for the fracture in the elective theatre the next day. Under C-arm guidance in the left lateral position, the fracture was reduced and two 6.5 mm partially threaded cannulated cancellous screws were inserted through a mini-incision under spinal anaesthesia (Figure ).\nThe postoperative period was unremarkable and the patient was kept non-weight bearing on the affected limb for two weeks followed by partial-weight bearing over the next two weeks. The patient was allowed full-weight bearing after one month. At the last follow-up of one year, the patient was asymptomatic with a full range of active and passive right hip joint motion. There was no evidence of hip osteoarthritis or osteonecrosis of the femoral head. |
An 83-year-old male patient came to the Department of Hand and Reconstructive Surgery of the People's Hospital (Zhejiang Province, China) complaining of mild pain and swelling, and upon inspection a mass was found in his left upper abdomen. This mass had been slowly increasing in size for 2 years. Two years ago, the patient had undergone an operation to remove an abdominal soft tissue fibrosarcoma. The local general surgeon had used a mesh to repair the peritoneal defect and to close the abdominal wall directly. Unfortunately, the incision did not heal due to infection, and the mesh was soon taken out by operation. The incision resulted in a draining wound, and bacterial cultures eventually showed that the wound had a methicillin-resistant Staphylococcus aureus infection. The patient repeatedly came to the clinic to have his bandage replaced, but the masses in his abdomen gradually increased in size. The patient was referred to the Hand Department, and while laboratory tests were normal, further examination by computed tomography imaging revealed that the tumor had recurred, and that the patient also had a hernia in the upper abdomen along with the infected wound. Considering the patient's condition, the main purpose of the operation was to resect the tumor and treat the hernia. The surgical procedure was designed to resect the recurrent tumor using a left upper abdomen approach under general anesthesia, but a very large (15 × 8 cm) abdominal wall defect was found on peritoneum, which could not be directly sutured (Fig. ). In this case there was no obvious skin defect. Because of this defect, a right upper abdominal lateral approach for the operation was planned. The operation was planned to include a vascularized partial 9 to 10 ribs-pleural transfer (without a thoracic umbilical flap) by the vessel pedicle of the deep inferior epigastric artery (DIEA). The vascularized partial 9 to 10 ribs-pleural transfer material was first harvested so that it was connected only by the artery pedicle (Fig. ).\nThe vascularized partial 9 to 10 ribs-pleural transfer was translocated to the left abdominal wall defect site via subcutaneous tunnel. The composite tissue was used to fill in the abdominal wall defect (Fig. ). First, we sutured the broken peritoneum to the pleura, and then sutured the intercostal muscles to the abdominal muscles. Next, we closed the skin and the abdominal wall defect. Examinations after the surgery revealed that the right lung was not harmed. The right rib donor was wired closed using 1 mm steel wire, and the muscles, subcutaneous tissue, and skin were all sutured directly.\nThree days after the surgery, the patient's basal temperature returned to normal and he began to eat a full liquid diet. Six days after the surgery, we pulled out a subcutaneous drainage tube and the patient was able to eat half liquid diet. The patient had been given an infusion of Claforan for 1 week (4 g every 12 h; North China Pharmaceutical Co. Ltd, China). Ten days after the surgery, we removed the abdominal cavity drainage tube and the patient had recovered to the point where he could eat a normal diet. Two weeks after the surgery the incision healed, sutures were removed, and the patient was discharged. One year after the surgery, no masses in his abdomen were evident, and magnetic resonance imaging scans revealed no evidence of tumor recurrence. The patient also reported no abdominal pain or swelling symptoms. The patients’ diet and breathing were normal and the patient was then able to be able to resume his daily activities. Nevertheless, we continued to observe and follow up with the patient (Fig. ).\nThese study protocols were approved by the medical ethics committee of the Zhejiang Provincial People's Hospital. Written informed consent for publication of clinical details and images was obtained from the patient. A copy of the consent form is available for review upon request. |
A 22-year-old woman had a crush injury (MESS 9) to the right hand with a press machine. There was a complete loss of the index and long fingers. The small and ring fingers had a mangling injury with metacarpal and proximal phalangeal. These digits had a loss of vascularity as well.\nShe also had volar and dorsal skin defects and loss of the palmar arch. After skeletal stabilization with K-wires, a vein graft was harvested from the dorsum of the right foot. One end was anastomosed to the ulnar artery while the other end was ligated. The proper digital artery to the small finger and second and third common digital arteries were anastomosed end to side with the graft. There was extensive soft tissue loss on the dorsum of the hand and the ring finger and soft tissue loss on the palmar aspect of the hand. Similar to the first case, in order to ensure revascularization of fingers and stabilization of the trauma zone, we used Integra® as a temporary cover.\nAn increase in defect size due to marginal necrosis was noticed in this case as well. On the fifth postoperative day, after removing the silicon layer of the Integra®, a groin flap was done to cover the dorsum of the hand and a split-thickness skin graft was placed over the dorsum of the ring finger and the hypothenar area.\nAt follow-up after two weeks, there was a loss of skin graft due to infection, but the groin flap and finger vascularity remained unaffected. She was taken for surgery again at three weeks and the groin flap was divided, the defect on the palm was skin grafted again and the dorsum of the ring finger which had a skin graft loss was covered with a transposition flap elevated from the divided groin flap.\nExpected outcome\nBoth of our patients’ hands survived, and their vein grafts and the anastomotic sites remained patent until we were able to achieve definitive flap coverage. This temporizing measure provided adequate time for any ischemic region to demarcate itself and digit revascularization to be confirmed. It also allowed patients to be stabilized and adequately counseled about their injury and treatment options.\nThe skin graft loss in our second case could be due to a combination of infection and premature application over Integra®, without adequate time for integration. However, the vein graft under the collagen layer remained patent and allowed for skin grafting later. We were able to graft it again at three weeks during groin flap division. |
A 26-year-old female reported to the Department of Oral and Maxillofacial surgery, Postgraduate Institute of Dental Sciences, Rohtak, Haryana with a chief complaint of pain on left side of posterior jaw region with a history of extraction of left mandibular third molar about 2 years back by some practitioner. On clinical examination, there was tender on percussion in the second molar. OPG revealed the vertically impacted Class III position C left mandibular third molar []. Cone-beam computerized tomography was further advised to elaborate the exact location and position of the tooth which further revealed fractured lingual plate and displacement of crown part of the third molar at the level of apex of roots of the second molar and apex of roots of the third molar almost at the level of lower border of angle of mandible []. On the basis of history provided by patient and radiographic investigations, it was anticipated that the operating practitioner had accidentally pushed the tooth into the lingual pouch and the even patient was not explained of the actual situation. So when the patient reported with pain after 2 years of the incidence, she was planned for intra-oral extraction and retrieval of the tooth from the lingual pouch under local anesthesia, as she refused of any extra oral procedure.\nAfter explaining the patient about the perioperative complications related with retrieval via intraoral surgical approach, intra-oral Vazirani-Akinosi nerve block was given with 2% lignocaine along with the local infiltration in the surrounding tissues. Modified ward's incision was planned for exposure of surgical site.[] Moreover, subperiosteal flap was reflected carefully to prevent damage to the lingual nerve. Envelope flap was raised with utmost care on the lingual side from the second premolar to anterior border of ramus region, protecting the lingual nerve from damage by careful retraction of lingual soft tissue. Overlying bone was removed using round bur to expose the displaced crown portion of the mandibular third molar on the left side of the mandible. After removing the overlying bone in third molar region adjacent to second molar, the crown of dislodged tooth was observed below the mylohyoid muscle. Fibers of mylohyoid muscles were stripped off with very care to prevent further displacement into spaces. Crown part of the third molar was exposed with the help of Howarth elevator and with extreme care of not displacing into further spaces. The tooth was luxated and was taken out with the help of the help of long artery forcep. After observation and irrigating the surgical site, silk suturing was done for the closure of the surgical site and the patient was discharged after 1 h. The patient was advised oral antibiotics for 1 week. Follow-up after 1 week revealed lingual nerve paraesthesia. The postoperative course was uneventful and the symptoms of lingual paraesthesia completely resolved after 3 months follow-up. |
A 30-year-old male, working as a tailor in an export company, presented to us with complaints of stiffness in lower back region for one and a half months duration followed by stiffness of limbs and slurring of speech for 1 month duration. The patient was apparently normal 2 months back, when he developed fever which was intermittent, high grade, and associated with chills and rigors. He had generalized myalgia. There was no history of headache or vomiting. Though he became afebrile after 5 days, he continued to have myalgia and general malaise. In addition he developed pain over the lower back region, which increased in intensity on exertion. He went back to his job after 10 days but had difficulty carrying out his work due to the low back pain. About 3 weeks later, he noticed stiffness over the lower back region, which restricted his activities. He could not bend down and also had difficulty in turning around. The stiffness gradually spread to involve the entire trunk and neck in the next 15 days. Two weeks later, the patient developed swelling of the face, right upper limb, and right lower limb. He also had diffuse pain and stiffness over the same regions for which he had consulted a local practitioner of alternative medicine. The swelling gradually subsided but the pain and stiffness persisted. Over the next 5 days, the patient developed pain and stiffness of the left upper limb and left lower limb also, but of a lesser intensity.\nThe patient noticed progressive increase in stiffness of neck, trunk, and limbs (Right > Left [R > L]) on walking about 20–30 meters, after which he was unable to take another step. He had to stop for 10 minutes before resuming to walk. He gave history of falling down en bloc backwards (4–5 episodes) when he had tried to walk during the periods of severe stiffness. The stiffness was moderate at rest. He had severe restriction of neck and trunk movements. He had difficulty in using his upper and lower limbs (R > L) for all daily activities due to the severe stiffness. He developed stiffness of hands while mixing food and brushing teeth. He had stiffness of jaw muscles on prolonged chewing. He developed stiffness of facial muscles after speaking for some time causing reduction in voice along with slowness and slurring of speech.\nThe patient's symptoms were initially progressive but had been static later on. He gave no history of precipitation of symptoms by auditory or tactile stimuli. He had no thinning of limbs or muscle twitchings or other involuntary movements of limbs. He had no sensory disturbances or higher function disturbances or cranial nerve involvement or bladder or bowel disturbances. He had no difficulty in releasing finger grip, no aggravation of symptoms by cold, no abnormal posturing of limbs, no lhermitte's symptom, no shooting pain in the limbs, no history of altered color of urine or reduced urine output, no breathing disturbances, no cough with expectoration or chest pain, no head or spinal injuries, and no drug or toxin intake. Past/personal/family history—uneventful |
A 28-year-old man was brought to our emergency department with severe right hip pain with deformity following a high-velocity motor vehicle accident due to the collision of his car with a truck. He was conscious with Glasgow Coma Scale 15 with stable vital parameters. After an initial assessment of the patient, according to the Advanced Trauma Life Support protocol, a secondary survey revealed his right hip in an abducted and externally rotated position with shortening of the right lower limb. On further examination, the femoral head was palpable in the ipsilateral inguinal region. There was no external bleeding wound and no associated distal neurovascular deficit.\nThe routine imaging investigations and examination ruled out any head, cervical, thoracic or abdominal injury. Plain radiograph of the pelvis with both hips revealed a pubic-type anterior dislocation of the right hip with ipsilateral greater trochanter fracture. A computed tomography (CT) scan of right hip was also ordered to look for any associated acetabular fracture, intra-articular fragment, occult femur neck or intertrochanteric fracture; it ruled out any associated injury and confirmed anterior hip dislocation with ipsilateral greater trochanter fracture (Figure ).\nWe performed a closed reduction of the dislocation under sedation within two hours of the accident in the emergency department. The patient was positioned supine and the reduction involved the collective effort of four persons; the pelvis was stabilized by one resident, another person pushed the femoral head into the acetabulum by direct palm pressure while the other two gave continuous axial traction in the extended position followed by flexion and internal rotation. A snap sound suggesting relocation of the femoral head followed this reduction maneuver. The post-reduction plain radiograph of the pelvis showed a congruent reduction of the hip joint along with a displaced fracture of the greater trochanter. Subsequently, open reduction and internal fixation were planned for the fracture in the elective theatre the next day. Under C-arm guidance in the left lateral position, the fracture was reduced and two 6.5 mm partially threaded cannulated cancellous screws were inserted through a mini-incision under spinal anaesthesia (Figure ).\nThe postoperative period was unremarkable and the patient was kept non-weight bearing on the affected limb for two weeks followed by partial-weight bearing over the next two weeks. The patient was allowed full-weight bearing after one month. At the last follow-up of one year, the patient was asymptomatic with a full range of active and passive right hip joint motion. There was no evidence of hip osteoarthritis or osteonecrosis of the femoral head. |
Our case is a 24-year-old primigravida woman. She conceived spontaneously and her due date was confirmed by crown-rump length measurements in the first trimester. At 18 weeks of gestation, there were no signs of a low-lying placenta or placenta previa. At 24 weeks of gestation, she complained of vaginal bleeding and came to the clinic for a consultation. On examination, the patient was found to have slight intermittent bleeding. Transvaginal ultrasonography showed signs of vasa previa, and she was referred to our perinatal center. On ultrasonography, the placenta was seen to be on the anterior wall and there were no signs of placental malposition. The presence of vasa previa as well as velamentous umbilical cord insertion was confirmed by transvaginal ultrasonography, which demonstrated the cord vessels running on the anterior lower uterine segment and covering the internal cervical os (Figure ). The vaginal bleeding ceased on examination, and it was found to be unrelated to the vasa previa. There was no fetal distress detected on fetal heart monitoring. She was hospitalized from 32 weeks and 5 days of gestation. At 33 weeks of gestation, the normal placental position as well as the absence of abnormal placental morphology was confirmed by an MRI scan (Figure ). In addition, MRI confirmed the precise course of the cord vessels running on the anterior lower segment of the uterus (Figure ). We performed a cesarean section at 35 weeks and 1 day of gestation. Because the cord vessels were running on the anterior lower uterine segment, the horizontal incision was made on the uterine fundus to avoid the rupture of the cord vessels. A male baby was delivered, and the neonate had a birth weight of 1836 g (small for gestational age) and Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The placenta showed velamentous cord insertion and the length of the vessels running on the membranes was about 10 cm (Figure ). There were no problems in the postpartum period, and the patient was discharged with her baby 7 days after the cesarean section.\nWe explained the possibility of publishing this study as a case report to the patient, and her consent was obtained. |
A 60-year-old male reported with the chief complaint of swelling in the lower anterior jaw region of 15 days duration. Patient related this finding to an episode of extraction which was carried out 2 days before the development of the lesion. The patient confirmed that the swelling was smaller initially and grew progressively to its present dimension of approximately 3 cm × 4 cm associated with a gnawing pain. There was no history of bleeding or pus discharge and mouth opening was within acceptable limits. History of tobacco use suggested that the patient was pan chewer and bidi smoker for over 20 years, with abstinence from these habits only in the last 1 year. Patient's oral hygiene was poor and the submental lymph nodes were palpable. General examination revealed that the patient was well built and nourished with no reported weight loss in the recent past.\nThe intraoral examination showed an irregular, solitary, sessile growth on the lower anterior alveolar region extending from the mandibular left first premolar region to mandibular right lateral incisor region with the involvement of the lower lingual vestibule []. The swelling was erythematous and tender on palpation with mucosal ulceration and sloughing on its inferoposterior aspect.\nIntraoral periapical radiograph of the lower anterior region revealed an irregular radiolucency in the symphyseal region with root resorption of the associated teeth. The mandibular occlusal radiograph showed slight expansion of the buccal cortical plate. The digital orthopantomogram suggested a diffuse radiolucent area extending from the roots of mandibular right canine to the left premolar region with resorption in relation to mandibular right lateral incisor []. A provisional diagnosis of intraosseous malignancy was made, and the patient was advised biopsy.\nThe tissue submitted for histological examination was pale white to brown in color, rubbery in texture and firm in consistency. Histopathologically, tumor cells arranged in the form of cords and islands were seen in the connective tissue stroma. Under higher magnification, multiple large ductal structures with cribriform growth pattern were seen []. In addition, ductal epithelium exhibited fenestrations resembling Roman bridge architecture []. Distinct necrosis was seen in the center which resembled comedo-like necrosis []. The invasive component was found to be dense with compressed small tumor islands and cords with cystic changes at places. The individual tumor cells were found to contain moderate amount of granular eosinophilic cytoplasm and large pleomorphic nuclei with coarse chromatin and prominent nucleoli []. The tissue was negative for both periodic acid-Schiff (PAS) and mucicarmine staining. Immunohistochemical staining showed luminal cells of ductal component and tumor cells in infiltrative component to be positive for HER-2/neu [] and cytokeratin-7 (CK-7) []. |
A 2 year old male child with a history of recurrent projectile non-bilious vomiting, since 4 weeks after birth, was referred for a barium meal study to rule out pyloric stenosis or gastro-oesophageal reflux disease. The patient experienced persistent hunger and was always underweight. The results of a full blood count test were within normal limits. A barium examination localised the stomach in the right upper quadrant of the abdomen, on the same side as the liver ().\nSubsequent images revealed a distended stomach with indented gastric antrum, narrowed pylorus and delayed emptying suggestive of partial pyloric stenosis ().\nComplementary ultrasound examination localised the spleen (which showed no abnormality) and two other structures with the same appearance as the spleen in the right upper quadrant adjacent to the right kidney (). The suspicion of other abnormalities and congenital transpositions of other organs lead to suggestions for other radiological procedures. Although MRI scan is the standard reference for definitive diagnosis of organ transposition, the procedure was, however, not performed owing to breakdown of the MRI equipment at that time. Hence a CT abdominal scan was undertaken with parental consent.\nThe CT scan confirmed the normal position of the internal viscera of the thorax and the abdomen, except the stomach and the spleen. The CT scan showed a dilated stomach on the right posterior to the liver and partial pyloric stenosis. The pyloric canal appeared elongated, and the whole pylorus was thickened. In addition, the spleen and the other structures with similar appearance as the spleen (suggesting multiple spleens) were found at the right side of the patient adjacent to the right kidney (). A surgical correction of the partial pyloric stenosis further confirmed the anomaly.\nA post-operative MRI scan performed 5 months later confirmed the anomaly as described above (–). The procedure was a free-breathing MRI scan as parental consent was without sedation. It also showed a thickened pyloric wall at the site of the repair and revealed the patient had multiple spleens (3) on the right ( and ). The child has had a normal life since the correction of the partial pyloric stenosis 2 years ago. |
A 25-year-old male was referred from a primary care facility for the management of dentoalveolar fracture involving the left maxillary tuberosity during attempted extraction of maxillary left first molar. He had no known medical problems and no known allergies.\nUpon examination, he presented with facial asymmetry with swelling occurring on his left face. The swelling was diffuse and slightly tender to palpation, involving the entire left buccal region from zygomatic arch to the border of the mandible. There was no limitation of mouth opening and no deviation of the mandible upon opening and closing of the mouth.\nIntraorally, there was a mobile fracture segment seen on his left maxilla involving the left maxillary first, second, third molar and maxillary tuberosity. The segment was extremely mobile and extruded preventing full occlusion of his teeth. The maxillary left second premolar was firm. The maxillary left first molar had a large occlusal caries which extends subgingivally and was reported to be tender to percussion prior to the attempted extraction. There was a small laceration wound on the buccal gingiva adjacent to the upper left first molar measuring about 6 mm (Figure ).\nAs the diagnosis as well as the extent of the dentoalveolar fracture was able to be determined clinically, no radiographical examination was done for this patient.\nAs the patient was a young healthy male, and the maxillary second and third molar that was involved in the maxillary tuberosity fracture was sound, the authors decided on a conservative approach to reduce and stabilize the fractured segment followed by transalveolar extraction of the unrestorable maxillary first molar at a later date. As the patient was seen toward the end of the working day, the fracture was first stabilized using eyelet wiring and an appointment was set for the following day.\nDuring his next appointment, closed reduction and fixation was achieved using upper and lower arch bars with intermaxillary fixation (IMF). At the end of this visit, occlusion was reachieved and the fracture segment was firm. The arch bars and IMF were left in situ for a period of 4 weeks to allow for healing of the fracture. The patient was placed on an antibiotic regimen of amoxicillin and metronidazole for 1 week to prevent infection as the upper left first molar had a large occlusal caries and was reported to be tender to percussion prior to the extraction. He was reviewed weekly to assess healing and to observe for signs of infection.\nDuring the review on the fourth week, the IMF was removed to assess the healing of the fracture and the stability of the occlusion. Some minor mobility of the fracture was noted but was deemed acceptable. The arch bars were kept in-situ for one more week should the need to replace the IMF arise.\nUpon review on the fifth week, the fracture segment was firm and occlusion was stable. There were no signs of active infection. The upper and lower arch bars were removed and a date for surgical removal of the upper left first molar was set for 1 month later (Figure ).\nThe carious upper left first molar was removed via surgical transalveolar approach with no complications. |
A 13-year-old boy presented with a 14-month history of a fixed left elbow with no movement. He had sustained significant trauma to the affected limb 1 month prior to onset of symptoms. He had received treatment in the form of native massage and bandaging with immobilization for 4 weeks. However, he had difficulty moving his left elbow, which resulted in a fixed flexion deformity with no further movement. He had difficulties with daily activities such as clothing himself and tying shoes. However, he managed using the normal limb, as he was right handed.\nA clinical examination revealed bony ankylosis of the left elbow at 40° of flexion. A palpable diffuse irregular bony mass was present in the anterior aspect of the elbow but the margins could not be delineated. No part of the bony mass or any other bony prominence was tender and warm. The arm and the forearm segment appeared to be wasted when compared to those of the other limb. No distal neurovascular compromise or any similar lesion was detected elsewhere in the body.\nStandard anteroposterior and lateral radiographs of the affected elbow revealed an unusually large mass connecting the distal humerus to the ulna (). Radio-opacity of the mass was similar to that of mature bone. Complete hemogram and erythrocyte sedimentation rate values were within normal ranges. Considering the physical demand of the patient and the unusual size of the myositic mass, surgical excision was planned. The procedure was performed under regional anesthesia with the patient in the supine position and the limb abducted at the shoulder. An 8-cm curvilinear incision starting about 3 cm proximal to the elbow crease and extending to the junction of the proximal and mid-third of the forearm was made. Skin, subcutaneous tissue, and deep fascia were incised in line with the skin incision. The neurovascular bundle was identified and retracted. The extent of the abnormal bone was exposed adequately ().\nThe mass was excised completely after detaching it from the humerus and ulna (). The elbow was mobilized intraoperatively, and full range resumed. The excised specimen was sent for histopathological examination and revealed lamellar bone both peripherally and centrally. The child developed neuropraxia of the median nerve postoperatively, which recovered within 2 weeks. Postoperative radiographs showed no trace of the myositic mass (). Elbow range of motion exercises were started by the middle of the first week, as tolerated. Active flexion of 30° to 90° was possible during the initial postoperative period. The patient was reviewed every 2 weeks for the first 2 months and once monthly for up to 6 months to assess functional status.\nThe patient regained full function of the affected elbow and returned to school in 10 weeks. He scored the maximum of 100 on the Mayo Elbow Scoring System, which was attributed to full functional status. The patient had the best possible functional status after 2 years. No signs of clinical or radiographic recurrence were detected (). |
A 53-year-old male patient visited our hospital due to a huge mass in the anterior area of the left lower leg as the chief complaint. Forty four years ago, the patient was bitten by a snake and the area below the left knee joint was tied with a string and maintained for 3 months to prevent the spread of snake venom. The area below the knee joint began necrotized gradually. A mass developed with time while the left lower leg was healing gradually. Over a period of several years, the mass gradually increased in size. No special findings were detected in his past medical history, except for diabetes.\nAt the time of admission, the physical examination revealed a huge mass in the muscle layer along the anterior tibial muscle in the left lower leg that was palpated. However, no redness, no heating sensation or no pyrogenic reaction was detected in the vicinity. There was no tenderness around the mass. The mass was hard and fusiform shaped. The ankle joint was in an almost ankylosed state at 5° of plantar flexion, there was no abnormal sensation below the lower leg, and the blood circulation was good. The complete blood test, blood chemistry, and serum electrolyte level were normal.\nThe radiograph showed well marginated radioopaque density in the parosteal area of the midshaft of the tibia (). The shape of the radioopaque dense material was ovoid in the longitudinal axis. The size of the mass was approximately 10 × 3 cm and there was no evidence of tibial erosion or cortical thickening. The MRI showed a dense bone forming tumor in the parosteal area of the midshaft of the tibia (). It showed homogenous low signal intensity on the T1, T2 weighted images and there was no evidence of medullary cavity communication or a connection stalk. There was no evidence of any significant soft tissue infiltration. Under spinal anesthesia, its resection was performed in the supine position.\nThe operative findings revealed the mass to be located in the anterior tibial area. It was 10 × 3 × 4 cm in size and covered with a hard fibrotic sheath. There was no connection between the mass and the adjacent bones, and the proximal and distal areas of the mass were connected by a fibrotic cord. The inside of the capsule was filled with a yellowish powder ().\nThe histological examination showed an extensive amorphous pink substance with calcific material due to necrosis of the skeletal muscle and fibrin (). The simple radiographs taken after surgery showed no residual mass, and the wound healed without necrosis or infection. |
The patient is a 28-year-old female with history of drug abuse previously on suboxone 5 months prior and migraine headaches who overdosed on intravenous recreational drugs. She has a family history of bipolar disorder in a paternal aunt but had no psychiatric disorders herself.\nWhile out of state, the patient was initially found unconscious for an unknown duration in the field by EMS with agonal breathing and acute hypoxic respiratory failure to an unknown degree requiring a nonrebreather mask. She had some positive response to naloxone via intranasal and intravenous administration with the patient less obtunded. Upon arrival at the Emergency Department, she became more alert but was confused and combative. Initial noncontrast head Computed Tomography (CT) was unremarkable for acute changes, as well as repeat imaging 24 hours later. Initial urine toxicology screening was positive for benzodiazepines but negative for opiates. Serum alcohol level was negative. A boyfriend reported intravenous heroin use immediately prior to this presentation, and the patient was noted to have track marks on her right upper extremity. The patient also used benzodiazepine immediately prior to the inciting event for anxiety, although no prescriptions were in the state's reporting system for controlled substances. On the second day of her hospitalization, the patient required elective intubation due to status epilepticus from suspected benzodiazepine withdrawal. She was uneventfully extubated the following day. She was alert and oriented ×3 with no focal neurologic deficits and left against medical advice on day 3 of the hospitalization.\nFive days following the initial hospitalization in the same state as the initial inciting event, the patient was noted by her family to have retrograde amnesia and an inability to care for herself due to confusion. Upon admission to a different hospital, the patient was noted to be only oriented to self and unable to provide history regarding her recent hospitalization. Urine drug screen was negative. Liver enzymes were elevated on admission (ALT 384 μ/L, AST 227 μ/L) due to Hepatitis C. She had an electroencephalogram (EEG) which showed frequent epileptiform activity in the occipital region without electrographic seizures. The patient was started on topiramate 50 mg BID and levetiracetam 500 mg BID for seizure prophylaxis. Imaging with head CT without contrast showed low attenuation of the caudate heads and lentiform nucleus, suggestive of hypoxic injury with clinical encephalopathy (Figure ). MRI of the brain was unremarkable during this admission (Figure ). Due to labile emotions, she was started on 0.25mg q8h lorazepam as needed. After 2 days of hospitalization, the patient was discharged, as she was alert and oriented ×3 without confusion and with a nonfocal neurologic examination.\nFour weeks after the initial event, the patient presented to our hospital due to acute psychosis of 2 days' duration, including confusion, agitation, lack of sleep, flat affect, and hallucinations. Family reported that she was doing well at home following discharge from the second hospitalization, except for short-term memory loss. Upon admission, the patient was alert and oriented to self only with a nonfocal neurologic examination. Montreal Cognitive Assessment (MOCA) administered on admission showed significant cognitive impairment with a score of 16/30. Urine drug screen during this hospitalization was negative. Liver enzymes were mildly elevated. Head CT without contrast revealed bilateral symmetric areas of abnormal low attenuation in the basal ganglia involving the caudate heads and anterior aspect of the putamen due to anoxic brain injury (Figure ). Brain MRI with contrast demonstrated a hyperintense T2 signal in the basal ganglia with mild white matter changes in bilateral frontal paraventricular areas (Figure ). Infectious Disease was consulted, and the workup was negative, including HIV, CMV, HSV, Lyme disease, syphilis, and acute EBV. No cerebral spinal fluid analysis was done due to patient's clinical condition and parent's wishes to monitor clinically with low to no index of suspicion for infectious etiology, as no fevers, leukocytosis, or meningeal signs were present. Arylsulfatase A level in leukocytes was within normal limits. The patient had multiple EEG's which failed to show any significant seizure activity, including during the patient's delusional episodes.\nPsychiatry was consulted, who declared there was no underlying primary psychiatric condition. Her home topiramate 50 mg BID and levetiracetam 500 mg BID were discontinued due to concern of worsening her clinical features. She was started on olanzapine 5 mg q6h, trazodone 100 mg nightly, and scheduled lorazepam 2 mg q6h. However, she had minimal response to this regimen with frequent agitation and delusional outbreaks. She was transitioned to quetiapine (50 mg, 50 mg, and 100 mg) TID with 50 mg PRN and lorazepam 2 mg q6h PRN with good response, which were continued as outpatient. Carbamazepine 200 mg BID was started during the admission for seizures and continued at discharge. Propranolol 10 mg TID was initiated and continued upon discharge for tachycardia due to agitation. The patient was alert and oriented to person, place, and time without hallucinations or paranoia upon discharge home. She was calm, relaxed and more interactive. She had improved sleep, with seven hours per night. |
A 39 years old female patient was admitted with a diagnosis of prolapsed intervertebral disc L4-L5 with radiculopathy left lower limb. The patient was taken up for routine microdiscectomy after pre anesthetic checkup. After doing the laminotomy, while the discectomy was being carried out with help of disc biting forceps anesthetists noticed a sudden drop in blood pressure of the patient. Even after checking the wires and cuff when the readings did not improved, it was decided to pack the wound and turn the patient supine. As there was no excessive pulsatile bleeding into the surgical field, major blood vessel injury was not contemplated. The surgical and the anesthetic team assumed it to be a severe drug allergic reaction. However an urgent ultrasound of abdomen was called for, which revealed frank collection in the abdomen. Blood was aspirated in abdominal tap and general surgeon was called in for suspecting it to be a major blood vessels injury. Urgent laparotomy was done and a 1 cm rent was identified in the antero-lateral and postero-medial wall of the inferior vena cava at the level of junction of common iliac vessels (). The torn vessel was compressed manually to minimize the blood loss till a vascular surgeon arrived. Hemodynamic status of the patient was maintained by giving massive blood transfusion. The vascular surgeon repaired the antero-lateral rent but the postero-medial defect on the under surface could not be repaired. At this time the vascular surgeon decided to isolate the tear by ligatures and do an end to end anastomosis of common iliac vessels with the gonadal vessels to maintain the circulation (). The patient was kept in ICU for observation for next 5 days. Over all she received 20 units of whole blood and 35 units of fresh frozen plasma. Abdominal drain was removed on day 5 when the 24-hour collection was less than 100ml. The ultrasound of the abdomen on the subsequent day revealed minimal collection. The patient was maintaining her vitals well however she developed swelling in her left calf and thigh 10 days post surgery for which she was given compression stockings. The patient was discharged in a stable condition from hospital 14 days post surgery after all stitch removal. Her radicular pain had disappeared post surgery. |
A 25-year-old male was referred from a primary care facility for the management of dentoalveolar fracture involving the left maxillary tuberosity during attempted extraction of maxillary left first molar. He had no known medical problems and no known allergies.\nUpon examination, he presented with facial asymmetry with swelling occurring on his left face. The swelling was diffuse and slightly tender to palpation, involving the entire left buccal region from zygomatic arch to the border of the mandible. There was no limitation of mouth opening and no deviation of the mandible upon opening and closing of the mouth.\nIntraorally, there was a mobile fracture segment seen on his left maxilla involving the left maxillary first, second, third molar and maxillary tuberosity. The segment was extremely mobile and extruded preventing full occlusion of his teeth. The maxillary left second premolar was firm. The maxillary left first molar had a large occlusal caries which extends subgingivally and was reported to be tender to percussion prior to the attempted extraction. There was a small laceration wound on the buccal gingiva adjacent to the upper left first molar measuring about 6 mm (Figure ).\nAs the diagnosis as well as the extent of the dentoalveolar fracture was able to be determined clinically, no radiographical examination was done for this patient.\nAs the patient was a young healthy male, and the maxillary second and third molar that was involved in the maxillary tuberosity fracture was sound, the authors decided on a conservative approach to reduce and stabilize the fractured segment followed by transalveolar extraction of the unrestorable maxillary first molar at a later date. As the patient was seen toward the end of the working day, the fracture was first stabilized using eyelet wiring and an appointment was set for the following day.\nDuring his next appointment, closed reduction and fixation was achieved using upper and lower arch bars with intermaxillary fixation (IMF). At the end of this visit, occlusion was reachieved and the fracture segment was firm. The arch bars and IMF were left in situ for a period of 4 weeks to allow for healing of the fracture. The patient was placed on an antibiotic regimen of amoxicillin and metronidazole for 1 week to prevent infection as the upper left first molar had a large occlusal caries and was reported to be tender to percussion prior to the extraction. He was reviewed weekly to assess healing and to observe for signs of infection.\nDuring the review on the fourth week, the IMF was removed to assess the healing of the fracture and the stability of the occlusion. Some minor mobility of the fracture was noted but was deemed acceptable. The arch bars were kept in-situ for one more week should the need to replace the IMF arise.\nUpon review on the fifth week, the fracture segment was firm and occlusion was stable. There were no signs of active infection. The upper and lower arch bars were removed and a date for surgical removal of the upper left first molar was set for 1 month later (Figure ).\nThe carious upper left first molar was removed via surgical transalveolar approach with no complications. |
A 72-year-old woman was referred to our hospital with pancreatic head and neck carcinoma for more evaluations and surgical operation. She had been suffering from abdominal pain for about 1 year, and the pain has become more intense in the last 6 months. The pain was postprandial and localized to the right upper abdomen. She has become icteric with generalized spread plus itching since past 2 months. The patient had no history of alcohol consumption or smoking. The patient was referred to us with a highly probable diagnosis of pancreatic head and neck carcinoma to be consulted for surgery. Also, a plastic stent was implanted for her in the previous health center due to intra- and extrahepatic duct dilation for the relief of patient symptoms and signs. After admission to our hospital, she was evaluated by abdominal computed tomography (CT), endosonographic imaging, and diagnostic ampullary biopsy. The abdominal CT scan with contrast exhibited an 18 mm × 20 mm hypodense mass at the head and neck of the pancreas (). Also, endosonographic imaging was performed to rule out periampullary lesions (). A 20 mm × 19 mm lesion was seen in the pancreatic head and neck region, and the main pancreatic duct was slightly dilated in the body of the pancreas. Moreover, the common bile duct (CBD) was distally thickened and contained sludge. Subsequently, diagnostic biopsy for pathological assessment was done. The biopsy revealed an irregular gray-creamy soft tissue which had undifferentiated malignant tumor features at microscopic evaluations. During the Whipple procedure, after cutting the neck of the pancreas in the left side of the portal vein, the frozen section revealed more involvement of pancreatic tissue. Although additional 2 cm was resected, the pancreas residue still had tumor involvement, macroscopically. Therefore, the patient was undergone total pancreatectomy.\nPostoperative pathological studies were established and indicated a tumor with the greatest dimension of 4 cm which was extended to the duodenum. Invasion of the venous, lymphatic vessels and perineural sites was seen; however, no exact evidence of distant metastasis was found. The periampullary occlusion had hindered the bile flow over time, leading to chronic cholecystitis and pancreatitis which was confirmed by histopathological assessments. The hematoxylin and eosin staining revealed the presence of two cellular populations including spindle fibroblast-like and pleomorphic cells within the tumor. In addition, the proliferation pattern of the mesenchymal cells was storiform (). There was not any well-differentiated component in the tumor tissue or adjacent tissue. Overall, the pathologic stage II A was assigned to the tumor. The immunohistochemical staining was performed, and the tumor was positive for CD68, lysozyme, alpha 1-antichymotrypsin, and vimentin (). Also, it was negative for S-100P, cytokeratin, epithelial membrane antigen, desmin, CD34, smooth muscle antigen, MDM2, and CDK4. Therefore, the tumor diagnosis was compatible with UPS. The tumor Ki-67 expression was more than 30%. To evaluate metastasis occurrence, contrast-enhanced thoracic high-resolution CT scan and multidetector CT scan of abdominopelvic were done at 6, 12, 18, 24, and 36 months after operation, and no evidence of metastasis was detected. Insulin and Creon were started after surgery for long life. The further follow-up investigations were done by periodic CT scan and ultrasonic imaging. Fortunately, she was disease-free during 5-year follow-up and tolerated total pancreatectomy, well. |
A 36-year-old female (gravida 2 and para 1) was referred to our hospital from a private clinic for placenta previa at 28 weeks of gestation. The patient had a history of a cesarean delivery, and in her current pregnancy, the placenta covered the entire anterior uterine wall and totally embedded within the lower uterine segment. We performed ultrasonography and magnetic resonance imaging, and diagnosed her with placenta previa and placenta accreta without bladder invasion (). The patient was considered at risk for severe obstetrical complications due to placenta accreta; therefore, a cesarean section was planned at 36 weeks of gestation to avoid emergency surgery. At 35 weeks, she experienced a sudden onset of vaginal bleeding from the placenta and was admitted to our hospital. Total blood loss was estimated to be over 500 mL, and we performed an emergency cesarean section under general anesthesia. Laparotomy revealed large blood vessels and portions of the placenta present throughout the anterior uterine wall (). Thus, we suspected placenta percreta and made an incision in the transverse uterine fundus to avoid cutting through the placenta. After elevating the uterus outside the abdominal wall, an ultrasonography-guided transverse incision was made at the uterine fundus to avoid rupturing the membrane or producing a bulge on the fetal membrane (). The incision produced minimal bleeding, and a sleeping male infant with a birth weight of 2,560 g was successfully delivered (Apgar scores of 2 and 6 at 1 and 5 minutes, respectively). The placenta was not spontaneously delivered because of abnormal uterine adherence; therefore, we performed a hysterectomy, which was completed without complications, and closed the abdomen. Operation time was 139 min, and total blood loss was approximately 2,000 mL (including the preoperative bleeding), and bleeding was primarily observed from the placental site. Minimal bleeding was observed from the surgical site. Although abnormal adherence was observed between the anterior uterine wall and the bladder because of placenta percreta, it was difficult to strip the bladder from the uterus; we were finally able to strip the bladder without injury to any part of the bladder. The patient was transfused with 840 mL of red blood cells. The patient was discharged 7 days later without any complications in good condition. Histopathological analysis was revealed the placenta percreta as shown in . Postoperative examination revealed no complications 35 days after surgery. However, postoperative day 48, she experienced a watery discharge and was diagnosed with a vaginal fistula by internal examination and cystoscopy. Her vaginal fistula improved after 20 days and no recurrence occurred after one year after the diagnosis. |
A 77 year old female presented to her primary care physician with a complaint of a right buttock mass. Her past medical history was significant for colonic adenocarcinoma treated surgically, twelve years prior. The skin overlying the 2 × 3 cm firm, non-fluctuant, non-tender mass was erythematous. Initially the mass was thought to be a boil or carbuncle. Six weeks later during a visit with a surgical oncologist for routine follow-up of her colonic adenocarcinoma resected 13 years prior, the patient noted that the mass was becoming quite painful and enlarging rapidly. The patient was then taken to the OR for local excision. Pathology revealed a small round blue cell tumor forming large nests and infiltrating as single cells between thick strands of fibrous tissue in the dermis and extending to the subcutaneous fat. There were abundant mitoses, a lack of necrosis or obvious vascular invasion. The epidermis was uninvolved. The histologic and immunochemical findings supported the diagnosis of Merkel cell carcinoma. A wide local excision and sentinel lymph node biopsy were performed. One sentinel lymph node was negative for malignancy and there was no residual tumor identified in the excision. No adjuvant therapy was given.\nTen months after the initial presentation the patient had increasing shoulder pain that radiated into the chest and flank. A CT of the thoracic spine revealed a 3.0 cm mass in the area of the fourth thoracic (T4) vertebra. A CT guided needle biopsy of the area revealed metastatic Merkel cell carcinoma. A bone scan revealed additional areas of concern in the right humerus and bilateral distal femurs. The patient received radiation therapy to the thoracic spine and right distal femur for palliation of bone pain.\nA year after first presenting for a right buttock mass, the patient was admitted to the hospital for increasing dyspnea. A chest radiograph revealed a large right pleural effusion, which was drained for both therapeutic and diagnostic purposes. The fluid was grossly bloody and cytology revealed abundant, round, basophilic single cells, many in mitosis, with characteristic granular, "salt and pepper" nuclear chromatin (Figure ). A cellblock was made and immunohistochemical staining with CK20 revealed characteristic positivity in a dot like rim pattern (Figures ). |
A 78-year-old man presented to cardiology clinic with complaints of instant chest pain accompanied with instantaneous headache at the left temporal region of the head with a strike of lightning. He had been suffering from this complaint for one week. He denied palpitation, dyspnea, syncope, or presyncope. In his detailed history, he had no hypertension, diabetes mellitus, and smoking. He underwent coronary angiography one year ago because of an anginal chest pain and there was no significant stenosis in the coronary arteries. He had been prescribed acetylsalicylic acid 100 mg, atorvastatin 10 mg, and metoprolol 50 mg at that time and the patient was compatible with his treatment. Cardiac examination revealed normal blood pressure, normal heart sounds with a regular rhythm, and no murmurs, S3 or S4. The electrocardiography revealed normal sinus rhythm with a single PVC on the ECG record and during the electrocardiographic examination he experienced the same instant chest pain and headache attack again. During the attack, he had no neurological or gastrointestinal signs. Neurological examination and radiological evaluation including cranial tomography and MR were found to be normal, previously. Echocardiographic examination was within the normal limits and there were no abnormal findings in the blood tests. Then, twenty-four-hour rhythm Holter monitoring was planned and he was told to record chest pain and headache attacks time during the day. Holter monitoring revealed normal sinus rhythm with 80 PVCs most frequently occurring during the night time, synchronous to the patient's chest pain and headache attacks. The patient's average heart rate was 63 beats per minute. Metoprolol therapy was reduced to 25 mg per day and amiodarone therapy has been added to the medical treatment of the patient which were thought to reduce the frequency of the attacks or terminate it. As thought, his complaints significantly improved at the end of the one month and there were no findings of PVC on the ECG recording and rhythm Holter monitoring. He has been followed up and was symptom-free for 6 months. Written informed consent was obtained from the patient. |
A 45-year-old man reported to his general practitioner with recurrent and strong, but self-limiting, left-sided epistaxis over the preceding 2 to 3 months, each time lasting up to 10 minutes. He also felt an intermittent, dull pain on the left side of his nose and the strange sensation of a slowly growing mass inside his nose, but neither nasal obstruction nor hypesthesia of the face. An excision under local anesthesia was then attempted. The effort was abandoned because of strong bleeding, a nosepad was applied and then the patient was referred as an emergency to our clinic. Upon arrival the bleeding had stopped.\nThe personal history showed an appropriately treated arterial hypertension and no regular alcohol or nicotine consumption or substance abuse. There was no high incidence of cancer in the family history.\nA clinical examination showed a healthy albeit obese man with a marginally elevated blood pressure level. After removal of the nosepad and suction cleaning, the nasal inspection showed a well-defined tumor of the lateral nasal wall on the anterior face of the inferior turbinate, approximately 10 mm in size. The tumor surface exhibited several incisions. Anterior and posterior rhinoscopy revealed a slight deviation of the nasal septum, but no other intranasal pathology. The external nose showed a slight, though distinctly palpable swelling in the area between the lateral cartilage and the nasal bone on the left side.\nTo further investigate the repeatedly bleeding endonasal mass a CT scan with contrast was conducted. It showed a tumor of the inferior turbinate, only marginally contrast enhancing, 24 mm in the largest diameter. No bony erosion was reported, and an infiltration of the lateral nasal cartilage could not be ruled out (). A biopsy under local anesthesia revealed the diagnosis of angioleiomyoma. To differentiate the tumor growth and the involvement of nasal cartilage, a MRI scan was ordered (). The scan showed a 9 × 11 × 8 mm (W × H × D) sized, nodular, contrast enhancing lesion emanating from the lateral nasal wall and extending to the anterior face of the inferior nasal turbinate on the level of the piriform aperture without any sign of infiltrative growth.\nA transnasal endoscopic tumor resection was performed under general anesthesia using a radiofrequency instrument (Ellman Surgitron) (). Intraoperative blood loss was minimal and no complications occurred. Nasal packing was applied and removed on the first postsurgical day. Postoperative nasal endoscopy showed a well-healing wound with no sign of infection. The histological examination confirmed the diagnosis of angioleiomyoma (). During the clinical follow-ups conducted at six and twelve months after the surgery, a nasal endoscopy showed no sign of tumor recurrence and the patient remained symptom-free. |
A 65-year-old female presented with recurrent liposarcoma of left groin and upper thigh of six months duration, following excision and radiotherapy four years ago. This 8 × 8 cms tumour was adherent to the previous surgical scar. The femoral pulse was not palpable due to encasement of the vessels as confirmed by MRI. Radical en-mass resection of the lesion with adequate margins included skin with previous surgical scar, whole of left inguinal ligament, partial left superior pubic ramus and retroperitoneal clearance with removal of external iliac - femoral vessels up to the upper thigh. The continuity of vessels to left lower limb was restored by PTFE grafts and a polypropylene mesh was used to reinforce the peritoneal defect at the inguinal region.\nThis defect of 15 × 22cms with exposed PTFE grafts and the mesh [] posed a new reconstructive challenge due to non availability of ipsilateral pedicled flaps as a long length of the external iliac and femoral vessels including the profunda were resected. Free flap transfer due to want of recipient vessels was not an option. Local random flaps were impractical due to the large size of the defect and previous irradiation.\nThe available donor sites were the opposite anterior abdominal wall and thigh. In view of extensive dissection and undermining of the anterior abdominal wall, we chose a flap from the contralateral thigh.\nThe desired skin paddle was marked (22 × 15cms) around a perforator identified by hand held Doppler. After elevating the skin paddle three musculocutaneous perforators through the vastus lateralis were identified without any septocutaneous perforators. Most of vastus except the lateral third was harvested with the overlying skin paddle. The length of descending branch of lateral circumflex femoral vessels obtained was 12 cms after ligating the branch to rectus femoris. The transverse branch was also ligated and further proximal dissection up to its origin from profunda gave an additional 3 cms to the pedicle length. The flap was tunnelled under the rectus femoris which provided unfolding of the 15 cms long pedicle for easier swing to the opposite groin [Figures -]. The pedicle was buried subcutaneously in the supra pubic region. The vastus muscle provided good bulk and the tendinous portion reached the opposite anterior superior iliac spine. The flap covered the composite defect comfortably without any stretch on the pedicle. The donor site was skin grafted and all other incisions closed primarily.\nThe flap and the donor site graft healed well. There was lymphorrhea from under the flap which was managed by a drain for three weeks. |
A 25-year-old Arabic female patient from the United Arab Emirates developed a right parotid mass lesion that was otherwise completely asymptomatic and of a stable size. She had no history of head and neck radiation treatment or a personal or family history of salivary neoplasms, but she was in the second trimester of her first pregnancy. Initially, the patient did not seek medical attention, but because of the progressive increase of the size of her parotid mass lesion, she obtained a referral to a head and neck surgeon. Her medical assessment, which included cytologic studies, indicated that the mass lesion was due to an acinic cell carcinoma.\nThe patient was managed surgically in the form of a right superficial parotidectomy with preservation of the ipsilateral facial nerve.\nThe patient remained well and had no recurrence of her malignant disease until four years later, when she became pregnant again. During the third trimester of her pregnancy, she developed a new mass lesion at the same site as her previous parotidectomy, which proved to be a recurrent acinic cell carcinoma. She also had a right submandibular malignant lymphadenopathy. The size of the recurrent acinic cell carcinoma and the ipsilateral malignant cervical lymphadenopathy progressively increased until the end of her pregnancy. The function of both facial nerves was intact. All investigations were essentially unremarkable, and no evidence of distant metastases or contraindications for surgical treatment were present. Her CT scan confirmed the presence of the recurrent mass lesion of the right parotid gland (Figure ).\nThe multidisciplinary management of this patient consisted of a right total parotidectomy with preservation of the facial nerve (Figure ) and an ipsilateral radical neck dissection followed by postoperative external-beam radiotherapy. The final histopathologic assessment confirmed the diagnosis of acinic cell carcinoma (Figure ).\nThe patient recovered from her treatment and was subsequently managed with close surveillance. Her disease has been well controlled until the time of this report, and she has had no recurrence of her acinic cell carcinoma. |
A previously healthy 28-year-old woman underwent autologous fat grafting for facial augmentation by a plastic surgeon at a local clinic. A total volume of 77 ml of fat was grafted for the whole face under general anesthesia. Twenty ml fat was injected into each temple, 20 ml into the forehead, and 17 ml was injected in the cheeks. The patient experienced left limb movement disorder and drowsiness following the procedure. The patient was referred to the emergency room 24 h later with Glasgow Coma Scale (GCS) 14 points (Eye 4+Verbal 5+Motor 5). The left limb muscle strength was grade 2 (muscle can move only if the resistance of gravity is removed.), while the right limb muscle strength was grade 5 (muscle contracts normally against full resistance) at the time of admission. Emergency computed tomography (CT) suggested that the patient had a large cerebral infarction of the right frontal, temporal, and parietal lobes, as well as the basal ganglia, causing a midline shift to the left (). The neck CTA suggested that the right external carotid artery was occluded (). She underwent emergency decompressive craniectomy for decompression of right massive cerebral infarction. Because the arterial occlusion resulted from autologous fat embolization, it would not respond to traditional pharmacologic thrombolysis. The patient was transferred to the ICU after surgery, and was treated for dehydration, infection prophylaxis, gastric protection, and seizure prophylaxis treatment, etc.\nThe post-surgery CT scan revealed a large cerebral infarction on the right side, as well as hemorrhage and gas accumulation in the operative field (). Patient was treated for 10 days with intravenous mannitol injection. A subsequent CT examination, completed after 10 days of treatment mentioned above, confirmed a reduction in brain edema and hemorrhage (). Physical examination completed on day 11 revealed that the patient had a left limb muscle strength of 2, with numbness on the left limb, and no obvious abnormality on the right side. The patient was transferred to a rehabilitation hospital for further treatment.\nThe follow-up MRI-FLAIR () showed attenuated brain edema, and MRA () showed vascular recanalization of the intracranial area. An MRI-SWAN () scan performed 2 months after onset showed that the hemorrhage was gradually decreased with no other obvious hemorrhage. The patient achieved better motor function of the left extremities (Her muscle strength recovered to grade 2+ on the left distal upper extremity, grade 4+ on the left proximal upper limb, and grade 5 on the left lower extremity) after 4 months of rehabilitation. Due to the outbreak of Corona Virus Disease-19 (COVID-19), the patient was discharged from the rehabilitation hospital in February. From that point forward, she continued her rehabilitation training from home. No imaging was performed on the patient at 4 months post-surgery. ' |
A 17-year-old male patient who had been vomiting and had poor oral intake for 4 days was admitted to our institution, after visiting another hospital. There he underwent an upper gastric endoscopy for further evaluation of any cause of gastric outlet obstruction symptoms. Upper endoscopy revealed the erosion with hyperemic mucosa in the duodenal bulb and complete obstruction of the second duodenal portion caused by external compression. Following abdominal CT scan revealed a large mass (about 8.7×4.5×5 cm) with an internal hemorrhage abutting and compressing the lumen of the duodenal second and third portion (). With the diagnosis of enteric cyst of duodenum 2nd–3rd, he was sent to our hospital for surgical management. And esophagogastroduodenoscopy (EGD) showing extrinsic compression and ulcerative mass like lesion of duodenum 2nd and 3rd portion ().\nOn his arrival to our hospital, there was no mention of any traumatic events written on referral from the other hospital, so we neglected the possibility of traumatic causes. We decided to take MRI scan to further distinguish the structural relationship of the cyst from other adjacent organs. The source of the GI symptoms revealed in MRI scan was found to be the acute intramural hematoma of duodenal 2nd and 3rd portion, and localized geographic infiltrative lesion of subcutaneous fat tissue of right anterior abdominal wall (). At the same time, we found out that the patient had the traumatic event the day before the symptoms developed, where he tripped on the threshold and hit his upper stomach hard on the metal doorknob which caused him significant pain. Excluding any hereditary coagulopathy or hemorrhage disease history, we diagnosed him with traumatic intramural duodenal hematoma.\nSince there is no standard treatment for traumatic intramural duodenal hematoma, and considering the fact that the patient had to take a national evaluation of educational achievement test in few weeks, we decided to take on conservative management rather than an invasive surgical treatment. Total parenteral nutritional therapy with adequate fluid replacement and nil per os (NPO) was applied. Levin tube insertion was not necessary since there was no significant gastro stasis. The patient was administered 2nd generation cephalosporin antibiotics. Blood tests were taken approximately twice a week to examine abnormalities of hemoglobin decreases or electrolytes imbalance caused with NPO. Soon after, the patient was able to take some sips of water or small bites of fruits with no abdominal discomfort or vomiting.\nOn the 14th day of admission, which also showed rare decrease in size of IMDH (). And the patient was able to eat small amounts of soft diets tolerably. Nevertheless, the patient was able to eat tolerable amount of food with no IV fluid replacement. After the patient took the national evaluation of educational achievement test, as the patient resolved in symptoms of vomiting and poor oral intake, we decided to further follow up the CT scan after 1 month of discharge.\n7 weeks after the diagnosis of IMDH, the patient revisited the outpatient clinic with 3rd follow up CT scan. On the CT scan, the intramural hematoma located in 2nd to 3rd portion of duodenum has completely resolved with very minimal periduodenal fluid left (). The patient had no limitations to consuming foods. We decided not to further follow up the patient. |
A 25-year-old male was admitted to our emergency department due to painful swelling in his left forearm. He experienced a slip down injury while walking. Simple radiograph revealed both radius and ulna fractures in proximal shaft (). His medical history was unremarkable. He had a history of motorcycle trauma which led to fractures to distal shaft of right radius and left distal humerus 5 years ago. He underwent an operation for open reduction and internal fixation on both fracture sites at our institution, and they healed without any complication. Second operation was performed to remove plates and screws 15 months after the surgery, and postoperative recovery was uneventful. Initial laboratory examinations revealed no abnormal findings. To treat his ulnar fracture, open reduction and internal fixation was chosen, and radial fracture was stabilized with a Khai nail under closed reduction. Postoperative radiography showed stable fixation for both bones ().\nPostoperative recovery progressed without a problem. However, postoperative review of the radiographs raised a suspicion of mild demineralization (). In addition, the minor traumatic nature of his slip down accident coupled with a fracture history led to a concern about fragility of his bone. We recommended bone densitometry to evaluate his bone quality, and the examination disclosed osteopenia in the spine (Z score=-2.3) and femoral neck (Z score =-1.3). To find the cause of his osteopenic condition, further laboratory evaluations were made, and his medical and personal histories were questioned and reviewed.\nInitial laboratory examinations showed slight increase only in serum liver transferases. Nonetheless the results were insignificant to suspect a condition such as hyperthyroidism, Cushing syndrome, myeloma or osteomalacia that is associated with decreased bone mass. The patient did not have smoking, alcoholic or drug use history, and the review of his past medical history was insignificant. However, during an interview with his family his sister commented about the patient's slow performance as a child, and recently she had noticed progressively more sluggish and slower behavior of the patient. When further questions were made, the patient stated that his speech became unclear to the point where his coworkers often complained of difficulty in communication, and he had experienced many incidences of accidental slip downs and dropping an object and had felt uneasiness in maintaining a control of his body. In addition, he noticed blurring in his vision often though he had thought that the problem was from fatigue due to his job as a manual laborer. The patient was referred to the ophthalmology department, and brownish pigmentation in the cornea was observed under slit lamp examination (). Additional laboratory tests revealed decreased level of serum copper and ceruloplasmin, and copper level of 24-hr collected urine was elevated significantly from normal range (). These findings led to the diagnosis of Wilson's disease. |
A 47-year-old male presented with a mass in the anterior mediastinum. The mass was incidentally detected on a chest X-ray during the evaluation of a minor trauma that he had sustained two months prior to his presentation to Asan Medical Center (). As such, he was referred to our hospital for further evaluation. On his admission, a chest computed tomography (CT) scan was taken, which revealed an 8.9 cm×7.1 cm×8.0 cm heterogeneous mass in the anterior mediastinum. The mass was located anterior to the ascending aorta and the main pulmonary artery in the left hemithorax (). The mass was well demarcated without the overt signs of invasion to the adjacent structures. Also, there was neither pleural effusion nor lymph node enlargement. The differential diagnosis for this tumor based on the radiologic findings indicated a thymoma, a germ cell tumor, or a mediastinal sarcoma. Due to the proximity to the aorta and pulmonary artery, a pre-operative tissue biopsy was not considered. Instead, it was decided that the patient undergo an excision. The procedure was performed via median sternotomy. Intraoperatively, a well-encapsulated mass was identified and noted to arise from the thymus. There was neither adhesion nor invasion to the adjacent structures such as the aorta, pulmonary arteries, or lung parenchyma. The tumor was excised completely with negative margins for a residual tumor. The intraoperative frozen biopsy revealed a rhabdomyosarcoma. The postoperative course did not show any particular issue; the patient was discharged on postoperative day four. The final pathology report identified a mature teratoma with embryonal rhabdomyosarcoma (). Postoperatively, the patient underwent five cycles of chemotherapy and subsequent radiotherapy. However, six months after the primary surgery, the patient was found to have a nodule, which was highly suspected to be a tumor recurrence, in the upper lobe of the left lung. On the serial follow-up CT scans, we learned that the nodule had grown in size up to 17 mm in the 8 months after primary surgery. After discussions with the medical oncology team, we decided to treat him with another cycle of chemotherapy, which shrunk the size of the nodule down to 15 mm (). Eleven months after the primary surgery, the patient underwent wedge resection of the nodule, which turned out to be a metastatic rhabdomyosarcoma from the primary mediastinal mass. As of the writing of this paper, the patient has finished the seventh cycle of chemotherapy and has not shown another tumor recurrence. |
A 29-year old female diagnosed with SLE for 4 years complicated with grade II lupus nephritis presented with status epilepticus. She denied a history of fever on admission, but was treated with cyclophosphamide 1 month prior for an episode of cerebral lupus. She had noticed a papule over the left deltoid region which progressed to an ulcer over 1 week. Fever was noted following several days of hospital admission and the ulcer site became painful. She had worked in paddy fields several months prior to the admission when she was in good health. However, she could not recall any precipitating injury at the affected site during working. She is a mother of two and both pregnancies were uncomplicated. She denied history of alcohol abuse or smoking.\nOn examination she was emaciated and had a GCS score of 15/15 following recovery of status epilepticus. There was no obvious lymphadenopathy. At presentation, the size of the ulcer was about a 3 cm lesion and it gradually developed in to an ulcer with a necrotic center with surrounding erythema. A tentative diagnosis of pyoderma gangrenosum was made with the appearance of the ulcer (Figure ). It gradually advanced into the underlying muscle over 3 weeks of onset despite the antibiotic treatment. Examination of the cardiovascular, respiratory systems, and the abdomen was normal.\nHer full blood count, blood picture, and other supportive investigations showed evidence of microangiopathic hemolytic anaemia, which was suggestive of thrombotic thrombocytopenic purpura which resolved following plasmapheresis. Her ESR was persistently normal. Renal functions were stable during hospital stay, so were the liver profile. Chest radiography revealed evidence of bilateral mild pleural effusions and echocardiography revealed a thin rim of pericardial effusion and good cardiac function. MRI, MRA brain showed evidence of Posterior Reversible Encephalopathy Syndrome. Repeat imaging showed resolved changes.\nA punch biopsy of the skin was done from the lesion and sent for fungal studies and histopathological studies. The direct microscopy examination revealed wide and irregular ribbon-like nonseptate hyphae with right-angle branching suggestive for Mucormycete fungi. Culture was done on Sabouraud dextrose agar with chloramphenicol (at 26°C and 37°C) yielded a white aerial mold, which covered the entire surface of the agar and came up to the lid of the culture bottles after 4 days of incubation (Figure ).\nThe lactophenol cotton blue mount of the growth revealed broad, nonseptate hyaline sterile hyphae. The slide culture test has been attempted with the hope of sporulation, however it was not successful. They only resulted in broad, nonseptate hyaline sterile hyphae without spores. Then the isolate was subcultured on to potato dextrose agar (PDA) and Rose Bengal (RB) agar for induction of sporulation. However, they yielded only sterile mycelia.\nThe isolate was inoculated on nutritionally deficient medium, tap water agar and incubated for 14 days at 37°C. It provided a hazy view of flask shaped sporangium with rhizoids in lactophenol cotton blue mount. Then floating agar method was used and it yielded characteristic flask-shaped sporangium in short sporangeophore with rhizoids after 10 days of incubation (Figure ).The sporangia had a long neck and the apex of the neck closed with a mucilaginous plug. The sporangiospores were cylindrical, with rounded ends. Those morphological features were suggestive for S. vasiformis and the isolate was identified as S. vasiformis.\nThe histopathology of the punch biopsy of the skin also reveled broad aseptate hyphae suggestive of Mucormycetes group of fungi.\nBased on the histopathological evidence of broad aseptate hyphae, suggestive of Mucormycete fungi, the patient was started on IV amphotericin B deoxycholate. Repeated surgical debridement was done and samples were sent for fungal studies. However, local application of antifungals was not included in the management. Her second tissue biopsy, which was taken during debridement after 5 days of IV amphotericin B also had similar direct microscopy findings and yielded S. vasiformis. However third tissue sample which was obtained after 10 days after IV amphotericine B deoxycholate became negative for fungal studies. Following the confirmation of sterile cultures from the subcutaneous biopsies, superficial skin grafting was done which was completely accepted from the wound site. She was treated with intravenous conventional amphotericin B for 28 days and she was asymptomatic when she was discharged from the ward. |
We report the case of a 29-year-old female eleven months postpartum, no longer breast feeding, who presented to her primary care provider with the complaint of a swollen and tender right breast, with a large area of firmness. She had no personal or family history of breast cancer, had no previous breast masses or biopsies, no previous breast surgeries, and had no history of chest radiation. Due to the degree of swelling and tenderness, a presumptive diagnosis of an infectious mastitis was made and the patient was prescribed a course of antibiotics. She subsequently failed to improve and was referred for a surgical evaluation.\nOn examination she was found to have a visibly swollen right breast, tender to touch, and with a large approximately 10 by 10 cm firm mass in the superior and outer portion of the breast. An ultrasound was performed to rule out abscess formation or fluid collection as well as to further characterize the mass (Figure ), which revealed a large irregular hypoechoic mass without any evidence of abscess or fluid collection.\nA core-needle biopsy was therefore performed to rule out breast cancer, as well as for cultures to definitively rule out an infectious mastitis. Cultures at this time were negative for bacterial, fungal, acid fast staining, or mycobacterial growth. Histologic evaluation of the biopsy revealed granulomatous inflammatory reaction centered on lobules, with granulomas composed of epithelioid histiocytes, Landerhans giant cells accompanied by lymphocytes, plasma cells and occasional eosinophils (Figure ), consistent with granulomatous lobular mastitis.\nThe patient was given a course of oral steroids starting with an initial Prednisone dose of 60 mg/d and tapering thereafter, and given a period of observation. Her condition began to improve after 2 wk on steroids, and on a 1-mo follow-up she remained free of any symptoms.\nShe then presented approximately 3 wk later with recurrent redness and tenderness of the right breast. A repeat ultrasound in the office revealed multiple fluid collections within the breast. A diagnostic needle aspiration of one of the fluid collections was performed and revealed purulent fluid consistent with abscesses. The collections were therefore all aspirated and the patient given repeat antibiotics and observed. Cultures of this purulent fluid were once again all negative for any bacterial growth or for acid fast staining.\nHer condition continued to deteriorate and the abscesses enlarged and increase in number. She therefore underwent operative incision and drainage of her multiple abscesses, as well as a third set of bacterial cultures. This time, the cultures grew Mycobacterium fortuitum. She was referred to an infectious disease specialist for treatment, and was prescribed a long term course of multiple antibiotics, consisting of Ciprofloxacin, Linezolid, and Sulfamethoxazole/Trimethoprim as per their recommendations for the treatment of her Mycobacterium fortuitum causing granulomatous mastitis. |
A 45-year-old female presented with complaints of swelling over the right lateral aspect of neck for the last 10 years associated with mild pain over the swelling. Occasionally, the patient also complained of difficulty in breathing and restricted opening of her mouth. She did not complain of any difficulty in swallowing. There was no history of any previous infection like fever, tooth ache or trauma or any other medical condition. Initially, the swelling was small in size and gradually progressed to a size of 10 × 12 cm, extending 4 cm below the lower border of mandible to upper border of clavicle, medial border being 4 cm lateral to midline and lateral border extending up to posterior triangle. On examination, the patient was pale and the swelling was measured to be of size 10 × 12 cm over the right lateral aspect of neck, which did not move on deglutition, was soft and cystic in nature, mobile, non-tender, no local rise in temperature, lateral border of the swelling was extending up to the posterior triangle, and medial border and superior border could not be made out, whereas the inferior border extended up to the clavicle. There was no discharge, redness, sinus from swelling and the overlying skin appeared normal. On intraoral examination, no abnormal findings were noted. Multiple palpable lymph nodes in the cervical region were noted. The nerve supply seemed to be in order.\nThe baseline investigations for complete blood count, routine urine test and renal function test were reported within normal limits. Ultrasonography of the neck revealed a large cystic swelling of size 13 × 9 × 8 cm (419 cc volume) on the right cervical region extending from the level of hyoid bone to clavicle, with external echoes, no vascularity and no calcification. Carotid vessels were pushed medially in inferior aspect and posteriorly in superior aspect. Multiple enlarged nodes in the cervical region were present with the largest measuring 1.2 cm. The impression was reported as an infected cyst/abscess in right cervical region. A magnetic resonance imaging (MRI) of neck was also performed, which showed a well-defined cystic lesion 13 × 8 × 8 cm extending from level of mandible to right supraclavicular fossa, displacing larynx and trachea to left, carotid vessel displaced medially. The impression was reported as a second branchial cyst or lymphatic cyst.\nThe plan for this patient was excision biopsy as there was uncertainty in the diagnosis as well as prognosis with a horizontal incision 3 cm below the mandible (Risdon’s incision). This involved complete removal of vesicles in order to prevent any further recurrences, although the risk of complications like scar and disfigurement significantly rises []. The excision was done under general anaesthesia and the tissue sample sent for evaluation. The biopsy specimen measured about 14 × 9 × 8 cm with irregular borders and soft in consistency.\nPost-operative period was uneventful. There was no neurological impairment. Patient was on antibiotics, analgesics and proton pump inhibitors. Biopsy report confirmed the diagnosis as lymphangioma. It had clusters of lymphoid tissue, large underdeveloped lymphatic channels with unorganized smooth muscle cells in its walls surrounded by connective tissue. It also contained vascular spaces lined by epithelial cells, which were thickened in some places []. |
A 68-year-old male patient was referred to our department from neurosurgery due to the occurrence of diplopia 10 days after a head surgery that was performed following a pedestrian traffic accident. On the day of the initial trauma, the patient was admitted to the intensive care unit after neurosurgical evaluation, because of a compound comminuted depressed fracture of the right temporal bone. In the initial ophthalmologic examination, there were no ocular symptoms. On day 4 after trauma, an open reduction and internal fixation were performed on the temporal bone fracture by the neurosurgeon. On day 2 after neurosurgery, the patient complained of diplopia and orbital computed tomography (CT) revealed bilateral orbital superior wall fractures. In contrast to the fact that a herniation of the brain parenchyma was unclear on the initial facial CT scan (Fig. a), the fracture fragment and the brain parenchyma were downwardly moved into the orbit, observed on CT scans taken when diplopia occurred (Fig. b). Upon physical examination at the time of admission to the department of oral and maxillofacial surgery, right eye movement limitation and right eye protrusion were observed (Fig. a, c). The surgical plan was to reconstruct the bilateral medial orbital wall using a titanium mesh via coronal approach. For better fitness of the titanium mesh, the mesh was contoured preoperatively on a model of the patient’s skull that included the orbital wall defect. The defect on the model was restored using a plate wax (Fig. ); following pre-operative manipulations, the mesh was sterilized.\nThe reconstruction of the orbital wall was performed 1 month after trauma. A bicoronal approach was attempted in order to easily access the tissue on the right orbital wall. Due to severe tissue adhesion, a craniotomy was performed on the frontal bone to approach the anterior cranial base, even though this is a more invasive approach. Despite utilizing this approach through the anterior cranial base, sufficient tissue dissection was not achieved due to severe adhesion. We thus decided to remove the superior orbital rim in order to secure the operating field, which was successful. Before the osteotomy of the superior orbital rim, a miniplate for fixation of the bony fragment was prepared to reposition the fragment in its original position. After osteotomy, strong adhesions between the brain parenchyma and orbital contents were found (Fig. a). Further forcible dissection of the adherent tissue was expected to cause damage to the meninges and parenchyma, so after a neurosurgery consultation, neurosurgical procedures were performed in order to dissect the adherent tissue, remove the fractured fragment and necrotic brain tissue, and repair the damaged meninges (Fig. b). After the adhered tissue was dissected, the superior orbital wall was reconstructed with a pre-prepared titanium mesh, and the superior orbital rim bone fragment was placed in the original position with a miniplate (Fig. c).\nIn the left superior orbital wall fracture where the tissue adhesion was not severe, tissue dissection was completed without an osteotomy of the superior orbital wall rim. The titanium mesh was placed and fixed through conventional methods. After fixation of the fracture fragment, which had been obtained from the craniotomy site, the surgical site was closed.\nWe could confirm the improvement of the exophthalmos immediately following surgery (Fig. d) as the CT scan taken immediately after the operation showed that the brain parenchyma that had been protruding into the orbit returned to its normal position (Fig. c). Postoperative diplopia and exophthalmos were improved, and the patient was discharged without complications. At 3 months after surgery, further improvements in diplopia and exophthalmos with no limitation of ocular motility were found (Fig. b, d). |
A healthy 35-year-old woman with a history of 2 elective cesarean sections and one miscarriage (G4 P2 A1) was accepted as a referred case to our hospital. The patient was admitted for the elective cesarean section at 37 weeks of gestation. She was referred from the rural primary care hospital where routine ultrasonography revealed low-lying placentation. A Doppler ultrasound at 35 weeks showed complete covering of the cervical os which was attached to the scar with incessant hemorrhagic lesions in the inner anterior myometrium, indicative signs of PA (Figure ). She had diagnosed placentation in the lower uterine segment and had given a history of irregular, painless bleeding of the vagina during the fifth and seventh months of gestation. Further, magnetic resonance imaging (MRI) was performed, images still revealed that the placenta was completely covering the cervical os and suspected implantation of placental villi penetrating the full thickness of the myometrium, which further extending posteriorly up to the bladder wall and anteriorly displayed vascular engorgement (Figure ). On the day of surgery, an expert urologic surgeon had been involved along with the interventional cardiology team. During the cesarean, the uterus was opened along the midline in upper segment of uterus, and a baby of the 3 kg was delivered with a good Apgar score. Due to invasive placentation and bleeding, cesarean hysterectomy was proceeded immediately after the birth of the baby. The lower uterine segment was noted to be relatively thin but was covered by a plexus of deep vessels which spread over the bladder near the broad ligament which was covered by peritoneum. The bladder was opened and repaired due to continuous bleeding as the placenta extended to the bladder. Left-sided salpingo-oophorectomy was also performed due to constant bleeding from the left tubo-ovarian ligament. The estimated blood loss was approximately 3500 mL during the procedure. Afterward, three units of whole blood were transfused, and two hemaccel infusions were given. The patient was kept on inotropic support in postoperative ICU for 24 hours. Later, the patient was moved to the surgical ward and discharged from the hospital on the 5th postoperative day. Foley's catheter was retained for 2 weeks, and a smooth postpartum recovery was observed. |
A 44-year-old male patient was admitted to our Vascular Surgery Department.
In 2001, the patient was in a traffic accident, resulting in a blunt injury to the chest and pelvis. This, presumably, was the mechanism of development of an aneurysm of the aortic arch.
In 2012, on the plane X-ray of the chest, an abnormal mass lesion was found, but computed tomographic (CT) verification was not performed due to unknown reason.
In 2014, the patient was hospitalized in our department when we confirmed the diagnosis of the aortic arch pseudoaneurysm (
). CT imaging identified a giant pseudoaneurysm with maximum size 136 × 72 mm. The size of posterior aortic arch wall defect was 28 mm. There were no signs of aortic dissection.
We performed an operation—the elimination of the aortic arch pseudoaneurysm and posterior wall tear and false aneurysm in the mediastinum without the use of cardiopulmonary bypass.
The position of the patient was on hs back with his left hand fixed above the head.
Under total anesthesia, through the L-shaped median sternotomy and left 5th intercostal thoracotomy, we identified and extracted the ascending aorta, aortic arch, left common carotid and subclavian arteries and mid part of descending aorta (
).
The brachiocephalic trunk was unable to mobilize because it was intimately fused with the anterior wall of the false aneurysm. Therefore, the right subclavian artery was controlled. A temporary bypass (TB) shunt of 20 mm between the ascending and descending aorta was created. In addition, from this bypass an anastomosis with a bifurcation prosthesis for temporary blood supply to the brachiocephalic trunk and left common carotid artery was formed. The first branch of the bifurcated bypass was anastomosed to the right subclavian artery, and the second connected through cannulation to the left carotid artery. The bloodstream was allowed to run through all temporary shunts. The ascending aorta was clamped distal to the shunt, and the descending aorta was clamped proximal to the shunts. Single clamps were placed on the brach |
A 31-year-old Caucasian woman was booked into our hospital for her first pregnancy. An ultrasound scan at 19 weeks confirmed a normal fetal anatomy and a large simple septate cyst arising from the pelvis measuring 11 cm. Neither of the ovaries was seen, so it was difficult to determine the origin of the cyst. The cyst was not complex and was reported to be a simple cyst with a single thin septum. Although both ovaries were not visualized, which is not unusual at 19 weeks, because of the relationship of the cyst with the uterus and the cyst being in the pouch of Douglas, it was suggested to be of probable ovarian origin. The overall morphological features of the mass did not indicate malignancy. In view of the large size and septation of the cyst, the surgical option to remove the cyst by the laparoscopic technique was discussed with the patient, which she agreed to.\nShe was admitted at 20 weeks' gestation. She was asymptomatic and the height of the fundus at 20 weeks corresponded to 26 weeks' gestation. After induction of general endotracheal anaesthesia, a nasogastric tube was passed to remove any gaseous distension of the stomach. The uterine fundus was palpated and a Verres needle was inserted through the Palmer's point. After insufflation with CO2 to a pressure of 20 mmHg, a 5 mm cannula was placed through the same site. A 10 mm infra-umbilical port was inserted. Two secondary ports, 5 mm each, were inserted under direct vision, the right and left lateral ports at the level of the umbilicus. Normally, right and left ports are inserted but it was impossible to reach the left side from the right port, therefore a further left port was inserted between the left lateral port and the Palmer's point port. The two left port placements facilitated exposure of the ovarian cyst, adhesiolysis of the bowel from the left adnexa, avoided potential injury to the gravid uterus and minimized uterine manipulation.\nAt laparoscopy, the gravid uterus was seen with normal right ovary with no ascites, smooth peritoneal surface, normal upper abdomen and no cyst could be seen. The left adnexa was obscured by congenital adhesions of the sigmoid colon and omentum. These are normally congenital adhesions from the sigmoid colon to the sidewall around the pelvic brim. Transvaginal ultrasound was therefore performed at this stage. The ultrasound scan confirmed an 11 cm simple cyst with thin septum in the pouch of Douglas behind the uterus. The bowel adhesions to the left adnexa were divided. The cyst was still not visible so the operating table was tilted towards the right which deflected the uterine fundus away from the midline. At this point, a small part of the left ovarian cyst was visualized between the pelvic side wall and the gravid uterus. The cyst was aspirated with a Verres needle avoiding intraperitoneal spill and 300 ml of serous fluid was drained initially. Once the cyst had shrunk, the ovary was pulled out from the pouch of Douglas. The remaining cyst was then completely aspirated (nearly 500 ml of more fluid). The pouch of Douglas was visualized, and looked normal. The ovarian cystectomy was performed by dissecting away the cyst wall from the ovarian tissue by stripping and sharp scissors dissection. The remaining ovarian tissue was refashioned with 3/0 PDS by purse string suture burying the ovarian edges. The pouch of Douglas and peritoneal cavity were washed with Ringer's lactate. The intra-abdominal pressure was maintained below 12 mmHg throughout the procedure. Theatre occupancy time for the whole procedure was 120 minutes. No tocolytics were used as there is no evidence for any role of tocolytics at this gestational age. Prophylactic antibiotics were administered. The fetal heart was auscultated before and after the procedure.\nHer postoperative recovery was uncomplicated and she was discharged home the following day. She was readmitted 12 days later due to anxiety and constipation resulting in some spasmodic abdominal cramps. She settled with reassurance, simple analgesia and laxatives. The patient was reviewed in the clinic 2 weeks later and discharged to routine antenatal care. Her subsequent antenatal course was uncomplicated. Histology of the cyst wall confirmed a mucinous cyst adenoma. She was admitted at 39 weeks in spontaneous labour and due to non-progress of labour, she had an emergency lower segment caesarean section. At operation, both her ovaries were normal and mobile. The baby was male and weighed 3.7 kg, with Apgar score 7 at 1 minute and 9 at 5 minutes. |
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